2005-145 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20050145 Date Issued: Wednesday, March 23, 2005
This is to certify that work requested to be done as shown by Permit Number P20050145
has been completed.
Tax Map Number: 523400-303-020-0001-067-000-0000
Location: 48 BOULEVARD
Owner: DANIEL & MELISSA BROUILLETTE
Applicant: DANIEL & MELISSA BROUILLETTE
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
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Director of Building&Code Enforcement
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20050145 Application Number: A20050145
Tax Map No: 523400-303-020-0001-067-000-0000
Permission is hereby granted to: DANIF.I,&MF.I,ISSA BROi1T1,I,FTTF
For property located at: 48 BOULEVARD
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. Type of Construction Value
Owner Address: DANIEL& MELISSA BROUILLET7
48 BOULEVARD Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804-0000
Contractor or Builder's Name / Address Electrical Inspection Agency
I_B_S_ SEPTIC
2 LOWER WARREN STREET
OITEENSBITRY_ NY
Plans&Specifications
2005-145
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID -THIS PERMIT EXPIRES: Thursday, March 23, 2006
(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 T f Quee ury; Wednesday, March 23, 2005
SIGNED BY i for the Town of Queensbury.
IV
Director of Buildin &Co Enforcement
Application for Permit—Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION: ........
Office Use
Location of installation: L/c, G C
File Permit No�0
Tax Map No.
Fee Paid
Owner's Name: rh L/ 61 714—
.....................................................................................................................................
Address: 6. L�C-
2. INSTALLER'S NAME zw"6, PHONE NO.
3. RESIDENCE INFORMATION: (circle year of'dwelling,indicate#bedroom(s)and multiply#of
bedrooms with applicable gallons per bedroom to equal total daily flow)
Year of House: No. of Bedrooms x Computation = Total Daily Flow
1980 or older x 150 gal/bdrm = r-S_d
1980-1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm =
Garbage Grinder Installed yes no
Spa or Hot Tub Installed yes no
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
Tg�ravhy SAR%ture Ground Water Bedrock or!MRervious Material Dome Water SgRply
Fl a_4Vj k_nd,,' at what depth at what depth
oiling loam /i4 feet A14 feet
Steep slope clay if well;water supply
%slope other from any septic-system
depth: absorption is_ft.
other
Percolation Test: (To be completed by licensed professional engineer or architect)
Rate: minute per inch
5. 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). Add 250 gallons to the size
of the septic tank and leach field for each Garbage Grinder,Spa or Whirlpool Tub.
Septic Tank: 0,00 ' gallon (min. size 1,000 gal.)
Tile Field; each trench Total System Length: ft.
Seepage Pit(s): number of size of each: _ft. by_ft.
Size of Stone to be used: depth or thickness feet
Bed System Size: x
Alternative System: length and/or size
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: Size of each:_gallons 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 i
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.
Id,� IeSr
Signature of responsible person Date
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"I have seen or observed, or believe I saw evidence of,
all objects such as houses, wells, trees,fences, etc., E
-IJ shown on this document. I also represent that I have �' 90
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personally sured the distaInces set forth on the diagram." �
SIGNATURE DATE
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Septic Inspection Report
Office No.(518) 761-8256 Date Inspection reque t received:
Queensbury Building&Code Enforcement Arrive: epart: l pm
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials:
NAME: PERMIT NO.:
LOCATION: t�
�, INSPECT ON:
RECHECK:
Comments and/or diagram
Soil Type. and/ a
Type of Water: unic' Well Water
Waterlines aration distance ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenches
Size of StoneIAJN G
..Seepage Pits: Number
Size: x
Stone Size:
Piping Si e Type
Building to tank �J
Tank to Distribution Box /L?f
Distribution Box to Field/Pit K �l
Sealed: Y/N/Partial
End C
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Of N
Engineer Report and As-Built Y N
Location of System on Pro erty:
Front Rear Left Side ight Side
Middle Fro Middle Rear
System Use Sta s•
Approved
Partial Approved and needs to be re-inspected, please call the Building&Codes Office
Disapproved
Last revised 1/6/05