application Office Use Only
SEPTIC DISPOSAL PERMIT APPLICATION Permit#: `b5�' 41
2-0
Permit Fee: $ �5— ; Invoice#: le, to kP
r� r,FcL h n Septic Variance? Yes ✓ No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensburv.net
Tax Map ID#:
Project Location: I Q G. ,S�)� ILEFj,)Slou .
• Applicant:
Name(s): LEAS I 1 * KIJIA 'nacu r
Mailing Address, C/S/Z: 30 CCLUJ I }. 14-1 W.laen MILS 4.IY I a-'S 3
Cell Phone: _( 51X ) .2..bo -- 6S'7( Land Line: _( Slk ) £'#x - 98 /f
Email:
• Primary Owner(s):
Name(s): SAW.: A A Q 0 Vt
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): mA-r- BF kE(2,
Contractor Trade: EAC RV KIT 1 t.3 6-
Mailing Address, C/S/Z: I 72 SL,E PAID 9,4 . rpm AN C Ny I xa.2-7
Cell Phone: _( 51g ) 14y - 4 5 Se Land Line: ( )
Email:
• Engineer(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( ) r
r
Email:
AUG 0 5 2019
TOWN OF QUEENSBURY
BUILDING& CODES
Contact Person for Building & Code Compliance:
Cell Phone: ( ) Land Line: ( )
Email:
Sentic Anolication Revicerl February 2mq
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No
1980 or older 150 L c(.9 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 110
PARCEL INFORMATION:
Topography XFIat Rolling Steep Slope %Slope
Soil Nature ) and _Loam _Clay Other(explain:
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply XMunicipal _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 //kti9 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 ft.; Each Trench ft.
Seepage Pit with#3 stone How many: S. ; Size: 4-,p
Alternative System Bed or other type:
Holding Tank System Total required capacity? ; 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: LeS M (ICU A DATE: o/Y/
SIGNATURE: DATE: ()/ -
Septic Application Revised February 2019