application M-1.-._ -
SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury, NY 12804
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P: 518-761-8256 www.queensbury.net Permit#: s?E - U4 l9 v- 10 l'I
Tax Map ID#: 2{'15; /1 - I -i j Permit Fee: $ '-+r-D— ; Invoice#: l'4-1•3
IProject Location: J P( n� Vv�� li .`7 Qw Septic Variance? Yes No
Primary Owner(s) B 1 ( 10 k ./.
Mailing Address -4) gi l"Q W0 / 0 I I0 _
Phone & Email L89 h 0 y=(3 @ L C; t. I V E 5 i
Installer/Builder S epf-I c
Mailing Address11
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Phone & Email 5—( —) 9 bt 9'-fTOWN OF C?I IFE
E�UILD!N - NSEs S
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Engineer CODE
Mailing Address
Phone & Email ( ([
Contact Person for Building&Code Compliance: / Y1' -3 I Phone: �( J f f )
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No
1980 or older 150 Installed? (circle one)•
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1981-1991 130 Spa or Hot Tub Yes
Installed? (circle one)
1992-Present 110 13 1 I 3 3l l
PARCEL INFORMATION:
Topography at Rolling Steep Slope %Slope
Soil Nature Sand Loam Clay Other
Groundwater At w t depth?
Bedrock/Impervious material At at depth?
Domestic Water Supply _Municipal _Well (if well,water supply from any septic system absorption is_ft.)
Percolation Test Rate: per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size Sr 3/11 gallons(min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub
System sorption field with #2 stone Total length TOO ft.; Each Trench 5 I J ft.
Seepage Pit with#3 stone How many: ; Size:
Alternative System Bed or other type:
Holding Tank System Total required capacity? ; tank size ; #of tanks
NOTES: 1. Alarm system &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.
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: i I I DATE: _.
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SIGNATURE: DATE: /
'i own of Queensbury Building&Code Enforcement Revised March 2018