91-399 TOWN OF O r ENS3URY
#-Oli RECEIVED
VACR TOWN OF QUEENSBURY !)
APPLICATION FOR SEPTIC DISPOSAL PE II 6 1991Permit # ±
Fee Paid /
// BLDG. & CODE DEPT.
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Date: ( ' ( +Reviewed By
LOCATION OF PROPERTY FOR INSTALLATION: C I-E V&4 7,J E AD
1 Owner' s Name: CAA %O,v
Owner' s Mailing Address: C L_VE_/s7 L-17 AD
Installer's Name:
00,127>0/s/(c �� i�c�� vi-174a1 h1' Serf Phone #: 7gg-85-ya.,
Number of bedrooms (if residential ):
Total daily flow (residential-compute @ 150 gal . per bedroom) : y,C0
Topography-Circle One: Flat Rolling Steep Slope % of Slope
Soil Nature-Circle One: Sand Loam Clay Other /Depth: / 2_0��
Ground Water-At What Depth? C Feet
Bedrock or Impervious Material-At What Depth? /Li Feet
Percolation Test-Circle One: Not Required Required/Rate 3 Min. Per Inch
Domestic Water Supply-Circle One: Municipal Well oggpL a4E e fo l E
If domestic water supply is a well -
Separation: Water supply from any septic absorption /00 feet
PROPOSED SYSTEM: Septic Tank9 ' gal . (Minimum size: 1,000 gal . )
Tile Field: Each Trench feet//Total System Length /70 feet
Seepage Pit(s): Number of / Size each: ft. x ft.
Size of Stone to be used: # '2- / Depth or Thickness feet
**************
HOLDING TANK SYSTEM IF REQUIRED
No. of Tanks Size of Each Gal .
Alarm system and associated electrical work to be inspected by a certified
agency.
****************
I have read the regulation on the reverse side of this sheet and agree to abide
by these and all requirements of the Town of Queensbury Sanitary Sewage Disposal
Ordinance.
SIGNATURE OF RESPONSIBLE PERSON: ‘8 UL? e 4_ , DATE: 6 4 `P/
Septic System Inspections:
A. All applications for septic system installation, alteration or repair,
as required by the Town of Queensbury Sanitary Sewage Ordinance, shall
be submitted to the Building Department at least 24 hours before start
of construction and shall include a plot plan showing:
1) the proposed location of the system
2) location and distance to lot lines
3) location and distance to structures
4) location and distance to any water supply
5) size and dimensions of all tanks, distribution boxes, tile fields
and/or drywells
B. No system shall be covered before inspection and approval by the Building
Inspector. Failure to comply with this requirement may result in the
uncovering of the system by the installer and a fine of up to $250.00.
C. An approved copy of the plot plan shall be available on the construction
site. Failure to produce said plot plan at time of inspection may result
in an immediate work stoppage.
D. Should unforeseen problems during construction prevent proper installation,
alteration or repair of an approved system, a new proposal must be submitted
to the Queensbury Building Department before further construction.
Town of Queensbury
Building & Code Enforcement
Department
531 Bay Road
Queensbury NY 12804
Remarks:
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