2005-228 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: P20050228 Date Issued: Monday, April 25, 2005
This is to certify that work requested to be done as shown by Permit Number P20050228
has been completed.
Tax Map Number: 523400-302-018-0002-072-000-0000
Location: 3 GRIFFING PI
Owner: MICHAEL & CARMEN DELLA BELLA
Applicant: MICHAEL & CARMEN DELLA BELLA
This structure may be occupied as a:
Septic Alteration Residential
By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the
property owner of the responsibility for compliance with Site Plan,
Variance, or other issues and conditions as a result of approvals by the Director of Building&Code Enforcement
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20050228 Application Number: A20050228
Tax Map No: 523400-302-018-0002-072-000-0000
Permission is hereby granted to: MIC;HAF,T,& CARMEN DF,I,I,A BF,I,T,A
For property located at: 3 GRIFFING P1
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: MICHAEL& CARMEN DELLA BE
3 GRIPPING PI Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
COOKS SEPTIC
NY 12804-0000
Plans&Specifications
2005-228
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday, April 21, 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 To eensbury, Th rsday,April 21, 2005
SIGNED BY for the Town of Queensbury.
Director of Building& ode&forcement
Application for Permit=Septic Disposal SyAteT
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) ,61-8256
1 OWNER INFORMATION:
.......... ..........................................................
Office Use
Location of installation:
I File P eimut No.
Tax Map No.
Fee Paid
Owner's Name:
.................................................................................................................
Address:
2. INSTALLER'S NAME PHONE NO.!2!?_--_4V0-- �%Z,
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 - 'on QpTMuta t Totalbaily Flow
1980 or older x 150 gal/bdrm =
1980- 1991 x 130 gandrm =
1991 —present x 110 gal/bdrm =
Garbage Grinder Installed yes no 7— 1B r--b Pc otA6 c)O Ey—vuTi OG
Spa or Hot Tub Installed yes no F_L_TEA. bEVj_%C_ b�,5-VF-O, 00
of �A C)tA
4.* PARCEL INFORMATION: (circle applicable information&indicke meaA*t,,-mnts)
p Too"a hy Soil Nature Ground Water Bedrock or impervious Material y. Domestic Water SgpRI_y
Flat san at what depth at what depth municipal
Rolling loam feet
—feet well
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 syste'rns 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 Garbageder,Spa orWhirlpool Tub. s�
0 lEi:b% Fa? _3 ,, .1 �i�C,5
0 0 �c-:�4 fl� bF- �Apll_
/#00. 07e )Septic Tank: gallon(min. size 1,000gal.) REC6*D
Tile Field: each trench Total System Length: 66
Seepage Pit(s): number of size of each: ft. b� ft. NOF QUA
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
of Queensbury, any permit or approval granted which is based u, Dil 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 lication and agree t o abide by these and all
requirements of the T Wn of e b ewage Disposal Ordinance.
Siifwiture of respidrisible person Date
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Septic Inspection Report
Office No.(518)761-8256 Date Inspection re st eive
Queensbury Building&Code Enforcement Arrive: m/p part: }--J(j
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initi s:
NAME: 11t2 �. ItMIT NO.:
LOCATION: ,.c C G SPECT ON: -- "�"
RECHECK:
.•- Comments and/or diagra
Soil Type: a
Type of Water: qunici ell Water
Waterline se arati istance ft.
Well separation distance _ft.
Other wells: $.
Absorption Field: Total length (g ft.
Length of each trench 2 — ft.
Depth of trenches + ft.
Size of Stone (:
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank E. ' t z)Q0
Tank to Distribution Box i
Distribution Box ield/Pit
Openin Seale Y %Partial
End Cap
Location/Separations
Foundation to tank
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Engineer Report and As-Built Y N
Location of System on Property:
Front Rear Left Sid Rig�S'
Middle Front Middle Rear
System Use St tus:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
Last revised 1/6/05
A�'Uyy
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RECEIVED
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TOWN OF QUEE u
BUILDING AND C E
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