application Office Use Only
J SEPTIC DISPOSAL PERMIT APPLICATION Permit#: �� `s`JZ(Q•-202.0
Permit Fee:$ 1 ; Invoice#.
Septic Variance? Yes - o
Town ofQucens.ury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
Tax Map ID#: 0 q — I
Project Location: 2. 1 'A? Ie�1u15e, L. �p� ;V L�-:�
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BUILDING&
•
• Applicant:
Name(s): Ektwo.rA•Mn.-‘
Mailing Address, C/S/Z: J srcj
Cell Phone: _( SicZ ) ' 5 7 —cla ' Land Line: _(
Email: )[at/ 51r-r- -50P-1 re-
• Primary Owner(s):
Name(s): Vcb^ C_cx now\
Mailing Address, C/S/Z: 2 14 1'4, sk hc),/Se Lt
Cell Phone: _( Sr g ) 3 Z I— s8t 8 Land Line: _(
Email: c-o.nn0w. 1.v1.0\ I @c cols-,
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): fbi-n;,1 S ho,v Ecc274. r
Contractor Trade:
Mailing Address, C/S/Z: S �c�G -� Q,
Cell Phone: _( ) Land Line: ( ) 793-22-MG'
Email: Turr(1.!... Ir,/ Ce h„?I_✓►�.�,4
• Engineer(s):
Name(s): Vcitsk /1I d9jzIN
Mailing Address, C/S/Z: /3 V n . Ave
Cell Phone: _( - )` 'Land Line: _( S' ) `7 `/C -- OZ6R
0
Email: e -\c\1 Ay L94 _ Fr -
Contact Person for Building & Code Compliance: 10.1 D.12_k: Ake/
Cell Phone: ($ig ) ? S 7— 9( 3 Land Line: _( )
Email: rem Q Nw��.v� S opi,t ( cn-��
Septic Application Revised February 2019
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes O
Installed? (circle one)
1992-Present 110 /to 3 '3 c9
PARCEL INFORMATION:
Topography " at Rolling Steep Slope %Slope
Soil Nature ,Sand Loam _Clay Other(explain:
Groundwater At what depth? c/
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: /—S per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size ALW 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 `2c., ft.; Each Trench LO 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 Sewage Disposal Ordinance.
%PRINT NAME: UDATE: / 7-0
SIGNATURE: DATE: ¶,I/Zed
Septic Application Revised February 2019