application svi
Office Use Only
SEPTIC DISPOSAL PERMIT APPLICATION Permit#: CEP'OZ` • 101
Permit Fee: $ ; Invoice#:
r ofcLuccn r~ Septic Variance? Yes No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
Tax Map ID#: 226.12-1-85
Project Location: 300 Cleverdale Rd FIECE " [EIN
SEP 102019 tij
• Applicant: TOWN OF GUEENSBURY
Name(s): Albert Friehofer BUILDING& CODES
Mailing Address, 40 Atrium Dr. Slingerlands, NY 12159
Cell Phone: ( 443 629-8688 ) Land Line: ( )
Email: alfreihofer@gmail.com
• Primary Owner(s):
Name(s): Mary Jane Friehofer Irrev. Trust
Mailing Address: 40 Atrium Dr. Slingerlands, NY 12159
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): Crandall Excavating
Contractor Trade: Site Contractor
Mailing Address, C/S/Z: 63 Woodchuck Hill Road Lake George,NY 1284.5
Cell Phone: (518 4704694 ) Land Line: ( )
Email: chriscrandalldigs@gmail.com
• Engineer(s):
Name(s): Dennis MacElroy
Mailing Address, C/S/Z: 900 Rt. 146 Clifton Park, NY 12804
Cell Phone: ( 518 376-4485) Land Line: ( )
Email: dmacelroy@edpllp.com
Contact Person for Building&Code Compliance: Chris Crandall
Cell Phone: (518 470 4694 ) Land Line: ( )
Email: Click or tap here to enter text.
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 Click or tap Click or tap here to
to enter text. here to enter enter text.
text. Garbage Grinder Yes No
1981-1991 130 Click or tap here Click or tap Click or tap here to Installed? (check one) ❑ El
to enter text. here to enter enter text.
text. Spa or Hot Tub Yes No
1992-Present 110 4 110 440 Installed? (check one) ❑ ►l
PARCEL INFORMATION:
Topography ® Flat Rolling ❑ Steep Slope %Slope
Soil Nature ® Sand El Loam ❑ Clay ❑ Other(explain:
Groundwater At what depth?48"
Bedrock/Impervious material At what depth?Click or tap here to enter text.
Domestic Water Supply ❑ Municipal ❑ Well (if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: 11 per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED 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 3 trenches of 32 If each -96 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: Dennis MacElroy
SIGNATURE: Date: q—t p_ 19
Septic Application Revised February 2019