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1 SEPTIC DISPOSAL PERMIT APPLICATION Permit Fee:$ - ; Invoice#: 3 11
Septic Variance? Yes ✓ No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
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• Applicant:
Name(s): c 14s S.ci #;c.. er'v' c-er
Mailing Address, C/S/Z: 12. Sis$ R d Sd L [Z'a 3
Cell Phone:_(6" ) `I -I- a13`7 3 Land Line: _(Sig ) 0-'03 T3
Email: tS �✓ ���}i :; Se.-v i c-e:. dJ Ct r tc�� ( • Cs
• Primary Owner(s):
Name(s): ZT 1; pk
MailingAddress, C/S/Z: O t I-I,f 124 0%-Jeci-t5u Ni 1 i2F�
Cell Phone:_( ) Land Line: _( )
Email:
In Check if all work will be performed by homeowner only,
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): lt-t-
Contractor Trade: _p l- c
Mailing Address, C/S/Z: =1-g5 l'i } '`I 2- S=Sst'"' rLd 5 • c .c i 2-7 03
Cell Phone:_(5-L-° )'l YV-`z 3'73 Land Line: (Si ) ``l a 5
Email:
• Engineer(s):
Name(s): p_+e_
Mailing Address,C/S/Z: 1 'l Ica' � -J 5n s s Ny v� S
Cell Phone:_( ) Land Line: _(. :g ) 7 e18-3g SS
Email:
Contact Person for Building & Code Compliance: b3
Cell Phone: _(E t ) 7 q q`" I373 Land Line: (Sig ) YRcO - t1 1.1
Email:
Septic Application Revised February 2019
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RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom I 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 I ) 0 a Z
PARCEL INFORMATION:
Topography x- 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 tfMlunicipal _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)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size rooc9 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:
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: -rr d u-= DATE: % caa`c=a�
S1GNA7L11?E:
DATE: l C�—c� `ol )0
Septic Application Revised February 2019