2000-501 TOWN OF QUEENSBURY
wow 742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
... Community Development- Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20000501 Application Number: A20000522
Tax Map No: 523400-080-000-0001-025-024-0000
Permission is hereby granted to: MARTIN & DENISE SHERMAN
Owner of property located at: 1 WESTLAND Ave
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: MARTIN & DENISE SHERMAN
1 WESTLAND Ave
QUEENSBURY,NY 12804
Contractor or Builder's Name/ Address Electrical Inspection Agency
I.B.S. SEPTIC
2 LOWER WARREN STREET
OUEENSBURY,NY
Type of Construction: Septic Alteration Residential Value : $
Plans & Specifications
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID - THIS PERMIT EXPIRES: Friday,July 19,2002
(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 sb ednesday,July 19,2000
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
Application for Permit—Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury, NY 12804 (518) 761-8256
1. OWNER INFORMATION:
Office Use 1
Location of installation: ( 76 a ,... "
File Permit No. c7 0 --- "
Tax Map No. / / a�
• Fee Paid 0 _
Owner's Name: (V)G, ( j 54c r".,„ .,,
Address: / L 5"7_,�,,,)
2. INSTALLER'S NAME : _T j, c--, S cpj i G PHONE NO. )9r- 1 �i
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 3 x 150 gal/bdrm = ((r .
1980- 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm =
Garbage Grinder Installed yes / no
Spa or Whirlpool Installed yes / no
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
T.. ••.raphy Soil Nature Ground Water Bedrock or lmpervious Material D. .ter Supply
sand at wh t epth att./ATM
nth
'ailing loam at
�I feet
Steep slope clay if well; water supply
_%slope other from any septic-system
depth: absorption is fl.
other
Percolation Test• o 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: ______gallon (min. size 1,000 gal.) � 5/ %/ �?,-
Tile Field: each trench fl. Total System Length: fl.
Seepage Pit(s): number of size of each: _____r_fl. by fl.
Size of Stone to be used: II / 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
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 f Queensbury Sanita Sewage Disposal Ordinance.''
/ —`/ ?-dooa
ature of responsib e person Date
TOWN OF QUEENSBURY
BUILDING& CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name V ' . mk s 0,
Location W4Lcmc �
Date `7.'1 (— (.)Permit # C) E 1�
SOIL TYP • a •a -Clay-
Resul s of Percola Test-
(if applicable) R- te-Mi to/Inch
TYPE OF SYSTEM:
ABSORPTION FIELD Total Length
Length of each Drench
Depth of trenches
Size of stone
SEEPAGE PITS: Number-
Size - . x , ft.
Stone size
PIPING: Size Type
Bldg. to Tank
Tank to Dist. Box 711/2
7
Dist. Box to Field O 1/4
Openings Sealed? `V oPartial
LOCATION/SEPARATII .
Foundation to Tank Opt
Foundation to Absorp ion r/ et
Separation of Pits y_414-feet
Conforms as per Plot P arrk� s No
LOCATION OF SYSTEM ON 'OPER :
(circle oi-
Front Rear Left Side Sim
Middle - .. •. , e .e,
COMMENTS:
SYSTEM USE APPROVED: NO
Arrived*
Depa
ui ding Ins c or
"I have seen or observed,or believe I saw evidence of,
`' e ;ts such as houses, wells,frees fences, etc.,
un this document. I also represent that I have
'' measured the distances set forth on the diagram."
7-/,. -0)0 ,
DATE
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