application Aik
Y Office Use Only
0 Permit#: - 01-1V-2-
j SEPTIC DISPOSAL PERMIT APPLICATION Permit Fee.$. `7 00; Invoice#: ot7 j('
_--____-, _ 2 (ram EE n "/n S tic Variance? • Yes No
Town of CLiccnsbury L� l4p tl V
742 Bay Road,Queensbury,NY 12804 i
P:518-761-8256 www.queensbury.net
JUL 20 2020 1
Tax Map ID#: ZS3 +r5— -To F QUEENSBURY
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Project Location: 3 144 01(s /z1), A,cii-ti
• Applicant: a
Name(s): £ Ni-{i1 4 Mtn I,) i a g rid:
Mailing Address, C/S/Z: 3 ! t1 d1 I-S i L. f oi-4-ii &f t- 1 I'j(JV 0 / 08vS,
Cell Phone: . 1:) 1 g -�, ,5� S Land Line: ! 1� rite Grp�I0
Email: Q`IN1 jr&F.Wt ' ..ti e do ik vv'i daII Iti itiCl t-444 5-'5 f ,01,,,ttv1
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• Primary Owner(s): // r
Name(s): t, 'l-i-e,i-� 4 (1 vt / ' I L(�� -"t'k
Mailing Address, C/S/Z: C3 i&t,,fl� r acc6e, ND4 r 007`ei'sLi,LY it / 8 4L
Cell Phone: ( �. , )553 " � beA Land Line: _( Si g") /UPI— e Si
Email: Ls k. A
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Compdocumentation must be sytbmitteA with this application
Contact Name(s): ' g:,--41` 0.- �. e / � CGS" . US on -I e_
Contractor Trade: ;� e4r- C �P I F'1
Mailing Address, C/S/Z:
Cell Phone:_() ) O(Q I — ( k 1 Land Line: _( )
Email:
• Engineer(s)•. lI,J •Em,�j r rr
Name(s): tf_i —Pe ti l ' &c,(AASK4A-Rati-jecittiKe....,l
Mailing Address, C/S/Z: `� ` I. ]
Cell Phone: _( ) Land Line: _( ) gY
Email:
Contact Person for Buildinj & Code. mpliance:• C k a/ �-�'
Cell Phone: _(S[cj ) d255 a Sb 0 Land Line: _( )
Email:
•
Septic Application Revised February 2019
ilA
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
i Cl,i 5 per day e) bedroom Garbage Grinder Yes o
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes 0
Installed? (circle one)
1992-Present 110
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature _Sand _Loam _Clay _Other(explain: - )
Groundwater At what 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 Rate: per minute per inch (test to be completed by licensed engineer/architect)
•
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 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:
Holding Tank System Total required capacity? ;tank size ;#of tanks
NOTES: 1. Alarm system and 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. 3. As-built drawings must be
submitted prior to the inspection, if there has been a change to the submitted plans.
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 Sewage1 isposal Ordinance. O�
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PRINT NAME: I (t/V AtL. I - d'c k DATE: 11 / do, ?0
SIGNATURE:. / 4. aclit 1, %'/! 414 DATE: i 167 AOW
Septic Application Revised February 2019