application µ< SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
"-. Bay 742 Road, Queensbury, NY 12804
r,,;1..,,,<<�,,�•,:,;r";,. Permit#: 0 Coca 4
• P: 518-7618256 - ..::;;: ''.,
Tax Map ID 4: 2-8 1 A —‘—' 6 ` 1 Permit Fee: $ n b ~ ; Invoice#: 1
1.11SI f f AOC/kJ\ Septic Variance? _ Yes No
Project Location: " ° _—_
Primary Owner(s) J_v \-f _ L l.ti U -
Mailing Address ___ --;1 C. [ f� \fI I_ :
Phone & Email S , (1l� 1 , ` i
Installer/Builder _ _.5- 1 \I OCT 2 7 2020 1 I{
Mailing Address per
TOWN tr31- t:zui-�y%y•v�,ll:`�'
Phone & Email (., ��(--� _ 4 1 FANG&CODES
Engineer _ E , 1 I
Mailing Address ``�� j G ,.� bl 5
_ 1J
Phone & Email I-0
•
Contact Person for Building & Code Compliance: Phone:
RESIDENCE INFORMATION:
Year Built Gallons # of bedrooms X gallons per = total daily flow
per day bedroom Garbage Grinder Yes
Igp
1980 or older 150 Installed? circle one) _ A
— • — Spa or Hot Tub Yes ► o
1981 1991 130 - Llnstalled? (circle one)
1992-Present 110Lt I I �� Lf�
PARCEL INFORMATION: _ _ --
Topography I__- Iat Rolling Steep Slope %Slope '
Soil Nature S nd tkI Loam Clay Other
Groundwater At what depth? J —
Bedrock/Impervious material`_ At what depth?
Domestic Water Supply _ Municipal _Well (if well, water supply from any septic system absorption isin0 ft.t
Percolation Test Rate: per minute per inch (test to be completed by licensed engineer/architect)
_PROPOSED S STEM FOR NEW CONSTRUCTION: —
Tank size j (_gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with #2 stbne Total length ft.; Each Trench ft.
Seepage Pit with #3 stone How many: ; Sze: _`
Alternative System Bed or other type:- 7 2�
-
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 a3ll requirements of the Town of Queensbury Sanitary Sewage
Disposal Ordinance. - L
\ 0—)
eDATE: 1 `r�V 1 i `(�
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PRINT NAME:
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SIGNATURE: DATE:
Town of Queensbury Building&Code Enfo cement Revised March 2018