2005-242 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: P20050242 Date Issued: Thursday, April 28, 2005
This is to certify that work requested to be done as shown by Permit Number P20050242
has been completed.
Tax Map Number: 523400-308-016-0002-008-000-0000
Location: 25 MERRITT Rd
Owner: CAROLYN M. GORRIE
Applicant: CAROLYN M. GORRIE
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 )J 4
4t
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
(2t 742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development-Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20050242 Application Number: A20050242
Tax Alap No: 523400-308-016-0002-008-000-0000
Permission is hereby granted to: CAROLYN M GORRIF,
For property located at: 25 MERRITT Rd
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: CAROLYN M. GORRIE
25 MERRITT Rd Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
SANITARY SEWER SERVICE
Plans&Specifications
2005-242
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday,April 26, 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 Town of Queensb Tu a ,April 26, 2005
T z
SIGNED BY for the Town of Queensbury.
Director of Building&C de En rcement
Application for Permit-Septic Disposal System l �1
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
........................................................................................................................................
/ etu/ t7 RID Office Use
Location of installation: 1 J ✓J
File Permit No.
Tax Map No.
Fee Pai j
Owner's Name: 6 �Z f r
............................................... ...............................................................................
...s
Address: (L l% ►�
2. INSTALLER'S NAME : PHONE NO.� 72-57
3. RESIDENCE INFORMATION: (circle yea 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 - v x 150 gal/bdrm
1980 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm =
Garbage Grinder Installed yes_ / no TOWN
OF
Spa or Hot Tub Installed yes_ / no BUILDING OENS80Ry
AND CODE
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
Toi5Mgphy SDiHftture Ground Water Bedrock or Im ervious Material Domestic Water Su 1
Flat sand at what depth at what depth —municipal')
`
o tng oam 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 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 Ta gallon (min. size 1,000 gal)
Tile Field: each trench ft. Total System Lengt ^.., ft.
Seepage Pit(s): number of /" A size of each: ft. by ft.
Size of Stone to be used: # I 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
requir `ents of t Town of Quee Sanitary S wage Disposal Ordinance,
Sig a ure of responsi a person ate
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7. SIGNATURE &INFQRMATION POP,. r0Nbwl-,r-mr-avim wtoos..,aw"%v
r
Septic
p c Inspection Report
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/ !part: _am/pm1/
742 Bay Rd., Qu sbury,NY 12804 Inspector's Initials: ( �"[�
NAME: PERMIT NO.:
LOCATION: INSPECT ON:
RECHECK: �,, � -,TG
Comments and/or diagram
Soil T e: San oam
T of Wat unicipa /Well Water
Waterlines a tion di nce ft.
Well separation is ance
Other wells:
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenches I ft.
Size of Stone L lzcroe ,
Seepage Pits: Number
Size: x
Stone Size:
Piping S' Type/
Building to tank
Tank to Distribution'pox tf 3
Distribution Box Id/Pit c1
Opening Sealed /N/Partial
End Caps
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Engineer Report and As-Built Y N
Location of SyPear
on Property:
Front Left Side Right Side
Middle Middle Rear
System Use Statu .
Approved
Partial Approved and needs to be re-inspected, please call the Building&Codes Office
Disapproved
Last revised 1/6/05
RECEIVED
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REVIEWED BY
DATE