septic applicationSEPTIC DISPOSAL PERMIT APPLICATION Office Use Only.
—742 Bay Road,Queensbury,NY 12804
;Tomfciscisry 518-761-8256 ww.queensbury.net Permit #:
SEP
-O\4}-
2020
Tax Map ID #:302.14-1-74 Permit Fee:$_+27;invoice #:Los
uv
Project Location:34 PERSHING ROAD Septic Variance?Yes __No
Primary Owner(s)JAMES &PATRICIA ROUND |Mailing Address 34 PERSHING ROAD QUEENSBURY,NY 12804
Phone &Email
Installer/Builder SANITARY SEWER SERVICES
Mailing Address LUZERNE RD,QUEENSBURY NY aPhone&Email 518-796-3760 D SVEIVEN
Engineer HUTCHINS ENGINEERING DT uy oe ong
|THT)
Mailing Address 169 HAVILAND ROAD,QUEENSBURY NY 12804 “ew Te
Phone &Email 518-796-2515 TCENTER36@YAHOO.COMOWN OF QUEENSBURY
HLEING&CODE
Contact Person for Building &Code Compliance:GEORGE DRELLOS Phone:__518-796-3760
RESIDENCE INFORMATION:
Year Built|Gallons|#of bedrooms|X gallons per_|=total daily flow
per day bedroom Garbage Grinder Yes
7980 orolder|150 Installed?(circle one)
1981-1991 730 _Spa or Hot Tub Yes |(o)
installed?(circle one)1992-Present|110 3 110 330
PARCEL INFORMATION:_
Topography y_Flat Rolling Steep Slope %Slope
Soil Nature ¥__Sand Loam Clay Other
Groundwater Atwhat depth?58"
Bedrock/impervious material|At what depth?GREATER THAN 65"
Domestic Water Supply __Municipal_¥Well (if well,water supply from any septic system absorption is__ft.)
Percolation Test Rate:__1 per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size |1,000 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:3 Size:
Alternative System Bed or other type:10x40 pipe-in-stone absorption bed
Holding Tank System Total required capacity?;tank size 3 #of tanks
NOTES:1.Alarm system &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.
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:Tam Ceni4 chien £7 pate:_G,oe)
SIGNATURE:Vp.KZ —
“Town of Queensbury Building &Code Enforcement Revised March 2018