2002-799 Application forPermit—Septic Disposal System RECEIVED
ILER
7bwn of Queensbury 742 ay Road Queensbury,NY 12804 (518) 761-82s65 1� 20CJ2
d�INFORMATION: 2: 1 Ct l- o �'4-
Location of installation: J / i }� " ' 1�i$v11D CODE
File Pennit N < '�
Tax Map No. ! J
Owner's Name: rX 0 T
�-;f. �, 1 Foo Paid � -
Address: ��__3 f�/') _.c�CSY') c�( .....................................................................................................................................
2. INSTALLER'S NAME : Cf ski/Z PHONE NO. /7 �
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate #bedrootn(s)and multiply If of
bedrooms with applicable gallons per bedroom to equal total dailyflv)V)
Year of Housee No. of Bedrooms x Computation = Total Daily Flow
1980 or older x 150 gal/bdrm =
1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm = "
Garbage Grinder Installed yes_ t no
Spa or Whirlpool Installed yes l no _ 36C 16
4. PARCEL INFORMATION: (circle applicable information &.indicate measurements)
Ll`tLt11S9 Q.rS94�tt �V�.tQr. 89SdroGk_Qr�tnpQ;Ys4l!�n1Pi�riall �tQr.S_upply
at what del,tl., tit what depth
loam feet feet ►
Steep slope clay if well; water supply
_°/a slope other front any septic-system
depth: absorption is Jl.
other
Percolation Test: (To be completed by licensed professional engineer or architect)
?fate: mimile per Inch
5, PROPOSED SYSTEM: For New Construction: All individual sewage disposal systems must be designed by it licensed
professional engineer or architect(unless.installed in a Planning Board approved subdivision). Add 250 gallons to Illc size
of the septic tank antddleacch field for each Garbage Grinder,Spa or Whirlpool Tub.
Septic Tank: (irtn. size !,000 gall (,.YjdC tts
Tile Field: each trench & Jl. Total System Length: 10 Jt• ��
Seepage Pit(s): number of size of each: fi. by fi.
Size of Stone to be used: //
Bed System Size: x
Alternative System: length and/or size
6, HOLDING TANK SYSTEM: (if required)
Number of tanks: / Size of each: gallons /TOTAL Capacity: gallons
Note: Alarm System and associated electrical work must be inspected by a Town approved
electrical inspection agency.
7. SIGNATURE Sc.INFORMATION FOR RESPONSIBLE PERSON(please read)
For your protection, please note that pursuant to Section 136-29 of the Code of the Town
of Queensbury, any permit or approval granted which is based upon or is granted in
reliance upon any material misrepresentation or failure to makes material fact or
circurnstanco known by or on behalf of an applicant, shall be void.
I have read the regulations with respect to this application and agree to abide by these and all
requirements of the wti o [teens iry Sanitary Sewage Disposal Ordinance.
N U
3 gnature of responsible person pate,
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SIGNATU
DATE
TOWN 0
RY
BUILDIN &
REVIEWED B 1
DATE d
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