applicationOffice Use Only
Permit #:_SEP +021 -29 20SEPTICDISPOSALPERMITAPPLICATION45Invoice#:2563
Septic Variance?Yes NoTowa
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
Tax Map ID #:-|-s
Project Location:_-S2,3 Ri Da
*Applicant:
Name(s):WMaraing Sky Exceuertin $Gopi
Mailing Address,C/S/Z:_S@]_Rlwehevel 2d
Cell Phone:_(3i@__)€$7—90g land Line:(sx _)247~2290
Email:@wurin Shetephe.te
+Primary Owner(s):
Name(s):Kimbecly {Nw Heyes
Mailing Address,C/S/Z:__523 Rude Rd
Cell Phone:_()Landline:(svg)763-2955
Email
CO check if all work will be performed by homeowner only
°Contractor:Nine Seepdocumentation must be submitted with this application
Contact Name(
Contractor Trade:.ete
Mailing Address,gee
Cell Phone:_()Land Line:_()
Email:
°Engineer(s):
Name(s):__Kexs Ih Ping Lt
Mailing Address,C/S/Z:t Rtackwn Ave
Cell Phone:_()landline:(9%)S22-~/?324
Email:,
Contact Person for Building &Code Compliance:be
Cell Phone:_()Land Lin
Email:
H Syston is Ging
‘Septic Application Revised February 2019
RESIDENCE INFORMATION:
Year Built [Gallons|#of bedrooms:|X gallons per |=total daily flow
per day bedroom Garbage Grinder Yes fe
1980 or older}150 Installed?(circle one)
acive 1430 ‘Spa or Hot Tub Yes [NoInstalled?(circle one)
1992-Present|110 bs an 330re
PARCEL INFORMATION:
Topography TZFlat Rolling Steep Slope %Slope
Soil Nature sand loam Clay __Other (explain:)
Groundwater Atwhatdepth?+72 ‘*aBedrock/Impervious material|At what depth?+72“
Domestic Water Supply ‘Municipal __Well if well,water supply from any septic system absorption is___ft.)
Percolation Test Rate:3:75 per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size oO 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 ELEKW|Bed or other type:
Holding Tank System Total required capacity?j tank size 3 #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:Ly bY.[ey vate:S//Y/22
SIGNATURE:pate:_S//4/20
Septic Application Revised February 2019