SEP-0455-2021 j SEPTIC DISPOSAL PERMIT office Use only
/ a 9:4 ��0 � Permit#:
Town ofCZecn ry
JUN 10 2021 Permit Fee:$
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Invoice#: 3�4�
742 Bay Road,Queensbury,NY 1 804rOWN OF QUEENSBURY
P:518-761-8256 www. ueensb net BUILDING& CODES Septic variance? Y N
Flood Zone? Y
Wetlands? Y $. R:eviewed B .
Project Location:
Tax Map #:
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? (choose one) ❑
1981-1991 130 Spa or Hot Tub Yes No
1992-Present 110 -330Installed? (choose one) ❑
PARCEL INFORMATION:
Topography Flat Rolling ❑ Steep Slope % Slope
Soil Nature Sand ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At w at depth?
Bedrock/Impervious material At hat depth?
Domestic Water Supply NIMunicipal Well ❑Lake
(if well or lake, water supply from any septic system absorption is
ft.)
_ Percolation Test Rate. per minute per inch (test to-be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
Z`};� spa/hot tub
System Absorption field w/#2 stone Total length ft.; Each Trench O ft.
Seepage Pit w/#3 stone How many: ; Size:
Alternative System Bed or other type:
Holding Tank System Total required capacity? ; tank size ;
# of tanks
Septic Application Revised April 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant; 1
Name(s): � 1 L C
Mailing Address, C/S/Z: c) e( Wcirren 5 �, ()kAef/\ j�i��r�
Cell Phon : JAI —���'�, Land Line:
Email: 5-P 0 cry
• Primar Owners
Name(s): I 4--Q II
Mailing Address, C/S/Z: f o U
Cell Phone: Land Line:
Email:
❑ Check if all work will be performed by property owner only
• Contractor:
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z: �����5�� ��
Cell Phone: : Land Line: LJ 4 194
Email:
**Workers' Comp documentation must be submitted with this application**
• Engineer(s)•
Name(s):
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email: �"
Contact Person for Compliance in regards to this project: CY1YNS
Cell Phone: Land Line:
Email:
NOTES: 1. Alarm system and 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. 3. As-
built drawings must be submitted prior to the inspection, if there has been a change to the submitted
plans. 4. If, for any reason, the building permit application is withdrawn, 30% of the fee is retained by the
Town of Queensbury. After 1 year from the initial application date, 100% of the fee is retained.
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 Sewag Disposal Ordinance.
PRINT NAME: -
SIGNATURE: DATE:
Septic Application Revised April 2021
60/2021 Town of[uoonobury Interactive Mapper
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Residential Septic Alterations
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https://qbygio.quoensuu ?pm=30o12-2~5o 1m