application 'Ids
;� .` --g SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
-'.'a,. 742 Bay Road, Queensbury, NY 12804 G�
P: 518-761-8256 Permit#: Z,P
Tax Map ID#: 9 T• n - " 1 — Permit Fee: $ 1-5 ; Invoice#: 2e:) -
Project Location: 9',Y-1 kot' , (\c\J , _ Septic Variance? Yes No
Primary Owner(s) ; y- r0�' 1-i-On
Mailing Address Li-L{.'] ` 5� A - , n(Aef�r
Phone & Email i c6 -----? (f)---off O ) rE i P '
Installer/Builder V S-e —t. _ 1
Mailing Address. \A J G11 AUG 0 7 2020 '
Phone & Email =7 4 �(,_.Y c TOWN
U 1 ^�
Engineer y- t3ius;� 1✓F�r
Mailing Address �_ ______? l;�?4; r� r _.,„.. _.
Phone & Email
•
Contact Person for Building & Code Compliance: C kr%J Phone: I) 1 3 U �Tb
RESIDENCE INFORMATION:
Year Built Gallons # of bedrooms X gallons per = total daily flow 11-Cr ( -�
per day bedroom Garbage Grinder Yes N
//
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes o
Installed? (circle one)
1992-Present 110 J)�
PARCEL INFORMATION:
Topography lat 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)
I,/ PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Gam'\ Tank size UM gallons (min. size 1,000 gallons, add 250 gallonsfor each garbage cylinder or spa/hot tub
n'6 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 &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 Ordinance ,, ; .
PRINT NAME: U 1 meLi
DATE:
SIGNATURE: )'1..:1
Town of Queensbury Building&Code Enforc Revised March 2018