applicationSEPTIC DISPOSAL PERMIT APPLICATION Qffice Use Onh
742 Bay Road,Queensbury,NY L2g04)meee itt anemn ANE GE 0 Vl 2 2026
Tax Map ID #;301.19-1.59 In Prtirit Fee:$7S:V;invoice:DOTYmyProjectLocation;25 FERRISS DRIVE Sbplté Vpriance?Yes No
Primary Owner(s)[JEFFREY &SANDRAWILD BUILDING 2 CODES
Mailing Address 25 FERRISS DRIVE,QUEENSBURY,NY
Phone &Email
Installer/Builder SANITARY SEWER SERVICES
Mailing Address LUZERNE ROAD,QUEENSBURY NY
Phone &Email 5187963760
Engineer TOM CENTER
Mailing Address 73 SHERIDAN STREET,GLENS FALLS,NY 12801
Phone &Email ‘TCENTER36@YAHOO.COM
Contact Person for Building &Code Compliance:GEORGE DRELLOS Phone:5187963760
[RESIDENCE INFORMATION:
[Year Built itofbedrooms|X gallons per bedroom_|=total daily flow||Garbage Grinder Yes |(No)
1980 or older Installed?(circle one)
7981-1991 _‘Spa or Hot Tub Yes |@o)
Installed?(circle one)1992-Present 3 110 330
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature Sand Loam,Clay Other
Groundwater At what depth?DEEPER THAN 6"
Bedrock/impervious material|At what depth?NONE
[Domestic Water Supply _¥Municipal __Well (if well,water supply from any septic system absorption is___ft)
Percolation Test Rate:1'-5'__per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size EXISTING 1000 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:
it Alternative System Bed or other type:20X25 FT BEDbE
|Holding Tank System Total required capacity?tank size 5 #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.
Decl 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:_GEORGEASRELLOS DATE:
SIGNATURE:<4 6/19/2020
‘Town of Queensbury Building &Code Enforcement Revised February 2017