Application SEPTIC DISPOSAL PERMIT Office use only
APPLICATION Permit#:_C%-P- Ob4"D2--Zc_�
7mm�(Zxrn<6un
Permit Fee:$ B
742 Bay Road,Queensbury,NY 12804 Invoice#: '5
P:S18-761-8256 vvv✓v.aueensbury net Septic Variance? Y N
Flood Zone? Y N
Wetlands? Y N Reviewed By:
Project Location: 1pg
Tax Map #: Z88. 1e�- 1—v,78
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 _ Installed? (choose one)
l lb
PARCEL INFORMATION:
Topography JigFlat Rolling Steep Slope %Slope
Soil Nature p
® Sand ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth?
Bedrock/Impervious material At what depth? 'J" Cp'
Domestic Water Supply 'B( Municipal ❑ Well ❑Lake
(if well or lake, water supply from any septic system absorption is
ft.)
Percolation Test Rate: 1+ per minute per inch (test to be completed by a
licensed engineer/architect) >Ar �z•-'�"f
PROPOSED SYSTEM INFORMATION:
Tank size t000 gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
spa/hottub
System Absorption field w/#2 stone Total length ft.; Each Trench ft.
Seepage Pit w/#3 stone How many: : Size.
—� Alternative System Bed or other
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:
Name(s): CX2tj3zAN�LFl�ttly�yai.i
Mailing Address, C/S/Z: 108 MCJc,= ZA^C*4 ��-
Cell Phone: 5M 5�58- 154 -PB Land Line:
Email: C.fn �a c. � a1 .co'rvt
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone: Ste 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: ( �pL���'{?0,4�
Cell Phone: Land Line: i5t$ r 9 G ,— y�pp �Z�'t4(o
Email:
"Workers' Comp documentation must be submitted with this application"
• Ensiinneer(s):
Name(s): .1 ]Er.dH�T 11�pr7,_��•1I
Mailing A dress, C/S/Z: _11Z �fj,,L�tr fs�f`�Ry4t L_
Cell Phone: 5C$ "574o-$-1 95 Land Line:
Email: W 2RP)IP- CC=VA
Contact Person for Compliance in regards to this project:
Cell Phone: '516 5j�3--3071!5 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 Sewage Disposal Ordinance.
PRINT NAMIE C
SIGNATURE:1L �Nl�l1a1 7V4G�L 2�r z F�iVDATE:
G LZ)V rVT �► 41_4
Septic Application
Revised April 2021