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applicationOffice Use OnlySEP -9137-2029 Permit Fee:$_12.5-;Invoice #: Septic Variance?_&“_Yes No SEPTIC DISPOSAL PERMIT APPLICATION Town of Qycensbury 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net ‘Tax Map ID #:289.13-1-11 Project Location:13 Chestnut Road i} IE]APR 27 2009 ©Applicant:i Name(s):William Smith Mailing Address,C/S/Z:13 Chestnut Road Lake George,NY 12845 Cell Phone:(518 955-1256 )Land Line:() Email:msmith1519@aol.com *Primary Owner(s): Name(s):same Mailing Address,C/S/Z:Click or tap here to enter text Cell Phone:(_)Land Line:() Email:Click or tap here to enter text. O Check if all work will be performed by homeowner only «Contractor:Workers’Comp documentation must be submitted with this application Contact Name(s):TBD Contractor Trade:Click or tap here to enter text Mailing Address,C/S/Z:Click or tap here to enter text Cell Phone:(_)Land Line:() Email:Click or tap here to enter text ©Engineer(s): Name(s):Dennis MacElroy Mailing Address,C/S/Z:900 Rt.146 Clifton Park,NY 12065 Cell Phone:(518 376-4485)Land Line:() Email:dmacelroy@edpllp.com Contact Person for Building &Code Compliance:William Smith Cell Phone:(518 955-1256 )Land Line:() Email:msmith1519@aol.com Septic Application Revised February 2019 RESIDENCE INFORMATION: Year Built [Gallons|#of bedrooms:|X gallons per|=total daily flow per day bedroom 1980 orolder|150|Clickor tap Click or tap__|Click or tap here to here toenter|here to enter |enter text._text.text.Garbage Grinder Yes|No 1981-1991 130|Clickortaphere|Click ortap|Clickor tap here to Installed?(check one)||& |toentertext.|hereto enter |enter text {text.‘Spa or Hot Tub Yes|No|1992-Present)110|3 310 [330 Installed?(check one)|1|62 PARCEL INFORMATION:a — Topography B Flat Rolling 0 Steep Slope %Slope Soil Nature Bisand Cloam Clay _C Other (explain:) Groundwater ‘At what depth?>6" Bedrock/Impervious material|At what depth?>6’ ‘Domestic Water Supply Gi Municipal &Well (if well,water supply from any septic system absor ft) Percolation Test Rate:7 minute per inch (test to be completed by licensed engineer/architect)Design rate used PROPOSED SYSTEM FOR NEW CONSTRUCTION —Tank size 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:Clarus 450 w/UV to Infiltrator H-20 Chambers in stone bed Holding Tank System Total required capacity?tank size=Hof 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:Dennis Macélroy sevarinlaDesensMaclirewDATE:April 24,2020 Septic Application Revised February 2019