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TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20130202 Application Number: A20130202
Tax Map No: 523400-302-018-0003-033-000-0000
Permission is hereby granted to: MARTHA PHILION
For property located at: 107 COOLIDGE Ave
in the Town of Queensbury,to construct or place
at the above location in accordance with application together with plot plans and other information hereto filed
and approved and in compliance with the NYS Uniform Building Codes and the Queensbury Zoning
Ordinance. Tyne of Construction Value
Owner Address: MARTHA PHILION Septic Alteration Residential
107 COOLIDGE Ave Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
MORNING STAR SEPTIC
793-2290 744-8139
107 JEWELL Rd
GANSEVOORT NY 12831-0000
Plans&Specifications
2013
Septic Alteration
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday,May 16,2014
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the Town of ' nsbury- Thursday,May 16,2013
SIGNED BY ✓' for the Town of Queensbury.
Director of Building& �En cement
r Community Development Office
S 1
Town of Queensbury - 742 Bay Road • Queensbury, New York 12804
Office Use Only
TAX MAP NO. ya l g--3-3.3 PERMIT NO. /3 PERMIT FEE
APPROVALS: ZONING TOWN CLERK
APPLICATION FOR SEPTIC DISPOSAL SYSTEM PERMIT: A PERMI UST BE OBTAINED
BEFORE WORK
tIBEGII�N/S.APPLICATION IS SUBJECT TO REVIEW BEFORE ISSUANCE OF A VALID PERMIT.
OWNER: /Yh.s. lam" ��+-aA;11 INSTALLER:
ADDRESS: �19 C D, A:—e ADDRESS: D 7
PHONE NOS. ?5� 361 L/C/ PHONE NOS.
LOCATION OF INSTALLATION: _
RESIDENCE INFORMATION:
YEAR BUILT NO.OF X COMPUTATIONTOTA
= L DAILY FLOW
BEDROOMS Gallons per bedroom GARBAGE GRINDER
1980 or older q X 150 = 60o INSTALLED? /tom
1981 -1991 X 130 = SPA OR HOT TUB
1992-present X 110 = INSTALLED? t/
PARCEL INFORMATION:
✓ TOPOGRAPHY: FLAT ROLLING-k" STEEP SLOPE %SLOPE
✓ SOIL NATURE: SAND /N LOAM CLAY OTHER
✓ GROUNDWATER: AT WHAT DEPTH?_
✓ BEDROCKIIMPERVIOUS MATERIAL: AT WHAT DEPTH?
✓ DOMESTIC WATER SUPLY: MUNICIPAL_ WELL (if well:water supply from any septic system absorption is: ft)
✓ PERCOLATION TEST: RATE IS PER MIINUTE PER INCH[mpi] (Test to be completed by a licensed professional
engineer or architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION: All individual sewage disposal systems must be designed by a licensed professional engineer or
architect(unless installed in a Planning Board approved subdivision).
TANK SIZE: /ZS-0 GALLON(MIN.SIZE IS 1,000 GAL.)Add 250 gallons to the size of the septic tank for each garbage grinder,
spa or whirlpool tub.
SYSTEM TYPE:
❑ABSORPTION FIELD(WITH NO.2 STONE) Total length _ft. Each trench_6 X )
❑ SEEPAGE PIT(S)(WITH NO.3 STONE) How many? Size?
❑ALTERNATIVE SYSTEM Bed or other type?
❑ HOLDING TANK SYSTEM Total required capacity? Tank size? /2s-o Number of tanks?
NOTE: ALARM SYSTEM AND ASSOCIATED ELECTRICAL WORK MUST BE INSPECTED BY A TOWN APPROVED ELECTRICAL
INSPECTION AGENCY. PLEASE REVIEW LIST PROVIDED.
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 QUESTIONS? CALL 761-8256 OR EMAIL
Sanita a e i sal Ordinance. codes(a aueensburv.net
Signature of P rson Responsible Date VISIT OUR WEBSITE FOR MORE INFORMATION
www.aueensbu�.net
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., Quee+n�sbury, NY 12804 Inspector's Initials:a�¢�
NAME: 1"l��~��` ' "� PE(RM;%IT NO.. 37-
LOCATION:
LOCATION: 10-7 INSPECT ON:
RECHECK: _
Comments and/or diagram
Soil T / Loam/ Clay
Ty of Water: 66glei6al Well Water
Waterlifl—eseparation distance ft.
Well separation distance
Other wells: ft.
Well Casing Length 50' +/- Y N/A
150'to well required if NO
Absorption Field: Total length
Length of each trench ft.
Depth of trenches '_..-A ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tankAl
. r v
Tank to Distribution Box1
Distribution Box to Field Pit `t
Opening Sealed: Y N
End Ca N
Inlet/Outlet Pipes&Baffles Y N
Manholes 12"or less below grade _Y_N
[provide extension collar if Yes Y N
Location Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits
Conforms as per Plot Plan Y N
Engineer Report and As-Built Y N
ETU Maintenance Contract Y_N
provided
Location of System on Property:
Front Rear Left Side Right Side Middle Front Middle Rear
System Use S to
Approve
Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
L:\Pam Whiting\2010\13uilding Codes Forms\Inspection Fomes\Septic Inspecdon Report-03 2910.doc
518-793-2290
374 Fax#518-793-2115
E-mail:morningstarseptic@hotmail.com
www.morningstarseptic.com
Date:
_ 107 Jewel 1Road,Gansevoort,NY 12831
:M010A 7P
7 4 4 ni 6i
sEPrlc PLOT PLAN
I HAVE SEEN OR OBSERVED ALL OBJ-GT8 - - .�—. 1
SUCH AS HOUSES, WELLS, TREES, FENCES, ETC 5
SHOWN ON THIS DOCUMENT,I HAVE PERSONALLY
MEASURED THE DISTANCE S RTH ON THIS DIAGRAM.
10'r
S+cNATURE DATE
TOWN OF QU
Reviewed B
Rafe: r
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518-793-2290
0)',0';Fkax#518-793-2115
374 E-mail: morningstarseptic@hotmail.com
www.morningstarseptic.com
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Date: 6n&4 3 107 Jewel Road,Gansevoort,NY 12831
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SEPTIC PLOT PLAN
I HAVE SEEN OR OBSERVED ALL OBJ
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SHOWN ON THIS DOCUMENT,I HAVE PERSONALLY
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