application Office Use Only
SEPTIC DISPOSAL PERMIT APPLICATION Permit# � O 'ZOZ0
` Permit Fee:$ 1j Invoice#: 2:-t5 ,
Town aicZuccnxnary Septic Variance? Yes No
742 Bay Road,Queensbury,NY 12804 •
P:518-761-8256 www.queensbu rv.net
Tax Map ID#: 289.7-1-16.
Project Location: 58 Reardon Road
• Applicant:
Name(s): Herbert Wassey
Mailing Address, C/S/Z: 58 Reardon Road, Queensbury, NY
Cell Phone: _( 914 ) 391-6648 Land Line: ( )
Email:wasseyfamily@aol.com
• Primary Owner(s):
Name(s): Herbert Wassey
Mailing Address, C/S/Z: 58 Reardon Road, Queensbury, NY
Cell Phone: (914 . ) 391-6648 Land Line: ( ).
Email: wasseyfamily@aol.com
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Copp documentation must be submitted with this application
Contact.Name(s): rh (crux 'orn - "horn tbiseNs $ IZo
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ._( .) --�
Email:
/IIII[JUN 30202*-0-7
Name(s): Hutchins En ineerin9PLLC 7°W716;---17-" If
_
Mailing Address, C/S/Z: 169 Haviland Road Queensbury, NY 12804 LDi'rO � ' _ Y
Cell Phone: _(. ). Land Line: (518 , ) 745-0307
Email: thutchins@hutchinsengineering.com
Contact Person for Building & Code Compliance: Tom Hutchins
Cell Phone: ( ) Land Line: _( 518 ) 745-0307
Email: thutchins@hutchinsengineering.com
Septic Application Revised February 2019
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 110 2 (designed to 3) 110 330
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 100 ft.)
Percolation Test Rate: 1:40 per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION: existing septic tank and existing 1,000 gallon pump station
Tank size 1.200 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: 15'x25' = 375 SF
Holding Tank System Total required capacity? ;tank size ;#of tanks
NOTES; . Alarm system and.,associated electrical,work st be inspected by1a awn approved electrical inspection
� V yi J '�k 1 .• r-.i y �,i�� � .'t
agency; �.'W�fn�ii� n�O Ton er allow systems to be cbv'ere d tin S'I sucti a an'as-built plan is'received and
apprAed. 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 Sewage Disposal Ordinance.
PRINT NAME: Herbert Wassey DATE: 6/19/20
� DATE: 6/19/20
'
SIGNATURE:
Septic Application Revised February 2019