SEP-0185-2021 ' SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 12804
Totm ofCZcensbury Permit#:
P:518-761-8256 www.gueensbury.net y
Tax Map ID M 302.19-1-10 Permit Fee:$ — ; Invoice#: �J d
Project Location: 11 AMES PLACE Septic Variance? Yes No
Primary Owner(s) ROGER WELCH
Mailing Address 11 AMES PLACE QUEENSBURY,NY 12804
Phone & Email F"�
Installer/Builder SANITARY SEWER SERVICE `~i
Mailing Address LUZERNE ROAD, QUEENSBURY NY
Phone & Email 518-796-3760
Engineer CENTER PROJECT SERVICES TOWN OF CULL
ir~ A GODES
Mailing Address 73 SHERIDAN STREET,GLENS FALLS,NY
Phone & Email 518-796-2515 TCENTER36@YAHOO.COM
Contact Person for Building&Code Compliance: GEORGE DRELLOS Phone: 518-796-3760
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)
1981-1991 130 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 110 3 110 330
PARCEL INFORMATION:
Topography ✓ Flat Rolling Steep Slope %Slope
Soil Nature ✓ Sand Loam Clay Other
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Suppl XX _Municipal _Well (if well, water supply from any septic system absorption is_ft.)
Percolation Test Rate: 1-5 per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION: ,
Tank size 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: 15x30 pipe-in-stone absorption bed
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: f DATE: —�/
SIGNATURE:
Town of Queensbury Building&Code Enforcement Revised March 2018