applicationSEPTIC DISPOSAL PERMIT APPLICATION
742 Bay Road,Queensbury,NY 12804
Office Use Only
Ierdinmen Nase erates oat Permit SEP"011-2020
Tax Map ID #:304-14 -1-1 Permit Fee:$t&>_;invoice #:
Project Location:£P t AM Waar Ave Septic Variance?__Yes No
PrimaryOwner(s)|Lin da AY anMailingAddressHLfkAvePhone&Email SikesoF -
Installer/Builder fs Sept it |Mailing Address LS Ly rer \Warce.StPhone&Email 5 1¥-19x-¥1 94
Engineer
Mailing Address
Phone &Email ;|u
.TOWrfmeOOSe|RESIDENCE INFORMATION:
Year Built Gallons|#of bedrooms |X gallons per=total daily flowIperdaybedroom Garbage Grinder Yes1980orolder}150 ~Installed?(circle one)|_1981-1991 130 |re or (cit ,
Yes=—||installed?(circle one1992-Present|110 XJ Ld £339|PARCEL INFORMATION:
Topography ‘F)ét Rolling Steep Slope %SlopeSoilNatureyJsandLoamClayOther _|“Groundwater ‘At what depth?
--|Bedrock/Impervious material|At/vhat depth?-Domestic Water Supply 2 Municipal Well (if well,water supply from any septic system absorption iPercolationTestRate:Per minute per inch (test to be completed by licensed engineer/architect)|PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size |\{YO0 gallons (min.size 1,000 gallons,add 250 gallons for each garbage cylinder or spa/hot tubSystem
___|
Absorption field with #2 stone |Total length QO _ft,Each Trench ft.
LC Seepage Pit with #3 stone How many:Size:Z _Alternative System Bed or other type:_|Holding Tank System [Total required capacity?j tank size 5 #of tanks
NOTES:1.Alarm system &associated electrical work must be inspected by a Town approved electrical inspectionagency;2.We will no longer allow systems to be covered until such time as an as-built plan is received and approved.The installed system must match the septic layout on file—no exceptions.
Declaration:Any permit or approval granted which is based upon or is granted in reliance upon any materialrepresentationorfailuretomakeamaterialfactorcircumstanceknownbyoronbehalfofanapplicant,shall be void.|have read the regulations and agree to abide by these and all requirements of the Town of Queensbury Sanitary SewageDisposalOrdinance.
__DATE:G4 =20PRINTNAME:C hr istohpe—by {1LON DATE:$-)-10SIGNATURE:
Revised March 2018
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