2007-361 (CO not issued yet) OFFICE USE ONLY .........
TAX MAP N PERMIT N — ��� ' RCCEI1��DI'
0�� � n. _PERMIT FEE L-� , '
o APPROVALS: ZONING i 0
TOWN CLERK
' , ; TO�vly_ -------------
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APPLICATION FOR SEPTIC DISPOSAL'SYSTEM PERMIT. s���_'
A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS.APPLICATION IS SUBJECT TO REVIEW BEFORE ISSUANCE OF A VALID
PERMIT.
OWNER: O INSTALLER: P e fyj Zc 6r
ADDRESS: �9 /A/D a
1 ADDRESS:
PHONE NOS. PHONE NOS.
LOCATION OF INSTALLATION: �1Q��y �
!!!S NO.OF I............r.............................................................
YEAR BUILT ""i"' RESIDENCE INFORMATION:
BEDROOMS X i COMPUTATION= ! = TOTAL DAILY FLOW
i................................................;.........................................t...........;................................
i1980 or older I .............................I.... ..................................
...............................................<...........
' i gallon per bedroom.... i .-. INSTALLED
iX ,......1.50
:.... ............ /
1981 -1991 ••�.........
AGE GRINDER
I ..................................... + X .'• 130 gallon per bedroom I _
..........................................................1• ......... — i I
i 1992 ..... .............I.....................
present ' X 110 gallon per bedroom 1 _
A AL HOT TUB,
t..................»............................:...............................................` INSTALLED? .(J .
................................................................ i
PARCEL INFORMATION:
✓ TOPOGRAPHY: LAT ROLLWG:: STEEP SLOPE %SLOPE
✓ SOIL NATURE: AND LOAM CLAY
OTHER
✓ GROUNDWATER: AT WHAT DEPTH
WHAT DEPTHS BEDROCK/IMPERVIOUS MATERIAL: AT
✓ DOMESTIC WATER SUPLY: MUNICIPAL WELL
(IF WELL: WATER SUPPLY FROM ANY SEPTIC-SYSTEM ABSORPTION IS/
FT )
✓ PERCOLATION TEST: RATE IS PER MIINUTE PER INCH (TEST TO BE
COMPLETED BY A LICENSED PROFESSIONAL ENGINEER OR ARCHITECT)
PROPOSED SYSTEM FOR NEW CONSTRUCTION: All individual sewage disposal systems must be designed by
a licensed professional engineer or architect (unless installed in a Planning Board approved subdivision). Add 250
gallons to the size of the septic tank and leach field for each garbage grinder, spa or whirlpool tub.
✓ SEPTIC TANK:1AS-V GALLON (MIN. SIZE IS 1,000 GAL.) TILE FIELD: EACH TRENCH FT.
✓ TOTAL SYSTEM LENGTH: FT. SEEPAGE PIT(S): HOW MANY?
✓ SIZE OF EACH FT. X FT.
✓ SIZE OF STONE TO BE USED: # 2- /DEPTH OR THICKNESS l FT.
✓ BED SYSTEM SIZE: /l, X _�
✓ ALTERNATIVE SYSTEM: LENGTH AND/OR SIZE
✓ HOLDING TANK SYSTEM:(If required) NO. OF TANKS:-I SIZE OF EACH
✓ GALLONS./TOTAL CAPACITY: GAL.
iti NOTE: ALARM SYSTEM AND ASSOCIATED ELECTRICAL WORK MUST BE INSPECTED BY A TOWN
APPROVED ELECTRICAL INSPECTION AGENCY. PLEASE REVIEW LIST PRrnvint=n it
A Z
Septic Inspection Report ]
Office No. (518) 761-8256 Date Inspection request received: v �Z
Queensbury Building &Code Enforcement Arrive: am/pm Depart: ` am/pm
742 Bay Rd., Queensbury, NY 12804 Inspector's Initials:
NAME: / PERMIT NO.:
LOCATION: INSPECT ON:
RECHECK:
Comments and/or diagram
Soil T Loam Cla
Type of Water: Municipal rjOell Water
Waterline separation distance ft•
Well separation distance ft.
Other wells: 11- 9 ft.
Abs
orption tion Field: Total length '. -ft.
Length of each trench ft.
��" c�
Depth of trenches =L ft.
Size of Stone
Seepage Pits: Number L
Size: x
Stone Size:
Piping Size Type
Building to tank A
Tank to Distribution Box
Distribution Box eld Pit
Opening Sealed: N Partial
End Ca
Inlet/Outlet Pipes&Baffles N
Location/ Separations
Foundation to tank `� ft•
Foundation to absorption I Iw ft•
Separation of Pits ft•
Conforms as per Plot Plan
En ineer Report and As-Built Y N vl ���►
Location of em on Property:
Front Rear Left Side Right Side
Middle Front Middle Rear
Svstem U tat s•
Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
Last revised 021006
Last revised 1/6/05