application tt.7! % SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
',:.•o+ . 742 Bay
y Road, Queensbury, NY 12804
P: 518-761-8256 :::.., Permit#: Gf- iJ
Tax Map ID#: Permit Fee: $ 13 ; Invoice#: j
Project Location:4-) Pir �I 17Q I Ter Septic variance? Yes No
Primary Owner(s) NI' c (t FUG i i )
Mailing Address 4 ^r�\o f e • J-er J
Phone & Email J — —1 3-062Y
Installer/Builder S
Mailing Address --�
' rer, 5—. Qu , v, Sly 0 r
Phone & Email 1 \ —19 ,--(K 1 11 r� �� i 'o A
Engineer � -- � _
Mailing Address ' __� ill
III AUG 14 202i i I
Phone & Email _J
OWN OF t)Ur^l.:k;31-3 JRY.
Contact Person for Building &Code Compliance: MI BUILDING&CODPRone:
RESIDENCE INFORMATION: V ,`
Year Built Gallons #of bedrooms X gallons per = total daily flow e(( I/
per day bedroom Garbage Grinder Yes No/
1980 or older 150 Installed? (circle one) v
1981-1991 130 Spa or Hot Tub Yes Di
1992-Present 110 ) Y 1 330
Installed? (circle one)
PARCEL INFORMATION: l
Topography V/lat Rolling Steep Slope. %Slop e
Soil Nature Sand Loam Clay Other
Groundwater At what depth?
I 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)
PROPO D WSTEM FOR NEW CONSTRUCTION: .
Tank sizell) rerQO0 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: / ( rn,,n( - )�(�Q
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 Ordinanc 1 n
x.
PRINT NAME: . ( +.9l G
t' DATE:
JI
SIGNATURE: DATE: Y. -) ) 0
Town of Queensbury Building Code En . • ent
Revised March 2018