2002-1031 Application for,l'ermit-_Septic Disposal,System
T'otvil of QueellSbut y 742 Bayl?ftad Queensbury,NY 12804- (518) 761-8256
L. OWNER INFORMATION:
'Location of iinstaltation•, _ .............................................--.o....,c............... ......._.........:..:............,...:
/ �/tt .........
. �_ } '?t'�'l(3 CCJG.v t-' C rf-c Use /
Tax Map No.
File Portrait No. -�
Owner's Name c Fee Paid S
--=-
Address::4_ „� •o 1�^
2, : INSTALLER'S NAME PHONE NO:`
3,. RESIDENCE INFORMATION: (circle year of dwelling, indicate ft.bedroom(s)and multiply N of
bedro&nts with.-applicable gallons J,,er,bedroom to.equal-total doily flow)
;Year of House: No. ofBedrooms' x 'Computation - Total Daily Fiow
1980 or bides
x 150 gal/bdrin
1980-1901 _ x 130 gal/bdrht =
1991 -present -m�4.F�-� D
F x 110 gallbdrm = .
Garbage Grinder Installed yes+ / no
DFr, E 2002- '
Spa or Whirlpool Installed,
yes no
TOWN of ;.1--ENSBuiaY'
aUlt-DINS Ally CODE
4. PARCEL IN (circle applicable information&indicate measurements)
9. aDt1y _-. LSIC9- C CpUttd^V�aLitt. �[3q,'S1roGk_o_r�lnp.of 4ti� 11p4gria3l gs To a r_ u>>l
1'Xn scrtu�` at what de :th _Pill �' 1 I.Y
/ / »arr�icrl/�cil
of/UrR cult ✓� ✓eet " RTye ►veN
steep_slope clay // y ifwe!/ water supply
_%slope other, (� from any septic-system
depth: absorption is
other
Percolation Test: (To be completed by licensed professional engineer oritrehllect)
hate: mintile per!rash
5: PROPOSED SYSTEM:,. For New Cosetructlore 'Ail individual sewage disposal systems most be designed by a licensed.
professional engiticer'or atchilecl(unless installed in a Planning t3oard al>nrovcci subdivision): Add 2SIl,gallons to the Si%C
of the septic tank and Icach field for each Girl iigc Grinder, Spa` Whirlpool Tab:
Septic Tank: gallon(thin. size !,000 gal.).
Tile Field: each trench- jt. Total System Length: fl.
Seepage Pit(s): ntimber size gfench: fl• by jl.
Size of Stone to be used i/ / u+vpth or thickness
Bed System Size: - x
Alternative System: length and/or size" .
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: / Size of each: gallons•7 TOTAL Capacity: gallons .
Note: Alarm System and associated electrical work must be inspected by a"Town approved
electrical inspection agency.
7. SIGNA.TURE'&.INFORMATION FOR RF-SPONSIBL.E PERSON (please read), .
For your protbction, please dote that pUrsnant to Section 136-29 oftlte C.oite.of tile'Towt
o£Quoonsbuiy, any permit or approval-granted which is based.upott or is"granted in
roliance upon any material misrepresent'it or failure to mako a rtiaterial fact or
circumstatrco known by or on behalf of an applicant, shall be void.
I have read the.rcgulstions with respect to-this application and agree to abide by these and all
requirements of the Town ueensbury Sanitary Sewage Disposal Ordinance.
Signature of responsible Date
Septic Inspection Report
P P P
Office No.'(518)761-8256 Date Inspection request received: t 31 0�—
Queensbury Building&Code Enforcement Arrive: am/pm Depart: am/pm
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials:
NAME: PERMIT NO.:
LOCATION: 0 0" INSPECT ON: 31 0
RECHECK:
Comments and/or diagram
Soil Type: Sand/Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft.
Well separation distance
Other wells: ft.
Absorption Field: Total length ft,
Length of each trench ft.
Depth of trenches ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
BuilqjR&to tank
Tank to Distribution Box
Distribution Box to Field/Pit
Opening Sealed: Y/N/Partial
Location/Separations p /� l /A. &tyhroz
Foundation to tank ft. t & ✓/m !
Foundation to abso tion ft. G
Separation of Pits ft. a'
Conforms as per Plot Plan Y N
Location of System on Property:
Front Rear Left Side Right Side
Middle Front Middle Rear
System Use Status:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
1
Septic Inspection Report
Office No. (518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/pm Depart: am/pm
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials:
NAME: /�r//�I ` � /C�pz .tr PERMIT NO.: �•(} � ��
LOCATION: INSPECT ON:
RECHECK:
Comments and/o dia ram
Soil Typeegangdy Loam/Clay
Type of Water: unici a /Well Water
Waterline se aration stance ft.
Well separation distance ft.
Other%yells:
Absorption Field: Total length ft.
Length of each trench 3 ft.
Depth of trenches
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box y ,-
Distribution Box to Field/Pit k
Opening Sealed: /Partial
Location/Separations
Foundation to tank
Foundation to absorption 3v ft.
Separation of Pits ft.
Conforms as per Plot Plan Y JE N
Location of System on Property: Ff
Front Left Side Right Side
Middle Front Middle Rear
System Use Status:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
�_Disapproved
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"I have seen or observed, or believe I saw evidence of,
all objects such as houses, wells,trees,fences, etc.,
shown on his document. I also represent that I have
MDOo
SIGNATURE DATE
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