application SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 12804
Town ofO censbury P:518-761-8256 www.queensburv.net Permit#: �
Tax Map ID#:- 316.17-1-27 Permit Fee:$ '5 ; Invoice#:3
Project Location: 61 Palmer Drive Septic Variance? Yes No
Primary Owner(s) JPGross Properties, LLC, Joseph P. Gross
Mailing Address 27 Silver Circle, Queensbury, NY 12804
Phone & Email Joe 518-792-0216, jgross@grosselectricinc.com � III
Installer/Builder . Gross Electric, Inc. oI
Mailing Address 27 Silver Circle, Queensbury, NY 12804 N
go`i ate• :
Phone & Email Jayme 518-792-0216, jgeroux@grosselectricinc.com i ,V,
Engineer Rucinski Hall Architecture
Mailing Address 134 Dix Avenue, Glens Falls, NY 12801 -
Phone & Email Ethan 518-741-0268, ephall@nycap.rr.com
Contact Person for Building&Code Compliance: Tom Mahoney Phone: 518-361-0628
RESIDENCE INFORMATION:
Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder es No
1980 or older Installed? (circle one)
1981-1991 Spa or Hot Tub Yes No
Installed? (circle one) .
1992-Present 6 110 660
PARCEL INFORMATION:
Topography X Flat Rolling Steep Slope %Slope
Soil Nature X Sand Loam Clay Other
Groundwater At what depth? not encountered
Bedrock/Impervious material At what depth? not encountered
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 (2) 2,500 gallons (min.size 1,000 gallons,add 250 gallons for each garbage cylinder or spa/hot tub
System Nbso„rptron field With#2 stone Total length 300 ft.; Each Trench 50 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 &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 knownby 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: Jayme Geroux DATE:
SIGNATURE: 0.A.T.,,L a- qp.,„0-.._x_ DATE: 11/20/20
Town of Queensbury Building&Code Enforcement Revised February 2017