2005-323 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20050323 Application Number: A20050323
Tax Map No: 523400-308-006-0001-061-000-0000
Permission is hereby granted to: QUEENSBURY VILLAGE MOBILE HOME PARK
For property located at: PETRIE Ln
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: SAMUEL & VIOLA WAHNON
39 SARATOGA ROAD Septic Alteration Residential
GANSEVOORT, NY 12831 Total Value
Contractor or Builder's Name /Address Electrical Inspection Agency
Plans&Specifications
2005-323 QUEENSBURY VILLAGE MOBILE HOME PARK
SEPTIC ALTERATION FOR LOTS 27 & 29
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday, May 25, 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 of ens ; , May 25, 2005
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,IYY 12804 (518) 1.61-8256
1. OWNER XNFORMATION: �j r—..._.___.......__ �_ _...�..._....,.._�.__.._.._....,
Office Use
Location ofinstallataom:
Tax Map No MI(0! / I ' File Permit No. �� — \'
Fee Paid
Owner's Name:
Address: ..
2. 1 N'S TALLER'S NAME PHONE NO.
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate#I;bedroom(s)and multiply#of
bedrooms with applicable gallons per bedroom to equal total dailyJlow)
Year of House: No of Bedrooms x Co�tation = Total Daily Flow
1980 or older x 150 gal/bdrm 1980—199I x 130 gallbdrm = E C E I V�/
E
1991 —present x• �110 pVbdrm =
Garbage Grinder Installed yes / no V - MAY 7 l Q 5
Spa or Hot Tub Installed yes I no
4. PARCEL INFORMATION: circle 'TOWN OF C)UiVSBUfZY
( applicable information 8a indicate measurements) BUILDING AND CODE
OTARMphy e oun Water Bedrock or LmRqrvicrus Material WateTSjWp1j
FIa an at what depth at what depth munici
olling fe w Steep slope clay if well;water supply
_VV slope other from any septic-system
depth: absorption is ft.
other
Percolation'fast: (To be completed by licensed professional engineer or.architect)
Rate: minute per inch
S. PROPOSED SYSTEM: For lYew Comtiuuetlon: 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
ofthe septic tank and leach field for each Garbage Grindex,Spa or Whirlpool Tub.
Septic'Tank: (�gallon(mint.size 1,000 gal.)
Tile Field: each trench —f1. Total Systemi Length:
Seepage Pit(s): number of size of each: l(�fit. by
Size Stone to be used: # , / de pth or thickness _feet
Bed System Size: x
Alternative System length and/or size
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: i 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 Queensbtay,any permit or approval granted which is based upoini or is granted in j
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 tto�oo abide by these and all
requirements the Town of Queensbury Sanitary Sewage Disposal Ordinance.
Signature of responsible person Date
£00/900 18 UaMdoTaaaQ 11TunuMOO 001 LSVV SVL 8TS YVd 89:TT moW 5009/9T/90
Septic Inspection Report
Office No.(518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: a epart:
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials: pm
rrf
NAME: 't- A �() _ G;�V PERMIT NO.: --
LOCATION: } INSPECT ON:
RECHECK.
Comments and/or diasram
Soil Type: Sand/Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft.
Well separation distance ft. /� L
Other wells:
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
Tank to Distribution Box
Distribution Box to Field/_Pit
Opening Sealed: Y/N/Partial
End Ca o
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 SynRearo
n Property:
Front Left Side Right Side
Middle Front iddle Rear
System Use Stat
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
Last revised 1/6/05
Septic Inspection Report
Office No.(518) 761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: ar ep rt: 'pm
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials:))
NAME: / PERMIT NO.: .-;24cjV 5 —
LOCATION v7 L INSPECT ON:
RE : Comments and/or diagram
Soil Typ< Sa / /Clay
Type of Wat : Municipal Well Water
Waterlines a is ance ft.
Well separation distance ft.
Other wells: $.
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenches ft.
Size of Stone
See age Pits: Number
Size: x
Stone Size:
Piping Si T e
Building to tank jo
Tank to Distribution Box
istribution Box to Field/Pit
Opening Sealed: Y/N/Partial
End Caps
Location/Separations 404L�`' N 0-r
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 &A FKLE— `
Location of Sys n Property:
Fron Rear Left Side Right Side
Middle nt Middle Rear
System Use Status-
Approved
y Partial Approved and needs to be re-inspected,please call the Building& Codes Office
Disapproved
Last revised 1/6/05
O ;T,\',;.r:S AP.PLICANTS
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LANE ' ( (IJ EASBIJRY, NY 12804 et
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0 ` ISSUED FOR DOH & TOWN REVIEW 3/1
No. Revisions Do
TOhrN OF QUEENSBURY
— - 462 COUNTY OF WARREN
_ N. Y. STATE LIC. NO. 35617
TOWN OF-QUEENS8URY-8k-9ftNfPAPWENT
Based on our limited examination,
comppliance with our comments shalt RECEIVED �o
--�� not be construed as indicating the
;•. ; and specifications are +n full i
y= c t it in;� Codes /
a.: 7--,�, MAY 7 )(!0
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