applicationpate:4-98-99
LOCATION OF PROPERTY FOR INSTALLATION:af
Owner's Mailing Address:|7 he u 146-401)
Installer's Name:Self Phone #:
Number of bedrooms (if residential):2,
Total daily flow (residential-compute @ 150 gal.per bedroom):A5o
Topography-Circle one Flat Rolling Steep Slope —%of Slope
sand am)Clay Other /Depth:Soil Nature-Circle One:
Ground Water-At What Depth?2 “Feet
Bedrock or Impervious Material-At What Depth?fe Feet
Percolation Test-Circle One:Not Required Required/Rate Af Min.Per Inch
Domestic Water Supply-Circle Onec Municipal)Well Other
If domestic water supply is a well -
Separation:Water supply from any septic absorption feeteenPROPOSEDSYSTEM:Septic Tank _}000__gal.(Minimum size:1,000 gal.)pump ap depten
Tile Field:Each Trench AZ feet//Total System Length /ff__feet
Seepage Pit(s):Number of /Size each:ft.x ft.
Size of Stone to be used:#/Depth or Thickness feet
Yebinbineinoii:
HOLDING TANK SYSTEM IF REQUIREDNo.of Tanks Size\of Each Gal.
Alarm system and associated electrical work to be inspected by a certified
agency.gency:FIST IIR
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:4 CALE pate:9-34-93