deep hole perc testDEEP HOLE/PERC TEST
Town of Queensbury REQUEST FOR TOWN ENGINEER REVIEW
Building and Code Enforcement SEP-Hlo7B -2015
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
Property Owner Swe Coss Phone #:
(GIB
Bbl-
CLO]
wailing Address (c/s/2:_Z4 Siiiee CAtcLe.,QUBENS Bub~r AY 12804-
Location of test:(ol p U v Ee Dei Ve Tax ID #:a\(o.11-(-2
*applicant’s Engineer:RUCINSHA HALL ARCHITECTURE:phones:(518)74!0208
Applicant's Agent:RUCINSKA HALL PreCHI TECTURE Phone #:_O1B )141 0248
Additional Notes:
1.Reason for request?O_New Septic system 9 Replacement Septic System
11 Failed Septic System J Subdivision C1 Site Plan Review
2.Are wetlands present?w yes No UNKNOWN
“Applicant is required to engage an engineer for design and testing of the system.The Tj in onsibility is
to witness system testing only./fh Ey VEHi!
PLOT PLAN:plot plan,to scale,must be submitted with application.[i {ocr 09
Tom 209
FEE SCHEDULE:L
1.$200 flat fee date paid:iola|201
check #:‘BLE
2.OR fee to be determined during to be determined:
ite plan/subdivision review process
PLEASE READ BEFORE SIGNING:
In carrying out the provisions of Article IV,the Local Board of Health or the enforcement office may engage the services of a
qualified professional consultant for expert review and recommendation arising from the carrying out of the provisions of
Aart.1V,including,but not limited to,the review of plans,specifications and reports,attendance at inspections,dye tests,deep
hole test pits,septic related deep hole and percolation tests,system installations and any other aspect of any matter
contained in this Art.IV,and any costs incurred in such review shall be paid to the Town by the owner of the property before
‘any approval can be granted under this Art.IV shall become effective within 30 days of presentment of an invoice for same,
whichever is sooner.Such costs shall not exceed $1500 without proper written notice to the party to be changed the same,
My signature below indicates I have thoroughly read and understand the instructions,agree to the submission
requirements and have completed the application.|also fully understand that additional engineering fees may
be necessary per Town of Queensbury Local Law 136-14 D.
SIGNATURE OF APPLICANT:DATE LOE
219
SIGNATURE OF AGENT:DAT!
Original (BC Fle)Canary Planning)Pink (Applicant)Gold (Town Clerk)
Deep Hole/Perc Test App Updated August 2017P