SEP-0776-2020 SEPTIC DISPOSAL PERMIT APPLI[AT(' N Office Use Only
74z Bay Road, Onccn»6upy, mv 12804
p: sz8-761-8zsa — � � � ���'��'� ����
Proiect Location: Septic Variance? Yes V/ No
Mailing Address U
Phone & Email C%
Mailing Address
Phone & Email J7
Phone & Email
Contact Person for Building Code Compliance: -Pkone --S) X-361
RESIDENCE INFORMATION:
Year Built Gallons # of bedrooms X gallons per total daily flow
I perclay bedroom Garbage Grinder Yes No
1980 or older 150 Installed?.-�rcle one)
Spa or Hot Tub Yes
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-PARCEL INFORMATION:
Topography lat Rolling Steep Slope %Slope
Soil Nature _A,/ Sand Loam Clay other
Groundwater At what depth?
Bedrock/impervious material__ At Piat depth?
Domestic Water Supply _VMunicipal _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 SYSTEM FOR NEW CONSTRUCTION:
Tank size �Ma gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub
-System Absorption field with 42 stone Total length ft.; Each Trenc�
V -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-bui(t plan is received and approved.
The installed system must rnatch the septic layout on file—no exceptions.
Ced�l�1���Any permit or,approval granted which is based upon or/s granted in reliance upon any material
representatiohorfaUoreton)akeamateria( factordrcumstanceknownbvoronbeha/fofanapp|icaot, shaUbevoid. /
have read the regulations and agree to abide by these and all requirements of the Town of.Queensbury Sanitary Sewage
Disposal Ordinance. �s '
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PRINT NAME: k r DATE:
S/u/v*/vnc: DATE:
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SEP-0776-202
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