applicationSEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 12804:518-761-8256 www.queensbury.net Permit
SEP=p29/2520
Tax Map ID #:301.12-3-64 Permit Fee:$_7;invoice #:265
Project Location;12 ZENAS DRIVE Septic Variance?Yes No
[Primary Owner(s)[GERALD ALLEN
Mailing Address 12.ZENAS DRIVE,QUEENSBURY,NY
Phone &Email
Installer/Builder SANITARY SEWER SERVICES
Mailing Address LUZERNE ROAD,QUEENSBURY NY
Phone&Email 5187963760
Engineer TOM CENTER
Mailing Address 73 SHERIDAN STREET,GLENS FALLS,NY 12801
Phone &Email ‘TCENTER36@YAHOO.COM |
Contact Person for Building &Code Compliance:
GEORGEDRELLOS=Phone:5187963760
RESIDENCE INFORMATION:
Year Built #of bedrooms:X gallons per bedroom_|=total daily flow Garbage Grinder Yes|No
1980 or older Installed?(circle one)
Viseraser Spa or Hot Tub Yes|No
L Installed?(circle one)1992-Present 3 110 330
PARCEL INFORMATION:
Topography 7 Flat Rolling Steep Slope %Slope
Soil Nature Sand Loam.Clay Other
Groundwater At what depth?DEEPER THAN 6°
Bedrock/impervious material_|At what depth?NONE
Domestic Water Supply ¥Municipal __Well {if well,water supply from any septic system absorption is__ft.)
Percolation Test Rate:1'-5'__per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tanksize |1000 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:20X30 FT BED
Holding Tank System Total required capacity?tank size #of tanks,
.Alarm system &associated electrical work must be inspected by a Town approved electrical inspection
..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 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:GEORGE DREULOS:DATE:_5/20/2020
SIGNATURE:es ZA
Town of Queensbury Building &Code Enforcement Revised February 2017