94-469 1,
-
CERTIFICATE OF COMPLIANCE
TOWN OF QUEEN58URY
WARREN COUNTY, NEW YORK
Date 901.4 f .,2..5 19
This is to certify that work requested to be done as shown by Permit No 4 4 '9
has been completed.
This structure may be used as a septic system
;
Location Sox 12 Ridge Road
John VanaDrwarker
Owner
54-1-14
By Order of Town Board
T OF QUEENSBURY
f
Director of Building & Code Enforcement
BUILDING PERMIT
TOWN OF QUEENSBURY b
No. 94-469 z
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WARREN COUNTY, NEW YORK •
to
PERMISSION is hereby granted to JOHN VAN DERWARKER
OWNER of property located at RIDGE ROAD Street, Road or Ave.
in the Town of Queensbury,To Construct or place a SEPTIC ALMATION
at the above location in accordance to application together with plot plans and other information hereto filed and
approved and in compliance with the Town of Queensbury Building and Zoning Ordinance.
1. OWNER'S Address is
Box 12 Ridge Rd
Queensbury NY 12804 d
2. CONTRACTOR or BUILDER'S Name
Queensbury Sewer Service
3. CONTRACTOR or BUILDER'S Address r�
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4. ARCHITECT'S Name
5. ARCHITECT'S Address X
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6. TYPE of Construction—(Please indicate by X) H-
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( )Wood Frame ( ) Masonry ( )Steel ( ) N
7. PLANS and Specifications
Septic alteration to include tank only, 1000 gallon as
No. per plot plan and application.
8. Proposed Use
Septic system
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$ 25 . 00 PERMIT FEE PAID —THIS PERMIT EXPIRES August 24 19 96
(If a longer period is required an application for an extension must be made to the Building and Zoning inspector of the
town of Queensbury before the expiration date.) rt
Dated at the Town of Queensbury this 24th Day of August 19 94 p'
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SIGNED BY eiklit � �NQ;l4v for the Town of Queensbury
�ing and Zoning Inspector
;lirairaki
TOWN OF QUEENSBURY
APPLICATION FOR SEPTIC DISPOSAL PERMIT Permit # :`I
Fee Paid
Date: 3 Reviewed By
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LOCATION OF PROPERTY FOR INSTALLATION: J e )( / 2- ? ,_mil q e /C ,
"47- l
Owner' s Name: a A. 'V Ce ✓i
Owner's Mailing Address: cS CC vvt.,..L... 1
Installer's Name: j� t, e,au (�;� ,ti- SI2,3 n Phone #: 1 pC __
Number of bedrooms (if residential ): __ '
Total daily flow (residential-compute @ 150 gal . per bedroom) :
Topography-Circle One: - Flat Rolling Steep Slope % of Slope
Soil Nature-Circle One: and Loam Clay Other /Depth:
Ground Water-At What Depth? Feet
Bedrock or Impervious Material-At What Depth? Feet
Percolation Test-Circle One: - ,ot Required Required/Rate Min. Per Inch
Domestic Water Supply-Circle One: Municipal Other
If domestic water supply is a well -
Separation: Water supply from any septic absorption i'E) feet
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PROPOSED SYSTEM: Septic Tank 76-2 -r gal . (Minimum size: 1,000 gal . )
Tile Field: Each Trench feet//Total System Length feet
Seepage Pit(s) : Number of / Size each: ft. x ft.
Size of Stone to be used: # / Depth or Thickness feet
**************
HOLDING TANK SYSTEM IF REQUIRED
No. of Tanks Size\of Each Gal .
Alarm system and associated electrical work to be inspected by a certified
agency.
****************
I have read the regulation on the reverse side of this sheet and agree to abide
by these and all requirements of the Town of Queensbury Sanitary Sewage Disposal
Ordinance.
SIGNATURE OF RESPONSIBLE PERSON: (`-\)- DATE:
Septic System Inspections:
A. All applications for septic system installation, alteration or repair,
as required by the Town of Queensbury Sanitary Sewage Ordinance, shall
be submitted to the Building Department at least 24 hours before start
of construction and shall include a plot plan showing:
1) the proposed location of the system
2) location and distance to lot lines
3) location and distance to structures
4) location and distance to any water supply
5) size and dimensions of all tanks, distribution boxes, tile fields
and/or drywells
B. No system shall be covered before inspection and approval by the Building
Inspector. Failure to comply with this requirement may result in the
uncovering of the system by the installer and a fine of up to $250.00.
C. An approved copy of the plot plan shall be available on the construction
site. Failure to produce said plot plan at time of inspection may result
in an immediate work stoppage.
D. Should unforeseen problems during construction prevent proper installation,
alteration or repair of an approved system, a new proposal must be submitted
to the Queensbury Building Department before further construction.
Town of Queensbury
Building & Code Enforcement
Department
531 Bay Road
Queensbury NY 12804
Remarks:
TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
531 Bay Road /PM
Queensbury NY 12804
518-745-4447 '
SEPTIC DISPOSAL SYSTEM INSPECTION
Name 71 ,/4'/
Location *
Date g-� G Permit # 9 5
SOIL TYPE: Sand-Loam-Clay-
Results of Percolation Test-
(if applicable) Rate-Minute/Inch
TYPE OF SYSTEM:
ABSORPTION FIELD: Total Length
Length of each trench
Depth of trenches
Size of stone
SEEPAGE PITS: Number-
Size - ft. J x ft.
Stone size _
PIPING: Size Type
Bldg. to Tan
Tank to Dist. Box;
Dist. Box to ieTd/Pit
Openings Sealed Yes No Partial
LOCATION/SEPA' IONS:
Foundation to ;,ank feet
Foundation to°,;l sore ti on feet
Separation 4f P is feet
Conforms as per 'lot Plan Yes No
LOCATION 0F SYSTU'I ON PROPERTY:
(circle ane)
Front - ;dear - Left Side - Right Side
Middle /Front - Middle Rear
COMMENTS: ,N IL..„/
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SYSTEM USE APPROVED: 1210. NO
Arrived:
Departed: /�3 d
Building Ins or
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TOWN OF QUEENSBURY
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REVIEWED BY -_ .. 4miltasfilt 1
DATE
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