application SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
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742 Bay Road,Queensbury, NY 12804
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•Permit# '� QO ` 7 r�17--ti
P: 518-761-8256 w+,uv�;.�uee�,s�ur+-.n�•'. •.� �—��—�
Tax Map ID#: Permit Fee: $ J ; Invoice#:
Project Location' Septic Variance? Yes No
Primary Owner(s) cA 'o GIr 61S
Mailing Address `77 e . ; V
Phone & Email 1Lf 471 S-7
Iristaller/Builder :1
Mailing Address n �- ^ e
y W-14
Phone & Email 4
Engineer
Mailing Address
Phone & Email
Contact Person for Building& Code Compliance:_41A?MPhone: ���
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms X gallons per = totaI-daily flow
per day bedroom Garbage Grinder Yes N
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes
1992-Present 110 Installed? (circle one)
PARCEL INFORMATION:
Topography lat Rolling Steep Slope %Slope
Soil Nature Sand Loam Clay Other
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply _Municipal _Well (if well, water supply from any septic system absorption i t.)
Percolation Test Rate: per min.ute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR EW CONSTRUCTION:
Tank size qq ns Imin. 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:
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-built plan is received and approved.
The installed system must match the septic layout on file—no exceptions.
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: ��' P� �/� DATE:
SIGNATURE: DATE: 'y n
Town of Queensbury Building&Code Enforclunt Revised March 2018