2000-634 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
C/C Number: C20000634 C/C Date: Thursday, August 24, 2000
Application Number:A20000634
Permit Number: P20000634
This is to certify that work requested to be done as shown by Permit Number P20000634
has been completed.
This structure may be used as a Septic Alteration Residential
Tax Map Number: 523400-057-000-0001-008-000-0000
Location: 454 RIDGE Rd
Owner: KENNETH & WILMA MASON
By Order of Town Board
TOW UEENS URY
Director of Building&Code nforce ent
1
Ahcsk
TOWN OF QUEENSBURY
VirS 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building & Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20000634 Application Number: A20000634
Tax Map No: 523400-057-000-0001-008-000-0000
Permission is hereby granted to: KENNETH &WILMA MASON
Owner of property located at: 454 RIDGE Rd
in the Town of Queensbury, to construct or place a Septic Alteration Residential
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.
Owner Address: KENNETH &WILMA MASON
C/O DONNA DRUMOND
1011 NW GLISON St#307
PORTLAND, OR 97209
Contractor or Builders Name/Address Electrical Inspection Agency
I.B.S. SEPTIC
2 LOWER WARREN STREET
QUEENSBURY,NY
Type of Construction: Septic Alteration Residential Value : $
Plans & Specifications
2000-634
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Saturday,August 24,2002
(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 o ue bury T ursd , ugust 24,2000
SIGNED BY for the Town of Queensbury.
Director of Building & Co e En cement
Application for Permit—Septic Disposal System
Town of Qtteensbnl y 742 Bay Road Queensbury, NY 12804 (518) 761-8256
1. OWNER INFORMATION:
s r Office Use
Location of installation: i !I� r �j �4 lio0:131Tax Map No. File Penult No.
^„ Sr, N, • Fee Paid
Owner's Name: l(C Ai / -`
Addross: c f J
2. INSTALLER'S NAME : , SC /,l t;_ PHONE NO.
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate Ii bedroom(s) and multiply II (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 3 x 150 gal/bdrnt = 0
1980— 1991 x 130 gal/bdrm =
1991 —
presentx 110 gal/bdrm =
Garbage Grinder Installed yes / no RUC, 2 ,3 2000
Spa or Whirlpool Installed yes / no / ;
4. PARCEL INFORMATION: (circle applicable information &indicate measurements)
Ph a ur Ground Water Bedrock or Impervious Material � Water Supn1y.
t�® sand a! ►vlu t lepth at► /i 1 lej l/a mimic!�a
1 oiling am (tfeetkfeet we
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 sire
of the septic tank and leach field for each Garbage Grinder, Spa or Whirlpool Tub.
Septic Tank: /D 0 D gallon (min. size 1,000 gal)
Tile Field: cads trench 5 b fl. Total System Length:)-- 6/3• fi.
Seepage Pit(s): number of size of each: ft. by
Size of Stone to be used: it _ / depth or thickness _feet /V
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
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 n of Queensbury Sanitary Sewage Disposal Ordinance.
KT)
gnature of responsible person
Date
"1111.1k --4
TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name KC-7, vL \(\f\a_scityl,
Location " l( ()Gr
2f_ C(c)
Date .8 ('- ermi t # ?C--(gl
SOIL TYPE: a oa C ay-
Results of Percolation Test-
(if applicable) Rate-Minute/Inch
TYPE OF SYSTEM: i
ABSORPTION FIELD: Total Length d
Length of each trench 4 gm'
Depth of trenches Z'
Size of stone
SEEPAGE PITS: Number-
Size - ft. x ft. 1&
Stone size
PIPING: Size T ype
Bldg. to Tank `
Tank to Dist. `Box "cm)
Dist. Box to Fi' ld/P' A I- A �-f'U
Openings Sealed. o i ort
LOCATION/SEPARAT
Foundation to Tank 31 feet
Foundation to Absorption 4 ► feet
Separation of Pits _
Conforms as per Plot Plain „0
LOCATION OF SYSTEM ON PROPS' :
(circle one)
Front - Rear - Lef - "ight Side
Middle Front - iddle Rear
COMMENTS:
•
0 V— -<D
SYSTEM USE APPROVED: YES
Arrived:
Departed- ;
ui ing Inspe
ii
08/24/2000 11:Q3 s7983213 IBS PAGE 02
r •W
fit
if
rIt
•
�4 J
1
5� TOWN OF QUEENSRY
1
BUILDING & `T,
REVIEWED BY
GATE
i
_________-------.rt
I
i
1
I
ifs 1 O
�3 .-/-
4
u r J"}(/ �� rip.l t�?
o Q° `� -C
have seen or observed or believe I saw evidence
1,n as ,houses wellstdetke
t, , trees, of
5 � .,:.z; ;��,; fences, etc.,
�pj ,{. I also represent have
I • j / rt uasti ed the distances set forth on the diagram."
"Z l� �, / gam
II SIGNATURE -- �� �ooe
. p v� DATE
G ci
H' ,
.v./U1
(.": Iv(.,
V j'
Tcc
1
1(c. Aip , ,, 5 �,V * ' ' �! 4c