application . -. ~—.
SEPTIC DISPOSAL PERMIT APPLICATION Office Use OnI
Tax Map ID PermitFee: .$ ; Invoice4:--5ZmQ
Project Location: Av�,
Primary Owner(s)
Mailing Address
ULU
Phone & Email
Mailing Address
Phone & Email
Engineer E4�
Mailing Address 1+ 0
Phone & Email 41- 01
Contact Person for Building & Code Compliance: Phone:
RESIDENCE INFORMATION:
Year Built Gallons 4 of bedrooms X gallons per total daily flow
perclay bedroom Garbage Grinder Yes 0-
1980 or older 150 Installed? t��rcle one)
Spa or Hot Tub Yes
Unstalled? (circle one)
-PARCEL INFORMATION:
Topography Steep Slope %Slope
)4t Rolling
Soil Nature --�/Sand Loam Clay Other
Groundwater At w at depth?
Bedrock/Impervious material At Vhat depth?
Domestic Water Supply �./Municipal _Well (if well, water supply from any septic systern absorption is ft.)
Percolation Test Rate: per minute per inch (test to be completed by licensed engineer/architect)
—PROPOSED SYS M FOR NEW CONSTRUCTION:
7
Tank size 0000 gallons (rnin. 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
eepage Pit with #3 stone How many:_; Size:
V" Alternative System Bed or other type: D!O!��'S
Holding Tank System -[�—otal required capacity?_; tank size of tanks
'
NOTES: 1.Alarm system & associated electrical work must be inspected by Town approved electrical inspection
agency; 2. We wil) 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 onfile—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. a
PRINT DATE:
SIGNATURE: DATE: