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SEPTIC DISPOSAL PERMIT Office Use Only��p
APPLICATION Permit#: �'G)`—t 3-20 26
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Town of cens6u
Permit Fee:$ S '
Invoice#: 6 4
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Septic Variance? Y N
Flood Zone? Y
Wetlands? Y Reviewed By:
Project Location: p .....t:toter y4 e- , I ,' ®1
Tax Map #: (3I(oaCA—vi,-2_1
TIUL
18 2023
RESIDENCE INFORMATION: OFTOWN QUEENS BURY
Year Built Gallons #of bedrooms: X gallons per =total daily flow BUILDING&CODES
_ per day bedroom r age Grinder Yes No
1980 or older 150 Installed? (choose one) ❑
1981-1991 130 Spa or Hot Tub Yes No
•1992-Present 110 , Installed? (choose one) ❑
PARCEL INFORMATION: l3-� �t 5 1 toe �j )yhwttivG\ k -
Topography ix Flat Rolling ❑ Steep Slope % Slope J
Soil Nature ®'Sand loam 0.Clay ❑ Other, explain:
Groundwater At what depth? P N
Bedrock/Impervious material At what depth?
Domestic Water Supply [Municipal A/ell ❑Lake
(if well or lake, water supply from any septic system absorption is
ft.)
Percolation Test Rate: ,C per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size 1U)D gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
spa/hot tub
System Absorption field w/#2 stone Total length ,P84 ft.; Each Trench %co ft.
Seepage Pit w/#3 stone How many: ; Size:
Alternative System Bed or other type:
Holding Tank System Total required capacity? 7,,,• tank size ,
# of tanks
6c, ;6 6)751.67: ,c, 1
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Septic Application > Revised Jul 2022
✓ I
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): \1S8 AA itTa 5( c s �j�3Q-fie L
Mailing Address, C/S/Z: '- t)1S' _�if3 / EZRe�bN, \ Z 6
Cell Phone: 9,-1:77____--(0776.1. Land Line:
Email:
• Primary Owner(s):
Name(s): ,6‘>13 `0-LOE4)
Mailing Address, C/S/Z: \p 1V__00c,et`W. A
Cell Phone: Land Line: r 46,6
Email:
❑ Check if all work will be performed by property owner only
• Contractor:Contact Name(s): , O� I0bMt.S '�tDO5 40
Contractor Trade: 4 EpF-E_____ �, ��,E kS r
Mailing Address, C/S/Z: R`C'C � R l p�rp6N �' C7
Cell Phone: Ff —ZXiZ--/'(iq Land Line:
Email:
**Workers' Comp documentation must be submitted with this application**
• Engineer(s):
Name(s):
Mailing Address, C/S/Z:_
Cell Phone: Land Line:
Email:
Contact Person for Compliance in regards to this project: NT 9}eS)\
Cell Phone: (gt(?)-7,7,7.°-62161 Land Line:
Email:
Declaration: Any permit or approval granted which is based upon or is granted in reliance upon
any material representation or failure to make a material fact or circumstance known by or on
behalf of an applicant, shall be voidj3ave read the regulations and agree to abide by these and all
requirements of the own of Quee ury Sanitary Se age Disposal Ordinance.
PRINT NAME:
SIGNATURE: DATE: 7✓i 3'
Septic Application Revised July 2022
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. • . 316.9-1-21 SEP-0443-2023 . . . . lek. /for 'al,. ../-44,J71-zd;sv5 _
i. . . Alden, Robert ' .. . • ' At 'E..44,C.44/".flyitc . •
. • • 1 10 Irongate Rd i
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• Residential Septic Alteration . . . i . . .
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