SEP-0358-2021 O ice.Use Onlil:.
(:. :
Permit:#:
"V-j�J�U " GFJ2-1
..............
r�ysxc .
Permit-Fee:$
:.792 Bajr Road,Queensbut.V T 22804,
Pr5i8-761�8255.:yduvytd:gtaeeasbury:ne� Invo
ice ��
.. F.00d.Zone? Y N Reviewed:.By _
_SEPTIC DISPOSAL'PERMIT APPLICATION �
D
ME
Praje01ocatiorn Ct
i
U'UAY 14 2021
a' Xi aP TnIA
-
F QUEENSSURY
BUILDING& CODCS
RES!DENCEINI=ORMATION
Ye4r:a3ui(t Gallons #of:bedrooms: X:gagvns per =total daily flcivir
per:day. ? bedroom Garbage;'Grintler Yes: Nq,
:198Q.or.o de't 1:50....... Installed?:.'(circie:or►e)
198 �199..1; 13f1: Spa.or Hot'Tub : Yes
139Z-P resent: 11
Installed?:{circle ane}
PARCEL INFI RMAT'ONs
I.Topography Flat Rolling. Steep Slope to Slope:
-...
5otl:Nature
and Loam S C(ay Oth_er,.exp.laili�
Groundwater At...what.depth?
Bed roc � fmpentous.material . .At what depth.:
........::--
Dorriti+c Water°:Supply urticipal _Well .i.ake'
(if well or'lake ivaifier>suppl.�from any septicayste,m absorption s
ft.)
...:........ per rrt p
Percolafilone�t.T Rate; eiriute: ;ernch test::to be cam .letedby a
I? (
licensed:engineer/architect}.
.. . ........ .
::PROPOSED:S1fSTEM I FORMATION:
---
-T k:size : (Q.Po
a ons mih.:size 1000.gall.ons, add 250 gallons fo;r::.'.h garbage cylinder or
spa..:.. otayb
Syste p ' g ' E #t..:
.. Abstir tion::tield w #2 stone Total len th ft..; ach Trench.
.::, .-seeps e'Pit'v / 3stane ' .......g 7 .
4lterraive:S stem Bed or othr::tYpe; �;c
v I f�
Holdin Tank S'stem Total..required ca aelt 'tank size
g Y .. . Y`�.
.. .. -
#of tanks:.
... .
......
....:.. . .....>'..:...... ...
$eptic application Revised 0ecemper2020.
, INF RI IATIC} I .PLEASE PRINT LEGIBLY OR:TYPE PLEASE INCLUDE AN EMAIL
.. .. :. ....... .. . ......... . .....
Jk
:A leant:
Name(s) C Ofm I'1 ir'v e
Maiiir ;Address; r r l Q,
Cell:Phi3rte : ✓j(Q(,� Land:Line::
`Ema(:> S
• Primai�;C?wner s i
Mailing:Add:ress Q! •_p1S lx
Cell:Phone::. { j . ~- Land Line: _{ )
Check if:all wi3rk will be performed by property Owner onto
• Contractor:
:.Contact.Nar e
Cohtractor Trade:.
Mailin
L0. ..., wl:wrP
Cell Phone:_( }
Land Line:. _{ j
Erriail: �. C
**Workers' +Comp>documentation must:b+ submitted withhi :a �p nation
Engineer s
Name. s
{. : ..::.... .................. .. .... _.
Mailirig;Address,
tell:Phone : .(. Land Line:° { j
Crintact:Fersori.:ft►r Com liance in regards to this project: _ . . .
..Cell Phone:: land Line.:_�� ----}.
Erilat
N,01,ES; .i Alarm.system en;d associated.electrical:work must be inspected key a T a ve e:own:app� : ectrica
....
inspection agency;2. We vuili na Ionger0ow systemn..to be-covered anti!such tiriie.as arias=built plan is
received and approved.The instalied,system.must match the septic::layout on..file--no exceptions.3:.:As-
built dra.vuings must:.be submitted prior to the:inspection;.if there has beers a change to the submitted
.... .
plans;;4 It: or; n.y reason;:the:building permit appt eatron is vuithdrawn; 3U° Q :the ee is retair�ed:by the
,.
Towwof Ctueehsb' urv.:After 1 year`from the initial application date, 100 of the fee:is retained.
y
declaration. An. :permit-or approval.granted which is based.upon:or.is.grantedin re lance upan;any-material
representation.orfailure.to make:a material fact or ciircumstance khov�►n by°or on:behalf of an applicant,shall be
void;l::have:read the regulations andagree to abide by these and4l requirements of the.owh of:Queebs Wry
Sanitary Sewage*Vsposal ordinance;.
...:?RINT:NAM E::.. O_r.
SiG�iATURE:
OATS: +'
Septii:AppCiCation: Revised.December2626