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s .2 Bat'Roars;Queensbuni,NY
rrrn,dCgiren>ruin• P::Z8-761—g2256 -,,`.x.- ..a-:=:-err'
S ^ - /% -.Y - 2 e, JUL 2 Z 2(19er-n ee:$ invoice::
Tax Map iD#: 6-2�
EEn Variance? Yes i\lo
OIEDINC,&UUUtO
Primary Owner(s) ( /3/'u c_e_ Poo
Mailing Address /9 aveft) /I' e
Phone &Email
Installer/Builder I _S Je -et- j?'/-v/CF'
Mailing Address ` ,&o ok' 7 2 61 6 /e ,-s ! ./a; /vV /1�v/
Phone &. Email c/ - 7 1-- 376�
Engineer
Mailing Address •
Phone & Email /j/�
Contact Person for Building&Code Compliance: ��
i -e--- Phone:S7f -7 6 5750
RESIDENCE INFORMATION: / ett/ /7 zi ' ,fe/9,//< /4 .
Year Built 1 #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yes
1980 or older // 550 Installed? (circle one) X
I f Spa or Hot Tub Yes fU
1981 1991 ( Installed? (circle one)
1992-Present I `
PARCEL INFORMATION:
Topography 1 .V Flat Rolling Steep Slope %Slope
Soil Nature a Sand Loam Clay Other
Groundwater At what depth? t-r'
Bedrock/Impervious material At what depth? /'''/)
Domestic Water Supply .Municipal _Well (if well,water supply from any septic system absorption is ft.)
Percolation Test I Rate:/- i per minute per inch(test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 1/G7/V gallons (min.size 1,000 gallons,add 250 gallons for each garbage cylinder or spa/hot tub
System I Absorption field with#2 stone � Total length
ft.; Each Trench ft.
I ` Seepage Pit with#3 stone How many: ;Size:
1 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
havrepresentation thor n o make a to abide these and all requirements of theaterial fact or circumstance known by or on bTowlf of an applicant,shall be n of Queensbury Sanitary Sewage
have read the regulations and agreeby
Disposal Ordinance. - /,
PRINT NAME: �(�
' f /'`tip �� DATE: 7 2?/9
DATE:
SIGNATURE:
Revised February 2017
Town of Queensbury Building&Code Enforcement