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application
Office Use Only. Permit #:_9EP-0174-Zozo Invoice#:252.7 Septic Variance?Yes No. SEPTIC DISPOSAL PERMIT APPLICATION Town of Queen 1742 Bay Road,Queensbury,NY 12804:518-761-8256 www.queensbury.net Tax Map ID #:289.15-1-31 Baan | Project Location:789 Bay Rd. ©Applicant: Name(s):William Jr.and Linda Thompson Mailing Address,C/S/Z:789 Bay Rd.Queensbury,NY 12804 Cell Phone:(518-321-3330)Land Line:(N/A) Email:Primary Owner(s)::billandlinda1970@gmail.com Name(s):William Jr.and Linda Thomson Mailing Address,C/S/Z:789 Bay Rd.Queensbury,NY 12804 Cell Phone:(518-321-3330 )Land Line:(N/A) Email:billandlindal970@gmail.com O Check if all work will be performed by homeowner only «Contractor:Workers’Comp documentation must be submitted with this application Contact Name(s):Rick McGuire Contractor Trade:McGuire Excavating Mailing Address,C/S/Z:65 Buttermilk Falls Rd.Ft.Ann,NY 12827, Cell Phone:(518-796-1730 )Land Line:(518-798-5662 ) Email:meguireexcavating@yahoo.com ©Engineer(s): Name(s):George Ysenchak Mailing Address,C/S/Z:8 Fielding St.Glens Falls,NY 12801 Cell Phone:(_)Land Line:(518-615-0201 ) Email:Click or tap here to enter text Contact Person for Building &Code Compliance:Click or tap here to enter text. Cell Phone:(_)Land Line:() Email:Click or taphereto enter text ‘Septic Application Revised February 2019 > RESIDENCE INFORMATION: Year Built |Gallons|#of bedrooms:|X gallons per|=total daily flow perday ||bedroom 1980 orolder)150|3 |150 a — 1981-1991 130|Cickortaphere|Clickortap|Click or tap here to to enter text.hereto enter|enter text.Garbage Grinder Yes|Noee{a Installed?(check one)||68 1992-Present Click or tap Click or tap_|Click or tap here to here toenter|here toenter|enter text.‘Spa or Hot Tub Yes|No text.text Installed?(check one)||& [PARCEL INFORMATION: Topography B FlatRolling 0 Steep Slope %Slope Soil Nature Bi Sand Dtoam Oclay 0)Other (expl ) Groundwater ‘At what depth?Greater than 4 ft.below grade Bedrock/impervious material|At what depth?Greater than 6 ft.below grade Domestic Water Supply &Municipal_C well (if well,water supply from any septic system absorption is___ft.) Percolation Test Rate:__2.48__per minute per inch (test to be completed by licensed engineer/architect) PROPOSED SYSTEM FOR NEW CONSTRUCTION: Tank size 1000__gallons (min.size 1,000 gallons,add 250 gallons for each garbage cylinder or spa/hot tub System ‘Absorption field with #2 stone|Totallength__128__ft.;Each Trench__32__ft. ‘Seepage Pit with #3 stone How many:___2__;Size:_4 ft.by 8 ft.stacked Alternative System_ Bed or other type: 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.|have read the regulations and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance. PRINT NAME:Wlliten C4 Ofgsor- SIGNATURE:Click or tap here to enter text.DATE:Click or tap here to enter text.Willin CTeamuo~ — $/2.39/20 Pe Septic Application Revised February 2019,