application SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury, NY 12804 ��Q
Town ofQuecns.nry 20/2.0
P: 518-761-8256 www.queensburv.net Permit#: SLR — �
Tax Map ID#:.311 . 11 —1 -l\ Permit Fee: $ .! ; Invoice#: �
Project Location: 14 GARNER STREET Septic Variance? Yes ✓ No
Primary Owner(s) JOEL BOBICK
Mailing Address 513 GLEN STREET,GLENS FALLS,NY _�
Phone & Email D �= f 0f` r
Installer/Builder SANITARY SEWER SERVICES 1191
RY
I
Mailing Address LUZERNE ROAD,QUEENSBURYNY f� /
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Phone & Email 5187963760 OWN
W LO FQUEEN &
Engineer TOM CENTER -
- CODES
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 2 110 220
PARCEL INFORMATION:
Topography ✓ 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 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: 20 X 20 FT BED
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 all requirements of the Town of Queensbury Sanitary Sewage
Disposal Ordinance.
PRINT NAME: GEORG REL OS DATE: 10/13/2020
SIGNATURE:
Town of Queensbury Building&Code Enforcement Revised February 2017