application Office Use Only
SEPTIC DISPOSAL PERMIT APPLICATION Permit#: Q 15 - ZOZ(0
Permit Fee: $ }-S ; Invoice #: )541
r of(Zucens umSeptic Variance? Yes L../ No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
303.16-1-14
Tax Map ID #: II1F
8 Courtney Lane �� If
Project Location: ).AY 1 ,
• Applicant:
Name(S): John & Courtney Wendell
Mailing Address, C/S/Z: 8 Courtney Lane Queensbury, NY 12804
Cell Phone: _( 518 ) 260-4297 Land Line: ( ) _
Email: cwendell@hfcsd.org
• Primary Owner(s):
Name(s): same as applicants
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: (
Email:
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): IBS Septic
Contractor Trade: Septic Installation
Mailing Address, C/S/Z: 2 Lower Warren Street Queensbury, NY 12804
Cell Phone: ( 518 ) 361-2465 Land Line: _(
Email: ibell@ibsseptic.corn
• Engineer(s):
Name(S): Hutchins Engineering PLLC
Mailing Address, C/S/Z: 169 Haviland Road Queensbury, NY 12804
Cell Phone: _( ) Land Line: ( 518 ) 745-0307
Email: thutchins@hutchinsengineering.corn
Contact Person for Building & Code Compliance: Chris at IBS (361-2465) OR Torn Hutchins (745-0307)
Cell Phone: _( ) Land Line: (
Email:
19 ;plication 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) X
1981-1991 130 Spa or Hot Tub Yes No
Installed? (circle one) X
1992-Present 110 3 110 330
PARCEL INFORMATION:
Topography / Flat Rolling Steep Slope %Slope
Soil Nature I Sand _Loam _Clay _Other (explain: )
Groundwater At what depth? 26"
Bedrock/Impervious material At what depth? greater than 47"
Domestic Water Supply ✓ Municipal _Well (if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: 3:50 per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 1,000 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 ft.
Seepage Pit with#3 stone How many: _; Size:
Alternative System Bed or other type: 15'x 30'Pipe-in-stone bed
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 Disposal Ordinance.
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Septic Application Revised February 2