application Office Use Only
�} ° SEPTIC DISPOSAL PERMIT APPLICATION Permit#: SE.P—
Permit Fee:,$ ; Invoice#: ,'o0�
Town nicj �cfiu{� Septic Variance? C/ Yes No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
Tax Map ID#: 226.19-2-17
Project Location: 2 Sunset Lane
• Applicant:
Name(s): Mario/Patricia Kowalczyk
Mailing Address, 47 Hilldale Rd. Albertson, NY 11507
Cell Phone: (x ) Land Line: ( ) 516 698-2620
Email: pjk0319@aol.com
SEP 2 it 2020 Pj
• Primary Owner(s): TOWN OF CUEENSBURY
Name(s): same as applicant BUILDING&CODES
Mailing:Address, C S Z:
Cell Phone: ( ) Land Line: ( )
Email: Click or tap here to enter text.
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): TBD
Contractor Trade:
Mailing Address, C/S/Z: Click or tap here to enter text.
Cell Phone: ( ) Land Line: ( )
Email: Click or tap here to enter text.
• Engineer(s):
Name(s): Dennis MacElroy
Mailing Address, C/S/Z: EDP 900 Rt. 146 Clifton Park,NY 12065
Cell Phone: (x ) Land Line: ( ) 518 376-4485
Email: dmacelroy@edpllp.com
Contact Person for Building&Code Compliance:Dennis MacElroy
Cell Phone: (x ) Land Line: (. ) 518 376-4485
Email: dmacelroy@edpllp.com
Septic Application Revised February 2019
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom
1980 or older 150 Click or tap here to
enter text. __.
- Garbage Grinder - Yes . No
1981-1991 130 Click or tap Installed? (check one) ❑ IZ
here to enter
text. Spa or Hot Tub Yes_ No
1992-Present 110 4 110 440 Installed? (check one) ❑ EI
PARCEL'INFORMATION: -.
Topography X❑ Flat Rolling ❑ Steep Slope %Slope
Soil Nature ® Sand 0 Loam ❑ Clay ❑ Other(explain: )
Groundwater At what depth?>5'
Bedrock/Impervious material At what depth?>5'
Domestic Water Supply ❑X Municipal ❑ Well (if well,water supply from,any septic system absorption is ft.)
Percolation Test Rate:20 per minute per-inch (test to,be-completed by licensed-engineer/architect)
P MSED SYSTEM FOR NEW CONSTRUCTION:
Tank'size 1250 gallons(min.size 1,000 gallons,add 250 gallons for each garbage cylinder or-spa/hot tub
System Absorption field with#2 stone Total length ft.; Each Trench ft:
Seepage Pit with#3 stone How many: - •Size: `'.
Alternative System , . Bed or other type: Eljen.GSF 4 trenches at .4 @ 32 If=128 If total
Holding Tank System Total required capacity? . ;tank size ' ;#of tanks
NOTES:•1. Alarm system and associated electrical work must be inspected by a Town approved electrical inspection
agency; 2.,We will no longer allow systems to be covered until such time as an as-built plan is received and
approved. The installed system must match the septic layout on file-no exceptions. 3:As-built drawings must be
submitted prior to the inspection, if there has been a change to the submitted plans. _ __ _ ______
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
void.;I-have read the regulations.and,agree to abide by these and all requirements of the Town of Queensbury
Sanitary Sewage Disposal Ordinance.
PRINT NAME: Mario or Patricia-Kowalczyk
SIGNATURE: /. '' P DATE: 9 g'•da` '
Septic Application Revised February 2019