applicationSEPTIC DISPOSAL PERMIT APPLICATION
742 Bay Road,Queensbury,NY 12804.
P:518-761-8256
Tax Map ID #:
Project Location:4 Lt Berry Pest hn 0
[Primary Owner(s)|f\v{]Sheq__LI oyMailingAddress.
Office Use Oni
Permit:SER-9 1B%2020
Permit Fee:$FD
_;invoice #:
wySepticVariance?__Yes
[Prove Bema TBE NGLLS CVGinstaller/Builder |Ips 5
Mailing Address +bowPhone&Email[Engineer R!|Mailing Address
Phone &Email
Contact Person for Building &Code Compliance:
_RESIDENCEINFORMATION:
7YearBuilt|Gallons|#of bedrooms |Xgalions per |=total daily flow
S _—[per day bedroom
{[Garbage G inder Yes|No1980orolder|150
AY 'gstalted (circle one)|[eo C
~4 Spa or Hot Tub Yes|No1981-1991 130
t
|L-
“1°(Installed?(circle one)|1992-Present|110 uy ||yf cf 4O NORGE _|PARCEL INFORMATION:7 -Topography
-lat Rolling Steep Slope %Slope -Soil Nature Sand ___Loam Clay Other |Groundwater At what depth?
--|Bedrock/Impervious material |At what depth?
_+|Domestic Water Supply —Municipal _-Awell (if well,water supply from any septic system absorption is|Qq'ft.)Percolation Test Rate:er minute per inch (test to be completed by licensed engineer/architect)|PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank sizF¥"(250 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:
__|[|VW [Alternative System Bed or other type:_)QO’X Yh*
-|__|Holding Tank System [Total required capacity?;tank size iH of tanks |NOTES:1.Alarm system &associated electrical work must be insagency;2.We will no longer allow systems to be covered until suTheinstalledsystemmustmatchtheseptic
Declaratic
have read the regulations and agree to abid:
Disposal Ordinance
print name:_(trots
SIGNATURE:CeTownofQueensburyBuilding&Code Enforce
Any permit or approval granted which is based uyrepresentationorfailuretomakeamaterialfactor
layout on file—no exceptions,
pected by a Town approved electrical inspection
ich time as an as-built plan is received and approved.
ipon or is granted in reliance upon any material
circumstance known by or on behalf of an applicant,shall be void.|
fe by these and all requirements of the Town of Queensbury Sanitary Sewage
Lobb
Y
_owe 57190
DATE:5-)-2 9
Revised March 2018