application xyi
SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
`°"r 742 BayRoad r , h .� ,Queensbury, NY 12804
' P: 518-761-8256 ta‘,1r,nr.c ta e ncp.0_.nE Permit#: - �' ��ZrJ
Tax Map ID#: 5,5k• $ ' L--a Permit Fee: $ 45-- ; Invoice#: 285(
Project Location: ) 14 C i 1 U 5-e -i' I \d* Septic Variance? Yes No
Primary Owner(s) 30 a Ine C I I I Ir`.5
Mailing Address 14 Co:n i t I RJ.
Phone & Email S 1311 1lb3 3 I
Installer/Builder 16 $ Se pti C
Mailing Address - Ln `/kAr VV c 1 ,en 54, /'\, inee 1 S( G, c
Phone & Email 51 Q'=1 9- —K r .4 l �l b
Engineer cl I 0 E E Q LE -
Mailing Address r tl6
Phone & Email AUG 0 7 2020 I
Contact Person for Building&Code Compliance: C I °OVVN OF QUEENSE', �j
p � {'�f �� o, �, c�i�b�ie: 0`� D I�4 LC)
1 LUILDk��L&OUi7 S
RESIDENCE INFORMATION: L `
Year Built Gallons #of bedrooms X gallons per =total daily flow V CC(-1—(I C _
per day bedroom Garbage Grinder Yes No
/
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes o
1992-Present 110 -3 i ID J-(�
Installed? (circle one)
PARCEL INFORMATION: [ 1
Topography teat Rolling Steep Slope _ %Slope
Soil Nature \/ Sand Loam _Clay Other
Groundwater At wh t depth?
Bedrock/Impervious material At at depth?
Domestic Water Supply l unicipal _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 YSTEM FOR NEW CONSTRUCTION:
Tank siz P•711 AO 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: -i` -�
Alternative System Bed or other type: Inl( 7e(�U (ZP(5 ti r t)11
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. L
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PRINT NAME: /` ��� ,a,
0fizd — vDATE. lJ
SIGNATURE: DATE:7'.---6— LJ
Town of Queensbury Buildi g& de rcemen Revised March 2018