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SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 12804
Town of Queensbury P:518-761-8256 www.queensbury.net Permit#: 50-06 1 - 2.O2a
Tax Map ID#: 309.11-1-27 Permit Fee:$ � ; Invoice#: 5ota
Project Location: 191/2 Garner Street Septic Variance? Yes if No
Primary Owner(s) John Jarvis
Mailing Address 191/2 Garner Street,QUEENSBURY,NY
Phone & Email
Installer/Builder SANITARY SEWER SERVICES
Mailing Address LUZERNE ROAD,QUEENSBURY NY
Phone & Email 5187963760
Engineer TOM CENTER
Mailing Address 73 SHERIDAN STREET,GLENS FALLS,NY 12801
Phone & Email TCENTER36@YAHOO.COM
Contact Person for Building&Code Compliance: GEORGE DRELLOS Phone: 5187963760
RESIDENCE INFORMATION:
Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yes No
1980 or older Installed? (circle one)
1981-1991 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 21 110 110
PARCEL INFORMATION:
Topography I Flat Rolling Steep Slope %Slope
Soil Nature Sand Loam Clay Other
Groundwater At what depth? DEEPER THAN 6'
Bedrock/Impervious material At what depth? NONE
Domestic Water Supply L Municipal _Well (if well,water supply from any septic system absorption is_ft.)
Percolation Test Rate: 1'-5' per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size NEW1000 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: 5 Eljen In Drain Trench
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 rel a e pon any material ii
representation or failure to make a material fact or circumstance known by or on be an®e�1iost, be �.
have read the regulations and agree to abide by these and all requirements of the Tow Queensbury Sanitary ewaige
Disposal Ordinance. TOWN OF QUEENSBURY
BUILDING&CODES
PRINT NAME: GEORGE D OS
SIGNATURE:
Town of Queensbury Building&Code Enforcement Revised February 2017