2002-271 ..518.•745. 4437 ,
FILE No.838 04i02 '02 AM y11:26 1 D:TOWN OF 9UEENSI�URY FAX:518'`745 '4437 PAGE 1
Application for Permit—Septio.Disp0601 system.
Town of Queenx6wy-742 Bay Road Queansbury,NY•1?804. (518) 76I 8ZS6 y�— Wy
I. O WNEIt INFORMATION: cc use
Location of installation.
File Permit
Tax Map
Fee Paid
owner's NsmOt �: t C1 ...........:.........................._....
7 92 17d,�_9
2. INSTALLEW S NAME
3. RESIDENCE INFORMATION: (circle year of dwelling.Indicate#bedroom(s) artd multiply# of
bedrooms with applicable gallons per bedroom to equal total datlyflow)
Year Qf Moline-- Ni3 af$esiroorns x QQ_MUUjRU= =. T �l nsily Floes IV E'
198003 older':, x .150 gaVbdrm t2
ry
1980—1,1991 x 130 gaVbdrm APR 6 20C1
1991—;'proaent, x 110 gal/bdrm 7
Garbage orlider Installed "':,yes— / no `TOWN OF:O17EENSt3UFV
Spa or,Whirlp'ool Installed yea _ / no d 13u1LDING AND CODE
4, PA.RCEL;;INFORMATION: (circle applicable information 8i indicate measurements)
ra
and at what depth at what depth- tfeet fkat weTr
slope clayifwell,water supply
.slope other from anysepttc-system
depth.-. absorption is }l-
other
Percolation Teat:,:(To.be completed by licensed professional engineer or arohitect)
Rate: ""mthute per Inch
5. PROPOSED.SYSTEM: -jr jr NTew gonrtmSgon: All individual sowago disposalYsystouzs must be designed by a licensed
professional cnginaer or nrrohitect(unless installed in a Planning Board approved subdivision):. Add 250 'gallons to the size
of the septic tatik and leach field fbr each Garbage Grinder,Spa or whirlpool Tub.
Septio Tank' 90.0 gallon(min. size 1.,000 gal.)
• ----
Tile Field: each trench °__ —.1r Total System Len : �J. 1t
. gth
Seepage Pits): number of size of each: _1t by�1
Size of Stone to be used: # t depth or thickness feet
Bed.System Size: x
Alternative gym ; length andhir size
6. HOLDINO TANK SYSTEM: (if required)
Number of tanks: / Size of each: gallons /TOTAL Capacity: gallons
Note: Alarim.System said associated electrical work must be inspected by a Town approved
R' elecU ical inaption-
ecagency.
7. SIGNATURE &INFORMATION FOR RESPONSIBLE PERSON-(please read).
For your protection;please note that purtusnt to Section 136-29 of the Code of the Town
of Queensbury,any permit or approval gratxted•which is based upon or is granted in
misrepresentation or failure to make a material fact or
reliance upon any material
circu:rYste noo knower by or on behalf of an applicant,'shall"be voice.
I have readthe'regulationx with respect to this application and agree to abide by these and all
recluir a Town of easbury Sanitary Sewage Disposal Ordinance,
V I_ t�,C rC/ ,'t,' 0
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81 n tore of reapo , "le person
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PECEIVE
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"I have seen or observed, or believe I saw evidence of,
all objects sutch .js houses, +wells, trees, fences, etc.,
so represent that I have
oru,�ent.
hire', 2-f
stances set forth on th diagr
SIGNATURE
SATE