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SEP-0290-2021 ........ s::::..... ...:. .. ::::: Office Use=Only:. Permit#i256> ©2�0" 2p 7j Permit Fee: ...........A Bay Road,Queeg;busy;NY:12804. I,, [+;518�71-8256:wwwc[ueeiishury:rieR' Inupice.#: �4!t�2i ..... ...... Fl©i-d.Zone? YN Revieviied By; NKS_ E'PTIC DISPISAL"REKNIT APPLICATION cam.......:.. ;: Pro'ect:Location: _ D M Yl ►1 P 4,--.. 4�. Tax Map.#c .. ,x RESIRENCE IN.FORMA-TION `; Year.suilf: Gallons #of:bedrooms: k�galions per =total daily flow. perday, ...... bedroom Garbage:Grinder Yes N 1.980 orolder _ 150 Installed? (circie.,one) 1981-1991; 130 Spa:or Hot--Tdb: Yes a x992-Present: : :110` — . .. .. . .... .:... .� Insta led?..circle orte} PARCEL:INFORMATION i=lat Rollin.opograp. y Stec Sloe °lo Slo e _...g P ... .p p..; :Boll.Nature: Sand. Loam Clay C}t..her, explain:. rig Grou'lad rry ate r. . , ,. .., At.what eptt ? Be, rod;' Impervivus::materiaf.. At w t depth?' APP .Dam sti.c:Water':Suppiy. _,_ .. .unlcipal We., . TO if well ar Take; water supply fro ., D � a rptionAS N g COD Y est. Rite: p ermnute pe nhtestto . cietPercolationT r med by. a aicensed:engineer/archrtet) ::PROP.OSEp 5Y5TENt:INFORNIATIQN Tank. .gal.lons (mi'n. slze.l,t}00-gallons,,add 250 gallons for�eacli:ga.riaage cylinder or Slap :hat tub System:; ': Absbrotian field:vu/#2 stone Total ler�gtfi' ft.; Each Trencn: '. ft.. How many:See a e Pi ;Siz i: ................ p.g ; t w/#3 stone Alte.r..native.5ystem Bed or other:tYpe: UU Holding Ta,n'kSystem Total required capacity? tanksize:.___,_____ #°of tanks:. Septic Application k4Mkd December:2020 r. �................ i... ,. C l�'�l�T'ANFt�RMAT- 10 .PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN ENtA(L .. •. Applicants: � G Cat C1 Se(-,1lCSC M ill-9.4-4 ress. C/S/.Z:. -..:. . r• Ce11Phvrte :_ ;ail n ��D Land:Line:: _ jqq Erna.l r c�K g b h 1 k1S ��-1 C • P r rrma . owiftedsl:. �� Name{s� �10 ... C'-1?.Ci� r\rn.-g� Mailing:Address;::C/S/Z . _( :Line• Ce Land ll Phone: • :Email;. Ctieck if all w±oirlc`will be.performed by property r6fily an .: ' -ontra'cton Coritractior Trade Nlailirrg:Address Wz. _ - Celf Phase: Lan d.Lin`e . ` `Workers':Camp docurn+entaton::mws :besubrittdwithahis aptiction... * Engineers Names : . _. Mailing Address e/S/Z:. _ _..... .. Land;Line- ....... Erriail. . _.... . Ctintact`:Person` orCompliance`in:regards_to:thisproject: - -Ccll Oho :.: .. :.... Land Line.: ..{. ) Email: NOTES: 1.Alarnsystem:and associated:electrical uuork must:be:inspected by.a Town:apP..:. ed electrical inspection agency;2.::M will no.longer allow systems to be touered.:until such time as art:as-built plan.is receive__:an d:approved:.The installed system:,must match the septic.layout:on°file—no exceptions. 3,:As bailtdravuings must.be submittedprior: o the inspection; if there has°been:a%change tothe subrriittecl plans :4. if :far:.any reason,°the building perrriit applicat an i.s-wethd:rawn 30°,r�:of file fee:is:re�a ned bar the Tawn:of QUeonsbury::After� 1 year from the Initial application date,°100 of.the'fee is retained.. Declaratian:Ariy perrri�t`or approval granted wfticki is based upon or is granted:in reliance upon any material representation orfaiiure to make amaterial fact or circotnstance known by or ori.behalf.of an applicant,shall be: yoirf,;.l.;hive read regulations arid agree to abide by these and ail:requirements of the Town a.:Queensbury Sanifary5ewage Disposal:ordinance: PRINT NAME;::...:.:: . 51��NAT UR E -air Septic;AppCieation Revised.December 2020 4/23/2021 Town of Queensbury Interactive Mapper Town Of Queensbury Interactive a r ' 308.16-1-77 SEP-0290-2021 ❑E] Urban, Andrew '-R� �ro C]❑ 1LLER ` 1.0 Minnesota Ave Residential Septic Alteration T1W OF QUEENx FJIL INSG & CODE `,>I �.=• [y - ti +I _ ; P- ::VtE'V�IeC� : r< _ Gate' z 2 r s ,r V 75, y' C _ GO 5 E ' G7k7 SBNO L: :i! ? 7 7 FO F �Cx TOWN OF QUEEINSBU BUILDING DEPARTIME Based n our limited exam' with ou comments shall nett indica6 g the plans and full iance with tht3. New Yot�c State. https:Hgbygis.queensbury.net/webapp/default.html?pid=308.16-1-77 1/2 VGt, �- G lipMAY 0 6 2021 It, �� f TOWN OF OUESNIOURY G-� 9 o � �- aA BUILT is j S V nr.t �Zo- ' 14 (J��P