applicationSEPTIC DISPOSAL PERMIT APPLICATION Office Use Only742BayRoad,Queensbury,NY 12804
Permit #:SE P-0\2%-2020
Jom of acer P:518-761-8256 uw.queensb:
TaxMapip#:__20,[o-\-24.2-Permit Fee:$4;invoice #:2494
Project Location:&Alta Aves Septic Variance?Yes No[Primary Owner(s)|Dia Ooms K |Mailing Address Ta -Phone &Email ab io 4Installer/Builder S ef:CcMailingAddressyeowe Warren ED raePhone&Email518-7 9K-e194 [
Engineer
Mailing Address
[Phone &Email
Contact Person for Building &Code Compliance:i[RESIDENCE INFORMATION:
Year Built |Gallons|#of bedrooms |x gallons per]=total daily flowperdaybedroom Garbage Grinder1980orolder|150 Installed?(circle one)|1981-1991 730 Spa or Hot Tub Yes Nyinstalled?(circle one)1992-Present|110 3 |[0 23 40PARCELINFORMATION:
Topography at Rolling Steep Slope ___%SlopeSoilNature__Y Sand Loam Clay’Other|Groundwater At what depth?Bedrock/Impervious material|At yhat depth?_|Domestic Water Supply sZMunicipal Well(ifwell,water Supply from any septic system absorption is__ft.)Percolation Test,Rate:Der minute per inch (test to be completed by licensed engineer/archtect)PROPOSED SYSTEM FOR NEW.CONSTRUCTION:
-Tank size°¥igish 009 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 GO)ft.Seepage Pit with #3 stone How many:;Size:Alternative System Bed or other type:Holding Tank System Total required capacity?j tank size 3 #of tanks |NOTES:1.Alarm system &associated electrical work must be inspected by a Town approved electrical inspectionSeency;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 materialpebresentationorfailuretomakeamaterialfactorcircumstanceknownbyoronbehalfofanapplicant,shall be void.1havereadtheregulationsandagreetoabidebytheseandallrequirementsoftheTownofQueensburySanitarySewageDisposalOrdinance,
enw wane Chyip Pell4y—ore"-20
SIGNATURE:L0L)Y;
pare:2-20TownofQuenBug&Cade hkl hs eva March 208