applicationSEPTIC DISPOSAL PERMIT APPLICATION Office Use Only742BayRoad,Queensbury,NY 12804
P:518-761-8256
a Permit a:SEP -VIGO-2020
Permit Fee:$4);invoice #:2542TaxMap1D#
Project vocation:_|)&F ary [n,Septic Variance?__ves _W/_Wo|Primary Owner(s)|Diane4 ver :Mailing Address
Phone &Email
Installer/Builder
Mailing Address
[Phone&Email
Engineer
Mailing Address
Phone &Email
CTasy RAN Or oe SeasContactPersonforBuilding&Code Compliance:u |
al
Phone:Ike ays
[RESIDENCE INFORMATION:)
1
a)relayaltoaa aepTic|ae Wareen St.O NY eof |TSROR einai 7 We
4
Xgallons per _[/=total dailYearBuilt|Gallons|#of bedrooms ly flow -—L |per day bedroom Garbage Grinder Yes|No1980orolder|150 ,Installed?(circle one)|0 7 ~Spa or Hot Tub Yes1981-1991|130[2984 _|Installed?(circle one)41992-Present |110 gf Loy]B90 |—PARCEL INFORMATION:
Topography
_____fat Rolling Steep Slope %Slope|Soil Nature
-Sand
__loam Clay’Other ||Groundwater At wht depth?
Bedrock/Impervious material_|frat depth?|Domestic Water Supply Municipal ___Well {if well,water supply from any septic system absorption sft )Percolation Test Rate:
__
per minute per inch (test to be completed by licensed engineer/architect)|PROPOSED SYSTEM FOR NEW CONSTRUCTION:-
--|[Tank size |TSE Rai size 1,000 gallons,add 250 gallons for each garbage cylinder or spa/hot tubSystem,Absorption field with #2 stone|Total length)()_ft.;Each Trench BQ)ft _|[Seepage Pit with #3 stone _
How many:;Size:__-Alternative System Bed or other type:L Holding Tank System Total required capacity?__;tank size 3H of tanks |NOTES:1.Alarm system &associated electrical work must be inspected by a Town approved electrical inspectionagency;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
Declaration:Any permit or approval granted which is based upon or is granted in reliance upon any materialyebresentationorfailuretomakeamaterialfactorcircumstanceknownbyoronbehalfofanapplicant,shall be void,|have read the regulations and agree to abide by these and all requirements of the Town of Queensbury Sanitary SewageDisposalOrdinance
PRINT NAME:
SIGNATURE:_
Town of Queensbury Building &Code Entor
Bell ome 520.
__vate:S“J-LO
Revised March 2018