application Office Use Only
� SEPTIC DISPOSAL PERMIT APPLICATION Permit#: G E--r" 616�� Z c.LzPermit Fee:$ " Invoi e#: 32y1
Septic Variance? Yes ✓ No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.oueensbury.net
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Tax Map ID#: J�Tv l 3 � y�
Project Location: [��1 /-yi o41- /-t1�
• Applicant:
Name(s): �S (�1�
Mailing Address, C/S/Z:
Cell Phone:_( J ) ZZZ-.s(obi`�Land Line: _( )
Email: 4 Uj c� n�RG c`ZAV
• Primary Owner(s):
Name(s): ` 7-0014 q
Mailing Address, C/S/Z: C0 7 20+70 r 2/1i7Z,-:K- A) `/
Cell Phone:_( ) Land Line: _( )
Email:
ildnAD.�6?111
Check if all work will be performed b r only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): �
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:_(a ) Land Line: _( )
Email:
• Engineer(s): TI-
Name(s): F
Mailing Address, C/S/Z: r `i 9 I
Cell Phone:_( ) Land Line:
Email: ?' '� �f:E� -V t-;U ,
Contact Person for Building & Code Compliance:
Cell Phone: _(, Land Line: _( )
Email: CipA-I
Septic Application Revised February 2019
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RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes o
1980 or older 150 Installed? (circle one)
1981-1991 130 f3D �O Spa or Hot Tub Yes No
Installed. (circle one)
1992-Present 110
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature Sand _Loam _Clay _Other(explain: )
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply Municipal _Well (if well,water supply from any septic system 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 _LQ00gallons(min.size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone Total length Q ft.; Each Trench�ft.
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 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: J DATE:. / �v
SIGNATURE: 16� DATE: /Z_ Z ( Z
V.
Septic Application Revised February2019