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SEPTIC DISPOSAL PERMIT APPLICATION
Permit#:
Permit Fee: $45- ; Invoice#:
Tom ofQjyeens Septic Variance? Yes ✓ No
742 Bay Road,Queensbury,NY 12804
P:-518-761-8256 www.gueensbury.net -
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Tax Map
ID#: I—
�l CSC 0 8 2020 I `
Project Location: cc 4
• Applicant:
Name(s):
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _.elf 272
Email: rx� �_�n..,r,��,�"�-.c S�rr-SP/a��C C_®
• Primary Owner(s):
Name(s): rkL,-% LJ A,,q cj
Mailing Address, C/S/Z: 3 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
Contact Name(s): d&rA`n� Jar-
Contractor Trade:
Mailing Address, C/S/Z: $mot
Cell Phone:_( ) Land Line: _(,�1� ) 29-3
Email:
• En ineer s :
Name(s): Q✓,p A
Mailing Address, C/S/Z: ✓ S�
Cell Phone:_( ) Land Line:
Email:
Contact Person for Building &Code Compliance:
Cell Phone: _( stet ) `:Q--cjoy1 3 Land Line: _( )
Email: 10✓�- �.,r„�)yy �� � L`�`�`
Septic Application Revised February 2019
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes
1980 or older 150 73 MV Installed? (circle one) _>�/
1981-1991 130 Spa or Hot Tub Yes N
Installed? (circle one)
1992-Present 110
PARCEL INFORMATION:
Topography at Rolling Steep Slope %Slope
Soil Nature and _Loam _Clay _Other(explain: )
Groundwater At what depth? • ,t
Bedrock/Impervious material At what depth? 7Z,A
Domestic Water Supply e25municipal _Well (if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: AW per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 49V gallons(min. size 1,000 gallons, add 250 gallons f each garbage cylinder r spa/hot tub
System Absorption field with#2 stone Total length ft.; Each TrVch___Y0 ft.
Seepage Pit with#3 stone How _-,
Alternative System Bed or other type:
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.
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: ` DATE: Z
SIGNATURE: DATE:
Septic Application Revised February 2019