plot plan drawing and septic app. TOWN OF OUFFNSBURY
BUILDING & ZONING DEPARTMENT
SER'AGF DISPOSAL PERMIT APPLICATION
1. Owner ' s Name
Address kv t ve ocl ee- fS
Telephone No. j`/s - S j Y
2. Property location_ fo x 17 c, //U7 C% �ec n C{9u e ens 6 u ✓y
3 . Name of person or firm responsible for installing system
�/" M C cc u/J�e //h H Telephone No. /
Address ( m r r1 �/1 �nf fps S �t��S u/
4. Number of bedrooms (residential buildings only)
5. Daily flow ei/gyp = �5p gallons/day
6. Septic tank capacity l .a U C� gallons
7. Topography: flat, rolling, steep
8 of slope LPS_S
8. Nature of soil and depth Sc� ✓> G( r
9. If ground water, bedrock or impervious material is apparent at what
depth does it begin? AIli, ft.
10. Percolation test: A is required
B —is not required
C If required what is the rate minutes/inch
11. Water supply: municipa , well, other
12. Type of system proposed: drywell, tile field, other �e pcza e- -f
—r
Any contractor, corporation, individual, etc. engaged in the construction
of a sanitary sewage disposal system who covers the same before inspection,
does not have an approved permit, or varies from the approved application
will be subject to a penalty of $250 as provide f in Sect' n 6 . 010 of the
Queensbury San ' tar Sewage Ordinance.
Date t
gn" ture of applicant
On separate sheet of paper submit a dZm of the proposed septic system
with all dimensions, including distance from any structure, distance from
property line and domestic water supply, etc. Include all dimensions of
the system itself . -yam
o% f x �
Form 3-8 �/���L,�
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