applicationSEPTIC DISPOSAL PERMIT oh
Dare Y-9-ol0 Received
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1-52 Pomne Pop eAwODS
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Aceucant Sewilarg Sewer Service Puone/Euan 51h [#3 766
ADDRESS Bde 227 Glens falls _po-pote?
JNSTALLER/BUILDER:Same PHONE/E-MAIL.
ADDRESS:
Sunn MacybothHageS$e Age £Puone/emanSIP-776-O570
Address pecgar pe.Kyeenspu Kye lefeg
¢Feorge Dre los Hone Sil 7M See
BESIRENCEINEORMATION nyo...W/Ater Save Fixtures
‘Year Built #0f bedrooms:X Gallons per bedroom ‘=Total Dally Flow
1980 or older 3 He 530
1981-1981
7902-ProsentPancetiuronwarioni
‘Topography —_2<Flatrolling ___Steep slope __%slope if —<———7
‘Soil Nature send ——loam ——Gay |L omAPR OG p09 |)
Groundwater ‘Atwhat depiny 277 __J]
‘Bedrock /impervious Material “At what depth?@_A~/1 al
Domestic Water Supply —Vitunicinat ___well (f wel,water supply rom any septic
system absorption is __ft)
Percolation Test Tate:7-5 per minute per inch (test to be completed by licensed engineering /architect)
PaoposepSyeTan
FORNewCONSTRUCTION
Tank Size Fr/shag V2Z2__gallons (minimum size 1,000 gallons,add 250 gellons to size for each garbage grinder or spa or hot tub)
‘System Type ‘Absorption field with #2 stone Total length _ZS@ ft;Each trench 52 x_3
‘Seepage Pit with #8 stone How many:
Alternative System Bed or other type?
Holding Tank System:Total required capacity?Tank size.‘#oftanks ___
Notas:7)Alarm system &associated electrical work must be inspected by a Town approved electrical inspection agency;2)We will no ionger
‘allow systems to be covered unl such time as en As-Bult plan is recelved &approved.The installed system must match the septic system
fayout on fle ~no exceptions.
DechanaTion:Any permit or approval granted which is based upon or is granted in reliance upon any material representation or
{allure to make a material fact or circumstance know by or on behalf of an applicant,shall be void.I have read the regulations
and agree to abide and ail requit of the Town of Queensbury Sanitary S o Disposal:ance.
Print Name:(eeerge.Dee Da gee ee
a7,Za Date:Y-7-22Signature:
Town of Queensbury Building &Codes ‘Septic Disposal Permit July 2014