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application (� a Office Use Only fit SEPTIC DISPOSA C. - Permit#: SE-P - 95t • 2CAci 7 2019 Permit Fee:$ 1-5 ; Invoice#: 1ej`i Town of(Zucencbury AUG Z Septic Variance? Yes No 742 Bay Road,Queensbury,NY 12804 _ P:518-761-8256 www.eueensbury.net TOWN OF QUEENSBURY BUILDING&CODES Tax Map ID#: , 30$ i /7 I ---"ZProject Location: i ' '- k',,L L071 Zo-Z/Ujeve �---. d ,i„,, nod • Applicant: Name(s): m��� �y 4 �4 �4c,.,S Mailing Address, C/S/Z: 3o C r, `�' - �, llo- ./'�c?,48 Cell Phone: _(�� Z- o`7 - Land 4ine: _(4/ ) iQ(bl5) Email: max C S rErLi as74^i-ee cG o,-=-. • Primary Owner(s): Name(s): / / ' Y..S Mailing Address, C/S/Z: ,� _�' , r61 u;�y , /2 c �Y— Cell Phone: _(7,) 7f 777� Land Line: _( ) Email: 0 Check if all work will be performed by homeowner only • Contractor: Worker ' Com docu nta ion ust be submitted with this application Contact Name(s): L �7�o.rG 5-7 p g d►-sC Contractor Trade: S/ 7' t _ �.-... S 3c��Mailing Address, C/S/Z: fib- cO _ .76. 6 Ems. /` ,�& ‘ Cell Phone: _(5/ 3 -) Z � ‘7©7 Land Line: _( JS// ) 5-8, -/p9,6) Email: • Engineer(s): iph , Name(s): r 7,, 5 `,.-,i? Mailing Address C/S/Z: zZ5 Xii f fjrf 1 ' ' S VA,74fr,w/ (2...el1‘,6 Cell Phone: �'_ /n ) �/]-- OG�F Land Line: _( ) Email: Contact Person for Building & Code Compliance: Z'4 .z ( .-fe/G 16 Cell Phone: (5, ) Z 3ZT 170 La ine: _ j , ) S��T�'� Email: C 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 3X Z. / 1 U Q PARCEL INFORMATION: C� Topography /—Flat Rolling Steep Slope %Slope Soil Nature3nd _Loam _Clay Other(explain: Groundwater At what depth? Bedrock/Impervious material A hat 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 SYST M FOR NEW CONSTRUCTION: Tank size Otvgallons(min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub System Absorption field With tt2s*.ope Total length Z/0 ft.; Each Trench S S 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 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 Dis sal Ordinance. PRINT NAME: "0 G DATE: Z i• SIGNATURE: DATE: 2 7" Septic Application Revised February 2019