application I �
Office Use Only
Permit#: SEf— 01 b b-n2_p
SEPTIC DISPOSAL PERMIT APPLICATION Permit
Fee:$_IL5_; Invoice#:
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Septic Variance? Yes No
Titan ofQueensh in
742 Bay Road,Queensbury,NY 12804
-P:518-761-8256 Www.nueensbury.nat
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Tax Map ID#: 239,15-1-18
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Project Location:_4 Highview Road
• Applicant:
Name(s):- Marci &Anthony Jackson
Mailing Address, C/S/Z: 163 Twin Hills Drive Long Mgadow, MA 01106
Cell Phone:_( 413 )__265-1876 Land Line: _( ) U U °fit '
Email: � a Q�;��nr�-�._�����`
• Primary Owner(s): � T
Name(s): SAME AS ABOVE
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application y
Contact Name(s): TBD
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line:
Email:
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• Engineerts):
Name(s):�IARRETT EnginPPrs, 211 C 1
Mailing Address, C/S/Z: 12 East Washing on , Glens Falls, NY 12801
Cell Phone:_( 518 ) 744-5019 Land Line: _( 518 )_ 792-2907
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Email: tjarrettOjarrettengineers_com
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Contact Person for Building & Code Compliance: Marci Jackson
Cell Phone:_( 413 ) 265-1876 Land Line:
Email: a}as1�48Q6s mail com
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Septic Application Revised February 2019 �+
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) X
Spa or Hot Tub Yes No
1981-1991 130 Installed? (circle one) X
1992-Present 110 6 110 660 '
PARCEL INFORMATION: (in area of leach system) (near lake shore)
Topography X Flat Rolling X Steep Slope unknown /Slope
Soil Nature X Sand _Loam _Clay Other(explain: )
Groundwater At what depth? No evidence of groundwater-see test pit information on drawing'WW3'
Bedrock/Impervious material At what depth? No evidence of bedrock-see test pit information on drawing'WW3'
Domestic Water Supply Municipal _ Well(if well,water supply,from any septic system absorption is >100 ft.)
Percolation Test Rate:3min 58s per minute per inch(test to be completed by licensed engineer/architect)
DomeUdC Wat Lake Source
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 2-1,000 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: Leach Bed(9'wide x 81'long)
Holding Tank System Total required capacity? ;tank size ;#of tanks ,
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.
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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: M R C- i DATE:
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SIGNATUR// ,/44 ATE:
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Septic Application Revised February 2019