application fitSEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 12804 2
1 otQ,ccn:bon Permit#: 3C _ V__
P:518-761-8256 www.queensburY.net
Tax Map ID#: 301.8-2-63 Permit Fee: $ 45— ; Invoice#: 2'-52,
Project Location: 384 AVIATION ROAD Septic Variance? Yes No
Primary Owner(s) DEBORAH HITLIN
Mailing Address 384 AVIATION ROAD Q44E5SmBURY, NY 12$414_._.-- n�/ ir l
Phone & Email �J _E I
Installer/Builder IBS SEPTI� ! ,,,.. '1:
MailingAddress JUL . -�t.) 1
WARREN STREET, QUEENSBURY NY Ii
Phone & Email 518-361-2465
Engineer CENTER PROJECT SERVICES `_ _..
Mailing Address 73 SHERIDAN STREET,GLENS FALLS,NY
Phone & Email 518-796-2515 TCENTER36@YAHOO.COM
Contact Person for Building&Code Compliance: CHRIS BELL Phone: 518-361-2465
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No
-
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 110 2 110 220
PARCEL INFORMATION:
Topography ✓ Flat Rolling Steep Slope %Slope
Soil Nature _ ✓ Sand Loam Clay Other _
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Suppl4XX))<'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 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: ; Size:
Alternative System Bed or other type: 10x40 pipe-in-stone absorption bed
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 Ordinan . 4
PRINT NAME: v:doori„!'r i iI DATE: 7.----.1 32)0y
SIGNATURE:
Town of Queensbury Buildin: : Code Enforcement Revised March 2018