application SEPTIC DISPOSAL PERM f ��Ilse Only
Dart_ Received,
Tax Map ID
TAXNAPIo Permit No. v_ �
Permit Fe
a a=770MW NsrattarraN App s;
APP,ucANT -e :J t,-J // PHONV E--MAIL
ADDRESS ZQ 7(1 �__O ,LLD/ S.
INS;PAtLEA/Bt1)tlJFA: PHONE/E--Marc
ADDRESS. ��Vi �' �
INNER d,O X 2-2 CY PHONE/E--MA& 1 f— -7l�
Address Merl 1,�4'1<f l ief_e)/
00NTACT PERSON F4R�IIILDINQ�r d.°ODES COMPLIANGE:�T'L�O rC1,� L�/��� PHOt11EJ
RSr®1:NCL INFORMAP/OfU
Year Built #of bedrooms X Gallons per bedroom =Total Daily Flow
1980 or older Iry Garbage grinder installed _Y _i11
1981-1981 Spa or Hot Tub installed 1 —Y —N
�992-Present
PARCELINFQRB(rQTtON
Topography Flat roping Steep slope % o �`
Soil Nature Sand Loam Cla r
Groundwater At what depth? 1 jim Q
Bedrock/impervious Material At what depth? 71,7511
Domestic Water Supply Munlclpal Well(if well,water suppl fMnTari ► s 13 #A
Percolation Test Rate: %--J per minute per inch{test to be mpl4ed-b licensed engineering 1 architact)
PROPOSED sI smw FOR NEW CONSTRUCnam
Tank Size gallons(minimum size 1,000 gallons,add 250 gallons to size for each garbage grinder or spa or hot tub)
System Type Absorption field with#2 stone Total length fL-.Each trench y x
Seepage Pit wdh#3 stone Now many: -size
Alternative System Bed or other type?
Holding Tank System Total required capacity? Tank size #of tanks
Wafts., 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-Built plan is received&approved. The Installed system must match the septic system
layout on file—no exceptions.
DECLARAFrON: Any permit or approval granted which is based upon or is granted in reliance upon any material representation or
failure to retake a material fact or circumstance know by or on behalf of an applicant, shall be void. 1 have read the regulations
and agree t0 abide y these and all rey mants of the Town of Queensbury Sanitary Sewage Disposal Ordinance.
Print Name: /i-p Date:
signature: Date: 1
Town of Oueensbury Building&Codes Septic Disposal PenTd Jply 2014 r