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Office Use Only
SEPTIC DISPOSAL PERMIT APPLICATION Permit#: - ZOZ�
Permit Fee: $ J" ; Invoice :
Septic Variance? Yes V No
;'ttn of t�nr n:hu rr
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
Tax Map ID#: — . 1- -
Project Location: // S 4 5S e m ti/
• Applicant:
Name(s): /Y7/C 144 C 7,/4GJSo4 f 6 1L A J 50,c1
Mailing Address, C/S/Z: //5 /95.s s M131- 7 6i ) ➢
Cell Phone: _( 678 ) SS! ---goo1& Land Line: _(5J )6 54 - 3 e4 ?—
Email: /14 o
• Primary Owner(s):
Name(s): /J7i C-i14 L (- r �i�/L. Dr/c✓Soi
Mailing Address, C/S/Z: // S" /1S,S e i 4 /97.- !'%' 7
Cell Phone:_( -S 11s ) 9578o 9r Land Line: ( 51 k ) 9V -go 9?
Email: G,e c__ 0 d f Zoo% ,Con
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): 6),c 4f/'4C i�ao%if eci ✓i/e,(c To rJ LL-
Contractor Trade: XooiiWS F �,�n,><r ,vC �o/Urx.f(Tor•
Mailing Address, C/S/Z: / y /3f ioor' 2J Qc,,(e,v.5-B6, r/ A r. /z
Cell Phone: _( 67.? ) 957 '6d9f I Land Line: _(-s/1 ) (S"4 '3L 69
Email: M ,p Cot-i
• Engineer(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: _( )
Email: NOV j 8 20i
E.AfgEtij
Contact Person for Building & Code Compliance: -p \.\
Cell Phone: ( ) Land Line: (
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 Garbage Grinder Yes No
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes S
Installed? (circle one)
1992-Present 110
/vo idol;4 e(.7 jo le,r✓c•
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope /s' %Slope
Soil Nature )c Sand Loam Clay Other(explain:
Groundwater At what depth? ?
Bedrock/Impervious material At what depth? Aid
Domestic Water Supply _Municipal Well (if well,water supply from any septic system absorption is doa ft.)
Percolation Test Rate: per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEMJOR NEW CONSTRUCTION:
Tank size f'%';' . .L:i'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: ` : ‘ 1 A
Holding Tank System Total required capacity? ;tank size ;#of tanks
At 03 V' 4 4 d ,evCAc e 4 x q e7'L y :/fe sdrn?. 40,7 f Lui(A o f iy fr1ALLf
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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:/72/(i(A P �G�l S07ti DATE: /// LG
SIGNATURE: DATE:////7 /GO •
Septic Application Revised February 2019