2004-432 41 TOWN OF QUEENSBURY
^� 742 BayRoad,Queensbury, 12804-5902 (518)761-8201
ow Q rY,
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20040432 Date Issued: Friday, June 18, 2004
This is to certify that work requested to be done as shown by Permit Number P20040432
has been completed.
Tax Map Number: 523400-296-006-0001-001-000-0000
Location: 1 MANNIS Rd
Owner: RONALD & VALARIE DAVIES
Applicant: RONALD & VALARIE DAVIES
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
Director of uil i e Edrc.;(r'
rhal
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Verg
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20040432 Application Number: A20040432
Tax Map No: 523400-296-006-0001-001-000-0000
Permission is hereby granted to: RONAT,D & VAT,ARTF,DAVIES
For property located at: 1 MANNIS 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: RONALD & VALARIE DAVIES
1 MANNIS Rd Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
Plans&Specifications
2004-432
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday, June 10, 2005
(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 ueens ry; u day, June 10, 2004
SIGNED BY for the Town of Queensbury.
Director of Building Code nforcement
Application for Permit=Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
Or\C` (0;
a • Office Use
Location of installation: l a-Ai � `/t
File Permit No.
Tax Map No. / / 1rt
Fee Paid
Owner's Name: Urt✓ Cc�V�
/ E
Address: (/ A-_0
2. INSTALLER'S NAME : ?` 5` ScP�HONE NO. ZS f• J
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 Computation = Total Daily Flow
1980 or older ) x 150 gal/bdrm = Cp 3c C
1980—1991 x 130 gal/bdrm =
1991—present x 110 gal/bdrm =
Garbage Grinder Installed yes / no
Spa or Hot Tub Installed yes! ./ no
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
-14 aphv ature Ground Water Bedrock or Impervious Material Domestic Water Supply
Fl sa•- ;teal de depth atpliq#depth municipal
'oiling loam it- N/`�f 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 Tank: 7c90e) gallon (min.size 1,000 gal.) rcp(o(G
Tile Field: each trench ft. Total System Length: ft.
Seepage Pit(s): number of size of each: ft. by ft.
Size c 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.
hif __ pod
gnature of responsible person Date
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received: l
Queensbury Building& Code Enforcement Arrive: am/pm art: am/pm
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials:
NAME: PERMIT NO.:
LOCATION: ) COA I 1 S INSPECT ON: filelliffir
RECHECK:
Comments and/or diagram
Soil Type: Sand/Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft. _
Well separation distance ft. A) a 1 F1—'
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
Tank to Distribution Box
Distribution Box to Field/Pit
Opening Sealed: Y/N/Partial
•
Location/Separations
Foundation to tank ft.
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 Fron Middle Rear
System Use Statu :
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:\SueHemingway'Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
Septic Inspection Report
Office No. (518)761-8256 Date Inspection requ t received: /z'
Queensbury Building&Code Enforcement Arrive: am/ Depart: V i m/pm
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials: `VV
NAME: �t\` ,C 1 415 Z�
PERMIT NO.:
LOCATION: � �y� � INSPECT ON: ra"
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:
Stone Size:
•
Piping Size Type
Building to tank
Tank to Distribution Box CO 8 -rc4
Distribution Box to Field/Pit
Opening Sealed: Y/N/Partial
Location/Separations
Foundation to tank ft.
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 Front Middle Rear
System Use Status:
A oved
rtial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:'\.SueHemingway'J3uilding.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
it) c4r
ii
1101 -41/\
Septic InspectionReport
p Re ort
Office No. (518) 761-8256 Date Inspection request received: 1
Queensbury Building&Code Enforcement Arrive: am/pm fart: am/pm
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials: ,Vl
LCI NAME: « ti U i C-_ S PERMIT NO.: LI _
LOCATION: I ( \ c;, r\� l _3 INSPECT ON: - c i
RECHECK:
Comments and/or diagram
Soil Type: Sand/Loam/Clay
Type of Water: Municipal/Well Water (-�J V �eipL 4 C&Ink,E-N
Waterline separation distance ft.
Well separation distance ft. v,4/ 4-1(
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 SipY Type
Building to tank 'jDik`3 S'
Tank to Distribution Box
Distribution Box -ld/Pit
Opening Seale.. ' 4/Partial
iiiit
Location/Separations
Foundation to tank 2-0 ft.
Foundation to absorption ft.
Separation of Pits _ ft.
Conforms as per Plot Plan —Y—N
Location of System on Property: G /
Front ear Left Side Right Side v x /d%- /4LC"7-- D v C.c-I
Middle Front Middle Rear /✓A-F r 4-S
System Use Status:
proved
artial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:\SueHemingwayV3uilding.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
Septic Inspection Report
Office No. (518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/pm epart: e am/pm
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials:
NAME: -DAV t�''`J PERMIT NO.: ilb
f 113
LOCATION: U•&A tuti1 t RC , INSPECT ON: 6 ASV)
RECHECK:
Comments and/or diagram
Soil Type: Sand/Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft. RC—C1'(C l< C C.-S '"
Well separation distance ft.
Other wells: ft.
Abso stion Field: Total lentth ft.
Length of each trench ft.
Depth of trenches ft. C-r ;CH /&JLT
Size of Stone
Seepage Pits: Number _ '`j'c - l'I A- LE
Size: x _\ r-�
Stone Size:
•
Pi in Size Type
CPL �a R.C.--C-i-eCZK
p g
Building to tank _
Tank to Distribution Box
Distribution Box to Field/Pit
Opening Sealed: Y/N/Partial
Location/Separations
Foundation to tank ft.—
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 Fr n Middle Rear
S stem Use Stat •
roved
artial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:\SueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
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TOWN OF QUEENSBURY B.U1LDNG DEPARTMENT
BUILDIt G & 0
Based on oiir limited mexmaemnitnsation, D T.
compliance with our coin icatingshall
the
not be construed as O REVIEW:. BY -
,.., plans and specifications are in full
DATE I a
compliance with the Buildtn,,i Codes
of New York State.
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