application721 -1-16,4&5
TOWN OF QUEENSBURY
APPLICATION FOR SEPTIC DISPOSAL PERMIT Permit #73-099
Fee Paid Jig
Date:_Y—/9-4?Reviewed BY\
OFQUEENSB.RECEIVED
LOCATION OF PROPERTY FOR INSTALLATION:291B John SP hy
Owner's Name:__Connia,Leury ut
Owner's Mailing Address:l qe nA.DEPT.
Installer's Name:TUzp [ell Phone #:7988194
Number of bedrooms (if residential):a
Total daily flow (residential-compute @ 150 gal.per bedroom):_,7AO
Topography-Circle One:Ela?Rolling Steep Slope —_&of Slope
Soil Nature-Circle One:loam Clay Other /Depth:
Ground Water-At What Depth?4o Feet
Bedrock or Impervious Material-At What Depth?wn Feet
Percolation Test-Circle One:Wat Required)Required/Rate Min.Per Inch
Domestic Water Supply-Circle One:Well OtherIfdomesticwatersupplyisaweTT=
Separation:Water supply from any septic absorption feet
ram EeiStNGPROPOSEDSYSTEM:Septic Tank ppb gal.(Minimum size:1,000 gal.)
Tile Field:Each Trench Yd feet//Total System Length Zag feet
Seepage Pit(s):Number of 220./Size each:24 ft.x Da ft.
Size of Stone to be used:#2 __/Depth or Thickness f__feet
InneHOLDINGTANKSYSTEMIF REQUIRED
No.of Tanks Size\of Each Gal.
Alarm system “and associated electrical work to be ‘nepecteda certifiedgenesIIIIII
I have read the regulation on the reverse side of this sheet and agree to abide
by these and all requirements of the Town of Queensbury Sanitary Sewage Disposal
Ordinance.
SIGNATURE OF RESPONSIBLE PERSON:Misa GL DATE:GAF-%Z