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. .: SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury, NY 12804
P: 518-761-8256 Permit#: c�� �
Tax Map ID#: Z .4 — `— C\ Permit Fee: $ n ; Invoice#: 262-1
Project Location: I I Pt r 5 b ; 1 K 01 I Septic Variance? Yes No
Primary Owner(s) ae dJo 5 — — —
�n5 — p---Mailing Address 1 ��5c �Phone & Email �1-NZ1 -g� LCE1M1
Installer/Builder Z S C
Mailing Address el__
LOW er ( ^Vv ncr Cj , I 1 ,� 2 3 2020
Phone & Email j 1r_ C _% l t T �J'
TOWN OF QUEENSBURY
Engineer E �. t1 LAC ( / r k•i4-e BUILDING& CODES
Mailing Address • , MI
Phone & Email 51. ---p-H_Qi 6
Contact Person for Building&Code Compliance: C krj S Phone: 5 I 3 ;1-1 1i 5
RESIDENCE INFORMATION:
Year Built Gallons # of bedrooms X gallons per = total daily flow
per day bedroom Garbage Grinder Ye N
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes N
1992-Present 110 -3 ( n 3 30
Installed? (circle one)
PARCEL INFORMATION: 4 J
Topography Fat Rolling Steep Slope %Slope
Soil Nature Sand Loam Clay Other
Groundwater At w at depth?
Bedrock/Impervious material At hat depth?
Domestic Water Supply Municipal _Well (if well, water supply from any septic system absorption is ft.)
Percolation Test —_ Rate: per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size kl..SO 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:�
Alternative System Bed or other type: I B 25
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 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. I
have read the regulations and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage
Disposal Ordinanc( kr
PRINTNAME: ()-t p� k lr gE U DATE: -7-)_3-2\J
SIGNATURE: (0(ThDATE: ���� �l/
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Town of Queensbury Building&Code Enforce nt Revised March 2018