2003-531 ea TOWN OF QUEENSBURY
0-4zo742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20030531 Date Issued: Thursday, July 17, 2003
This is to certify that work requested to be done as shown by Permit Number P20030531
has been completed.
Tax Map Number: 523400-289-011-0001-017-000-0000
Location: 12 HALL RD. EXT
Owner: MARTIN G GALLUP
Applicant: MARTIN G GALLUP
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
(-- 1P 1St'
Director of Building&Code Enforcement
TOWN OF QUEENSBURY
F 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20030531 Application Number: A20030531
Tax Map No: 523400-289-011-0001-017-000-0000
Permission is hereby granted to: MARTIN G GALLUP
For property located at: 12 HALL RD. EXT
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: MARTIN G GALLUP Septic Alteration Residential
3070 FULTON Rd Total Value
FRANKLIN,NC 28734-4936
Contractor or Builder's Name /Address Electrical Inspection Agency
OUEENSBURY SEWER
JAY SWEET
Plans&Specifications
2003-531
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday,July 16,2004
(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 of ensb e j sday,July 16,2003
SIGNED BY for the Town of Queensbury.
Director of Building& ode E orcement
Application for Permit—Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury, NY 12804 (518) 761-8256
1. OWNER INFORMATION:
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Location of installation: / f7 / .f??l.J Fv I Office Use
Tax Map No. / / File Permit No.
Owner's Name: &U'f/ ra. / /
Fee Paid
Address: /4(
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2. INSTALLER'S NAME : cc ge k1s' (avr-y ac.� �✓ PHONE NO. irti6v/r
I
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate#bedroom(s) and multiply#of
bedrooms with applicable gallons per bedroom to equal total dai
..; �
Year of House: No. of Bedrooms x Computation = Total Daily Flow 6, ---
1980 er ( x 150 gal/bdrm = ( JUL 1�D 2r( ?
980— 1991 x 130 gal/bdrm = TO VrNl;
1991 —present x 110 gal/bdrm =
Garbage Grinder Installed yes_ /Cc
Spa or Hot Tub Installed yes Ist
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
To ography Soil Nature Ground Water Bedrock or Impervious Material Domestic Water Supply
r� at what depth at what depth municipal
Rolling loam feet feet tffli r0
Steep slope clay "well; water supply
_%slope other from any septic-system
depth: absorption is G t.
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:a&-z) gallon (min. size 1,000 gal)
Tile Field: each trench ft. 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
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.
1:41/ \L.,0
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Sign a of responsible person Date
7.--
Septic Inspection Report
Office No. (518)761-8256 Date Inspection reque ceived:
Queensbury Building& Code Enforcement Arrive: p r-. rt: \'.2 an�
742 Bay Rd., Queensbury,NY 12804' Inspector's Initial
NAME: x �11 ERMIT NO.: ,..� —$3 I
LOCATION: r \ (..R, _.�, _���� INSPECT ON: 1 —• � 7—�v
RECHECK:
Comments and/or diagram
Soil Type: Sand/Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenches ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
•
Piping Size Type
Building to tank £ 1,i 1 5n
� 9" ¢-"2,S
Tank to 4 i% 11Pe-35"
Distribution Box to Field/Pit
Opening Sealed: Y/N/Partial
Location/Separations
Foundation to tank 5 ft. ‘01 _
Foundation to absorption ft. � �� � �—� ��
Separation of Pits ft.
Conforms as per Plot Plan Y—N
Location of System on Property:
Front Rear Left Side Right Side
Middle Fro t Middle Rear
S stem Use St us:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:\SueHemingway\I3uilding.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
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