application • Office Use Only
• SEPTIC DISPOSAL PERMIT APPLICATION Permit#: P— � 7J�
Permit Fee: $ `�`3 ; Invoice#: t' a r-
Septic Variance? Yes No
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742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
Tax Map ID#: 289.7-1-31
Project Location: 26 Reardon Rd
• Applicant:
Name(s): Patrick Seelye
Mailing Address, 28 Reardon Rd. Queensbury, NY 12804 c _ .
� 2 Cell Phone: ( 518-222-0061 ) Land Line: ( 518-798-1867 )Email: teamseelye@gmail.com � o \
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• Primary Owner(s): ezth c, ��ti`1 k
Name(s): Timothy and Kimberly Larned ��iG ----
Mailing Address: 210 Wendy Ct., Schenectady, NY 12306 U'
Cell Phone: ( 518-461-4021 ) Land Line: ( 518-355-9106 )
Email: N/A
Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): Nate Kingsley
Contractor Trade: Donald Kingsley Excavating
Mailing Address: 743 Edgecomb Pond Rd., Bolton Landing 12814
Cell Phone: ( 518-361-6035 ) Land Line: ( 518-644-2306 )
Email: Unknown K,(9.6ki £xca Va-+tam, ( ttokrvl -t( - cc�
• Engineer(s):
Name(s): Bret Wincheip / Winchip Engineering PC
Mailing Address: 36 Cougar Lane PO BOX 116 Chestertown, NY 12817
Cell Phone: ( ) Land Line: ( 518-494-2555 )
Email: bwinchip(dwinchipengineering.com
Contact Person for Building & Code Compliance: Patrick Seelye
Cell Phone: ( 518-222-0061 ) Land Line: ( 518-793-7053 Ext: 301 )
Email: teamseelye i,gmail.com
Septic Application Revised February 2019
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom
1980 or older 150 Click or tap here Click or tap Click or tap here to
to enter text. here to enter enter text.
text. Garbage Grinder Yes No
1981-1991 130 Click or tap here Click or tap Click or tap here to Installed? (check one) ❑ X
to enter text. here to enter enter text.
text. Spa or Hot Tub Yes No
1992-Present 110 4 110 440 Installed? (check one) ❑ X
PARCEL INFORMATION:
Topography X Flat Rolling ❑ Steep Slope %Slope
Soil Nature X Sand ❑ Loam ❑ Clay ❑ Other(explain:
Groundwater At what depth? Unknown
Bedrock/Impervious material At what depth? Unknown
Domestic Water Supply ❑ Municipal X Well (if well,water supply from any septic system absorption is_96_ft.)
Percolation Test Rate: per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size _1250 gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone Total length 56 ft.; Each Trench_20_ft. and 1 @ 16
Seepage Pit with#3 stone How many:_0_; Size:
Alternative System Bed or other type: Eljen in drain system_
Holding Tank System Total required capacity? N/A ; tank size ; #of tanks
NOTES: 1. Alarm system and associated electrical work must be inspected by a Town approved electrical inspection
agency; 2. We will no longer allow systems to be covered until such time as an as-built plan is received and
approved. The installed system must match the septic layout on file—no exceptions. 3. As-built drawings must be
submitted prior to the inspection, if there has been a change to the submitted plans.
Declaration: Any permit or approval granted which is based upon or is granted in reliance upon any material
representation or failure to make a material fact or circumstance known by or on behalf of an applicant, shall be
void. I have read the regulations and agree to abide by these and all requirements of the Town of Queensbury
Sanitary Sewage Disposal Ordinance.
PRINT NAME: Patrick S lye
SIGNATURE: DATE:
Septic Application Revised February 2019