applicationX
‘2 OnTHTnemHL,3p -0324-Coto
“Perit Fee §7S.W;invoice 1:2b EO
SEPTIC DISPOSAL PERMIT
742 Bay Road,Queensbury,NY 1281
P:518-761-8256.www.cueensbu:
TaxMapio#:29%.Ib—-|-S./
Project Location:+34 Nortl,Ww
Primary Owner(s)Colles ave|Mailing Address|Phone &Em:
oySYSpeanas|the tee OhMailingAddresscalf.“[Phone &Email |ry “KIGYsecsDE—|Engineer
Mailing Address
Phone &Email
Contact Person for Building &Code Compliance:hh Cy Phone:
RESIDENCE INFORMATION:
Tin of Caceres
Septic Variance?Yes no |
Year Built|Gallons |#of bedrooms |X gallons per jotal daily flow
-per day bedroom
1980 or older|150
~~
‘Spa or Hot Tub1981-1991 130
>
3 |—||Installed?(circle one)21992-Present
|110 3 ly [330|PARCEL INFORMATION:
7Topography___vo flat Rolling Steep Slope %SlopeSoilNatureLVsand____loam Clay Other|Groundwater At wat depth?
Bedrock/Impervious material|At What depth?
_|Domestic Water Supply Municipal __Well (if well,water supply from any septic system absorption is___ft)Percolation Test ___[
Rat er minute per inch (test to be completed by licensed engineer/architect)PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size___[{0B0 gallons (min.size 1,000 gallons,add 250 gallons for each garbage cylinder or spa/hot tubSystem|Absorption field with #2 stone_|Total length 2.00 ft;Each Trench ft.
L—Seepage Pit with #3 stone How many:;Size:_Alternative System _Bed or other type:
-Holding Tank System Total required capacity?
___tank size ;#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.
Declarat ‘ny Permit or approval granted which is based upon or is granted in reliance upon any materialrepresentationorfailuretomakeamaterialfactorcircumstanceknownbyoronbehalfofanapplicant,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:_(bes st aphe,DATE:6-229Re\\
sounse_LLA,LPUI bu one 6-22)9oTownofQueensburyBuilding&Code Enforcement Revised March 2018