application 4-
r
/ fiit Office Use Only
Permit#: e c-ZU
SEPTIC DISPOSAL PERMIT APPLICATION
2 (�'� • $ C,G� ; Invoice#: 2-
Town of c Luccnsbun• D E v S ti r c�?
1Yes No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net JUL 2 2 2019
l 2TOWN OF QUEENSBURY
Tax Map ID#: S/_ 3o3 G DING& CODES
Project Location: _ -S ct H 0 0( avC.r.ol-c
• Applicant: `\ J
Name(s): TC.T f.�-!t j� ,rX-.
Mailing Address, C/S/Z: ¶ 6 Al Qom/ Q5I
Cell Phone: _( ¶ ik ) 2 2 Z-5?-65— Land Line: _( -- ) --
Email: 6, Lr,[t ^7I c ( Jc cj.rAArr.
• Primary Owner(s):
Name(s): Ki v,,. PV 0 -Teo kiGn
Mailing Address, C/S/Z: 35 ' 1); A✓c 0 (Ly AI )26-0 N
Cell Phone: (S4' ) 8'ieZ ~ 100 Land Line: ( )
Email: )) ,,-)t 9-7-654 p,a:!•con
El Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
• Engineer(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
Contact Person for Building & Code Compliance: (k\-c 'Li\c '
Cell Phone: ( $ ) ) 2 ? —'76 f Land Line: ( )
Email: � t l 6 .Sr c r�A 1...Lorn
Septic Application Revised February 2019
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)
1981-1991 130 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 110 ' - -
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature " Sand Loam Clay Other(explain:
Groundwater At what depth?
Bedrock/Impervious material At what depth? l‘
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 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 140 ft.; Each Trench 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
\6 \ , t , ';i S y S
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 d
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: 7
DATE:Clc� h� 2L//
� 1 ti
SIGNATURE: q� DATE: 7/22 i
cpntir Annliratinn Rnvicnd Cnhr,ury 7fl10