2000-748 Application for Permit -- Septic Disposal System
Town of Queensbury 742 Bay Road QueensbuM NY 12804 (518) 761-8256
1 . OWNER INFORMATION:
Location of installation: ,C [ //6 (C//c (�}''�E(j�y 0frace Use
Tax Map No. ! ! File Permit No c. W 000 _ �+
Fee Paid S- Ca �
Owner's Name a t"
............................._....-.........
Address: h,
2. INSTALLER'S NAME : 27 raj{"yi' e +G. PHONE NO.
3 . RESIDENCE INFORMATION: (circle year of dwelling, indicate 0 bedroom(s) and multiply 11 of
bedrooms with applicable gallons per bedroom to equal total dadyflvw)
Year of House: No. of Bedrooms x Computation - Total Daily Flow
1980 or older x 150 gaVbdrtn = d
1980 - 1991 x 130 gallbdrm =
1991 - present x 110gallbdrm =
Garbage Grinder Installed yes / no
Spa or Whirlpool Installed yes ! no
4. PARCEL INFORMATION: (circle applicable information & indicate measurements)
r QrQUne1 '�4latVr B! rock or Imper�riQ s Material Dom @st c W ter_Sinppiy
at sand,/l (Ft w t delxth eft wf cicyrtlt mi�raic l r
t ling t� feet feet we
Steep slope clay ifwell; water supply
slope other from any septic-system
depth. absorption is f7_
other
Percolation Test:. o be completed by licensed professional engineer or architect)
Hate: minute per inch
5. PROPOSED SYSTEM; For New Construction: All individual sewage disposal systems must be dcsigned 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: !'f 0 c gallon (min. size 1, 000 gal;)
Tile Field: each trench - � Total System Length: �2 J1
Seepage Pit(s): number of size ofeach: ft. by fit.
Sloe of Stone to be used: N / depth or thickness
Bed System Size: x
Alternative System: length and/or size
6, HOLDING TANK SYSTEM: (if required)
Number of tanks: I Size of each: gallons I TOTAL Capacity: gallons
.Note: Alarm System and associated electrical work must be inspected by a Town approved
electrical inspection agency.
7. SIGNATURE & 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 make a material fact or
circumstance 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 Town of Queensbury Sanitary Sewage Disposal Ordinance_
Si tube of responsi person Date
TOWN OF QUEENSSURY
BUILDING & CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804
(519) 761-9256
SEPTIC DISPOSAL SYSTEM INSPECTION
NameL° ' l
Location -
Date C 24 rmit # rz 7�
SOIL TYPE- Sand- am C1 Results of Percol a on T t-
( if applicable ) Ra e- Min a/ Inch.
TYPE OF SY5TEM1: l .-, 6
ABSORPTION FIELD: otal engath
Length of each tr nch r +�
Depth of trenches
Size of stone
SEEPAGE PITS : be -
Size - ft ft .
Stone size
PIPING: S ze ype
Bldg . to Tan `r SDI �Sr
Tank to DiTfw Box " 44
Dist . Box to Fiel Pi ,. r 0
Openings Sealed ? es No art1 a
LOCATION/SEPARATI
Foundation to Tank ,� > feet
Foundation to Abso ti on feet
Separation of Pits feet
Conforms as per Pl t Plan a No
LOCATION OF SYSTEM ON 'PROPER
( ci rcl
Front N Re r)- Lef Side _ Right Side
Middle - Middle Rear
COMMENTS :
SYSTEM USE APPROVED : OES NO
Arrived:
Departed :
Building Inspector
TOWN OF QUEENS- URY
BUILDING & PT.
REVIEWED B
DATE
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