2005-554 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: P20050554 Date Issued: Thursday, July 21, 2005
This is to certify that work requested to be done as shown by Permit Number P20050554
has been completed.
Tax Map Number: 523400-309-013-0001-003-000-0000
Location: 11 INDIANA Ave
Owner: JOANNE LA BOMBARD
Applicant: JOANNE LA BOMBARD
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
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
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20050554 Application Number: A20050554
Tax Map No: 523400-309-013-0001-003-000-0000
Permission is hereby granted to: JOANNF, LA BOMMARD
For property located at: 11 INDIANA Ave
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: JOANNE LA BOMBARD
11 INDIANA Ave Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
Plans&Specifications
2005-554
septic alteration
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday, July 19, 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 ate.)
Dated at the own of uee U4 sday, July 19, 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,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
:.....................................................................................................................................
ice Use {
Location of installation: ✓��/ `c-
Tax Map No. / / File Permit N
Fee Paid
Owner's Name: 1� i✓ (-a1 /�/�! l��' ` "
...................... ......................f.... ._... .... .............�....................
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2. INSTALLER'S NAME PHONE NO.
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 = OD
1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm = � "
Garbage Grinder Installed yes— / no JUL 1 a 2005
Spa or Hot Tub Installed yes / no
TOVVN 01-i i1€L.tvBURYf
BUILDING;ANQ CODE
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
a h ture Ground Water Bedrock or Im ervious Material PAgggk3Kater Su 1
Fla sand at what depth at what epth municipa
oiling eet eet
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: IOZL-, gallon (min. size 1,000 gal.) G
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.
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Signature of responsible person Date
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7. SIONA►TURE &INFORMATION FWL- F(JN;SwLz rr4%4wL,4 u wodi.,.. %v
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Septic Inspection Report
Office No. (518)761-8256 Date Inspection re es r eiv
Queensbury Building&Code Enforcement Arrive: am/ in part7':- a pm742 Bay Rd.,Queensbury,NY 12804 Inspec is Initi s:
NAME: �`�� 1T NO.: -
LOCATION:
r SPECT ON:
RECHECK:
Comments and/or diagram
Soil T : San oam 1
Type of unicipal YAVell Water
Waterline se tion disLvfce
Well separation ce ft.
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: 122
Piping Size Type
Building o tank
Tank t ox
DisA6bkVjranox to Fie /P. _
Opening Sealed: Y/N artial
End Cap
Location/Separations
M �mo
o tank ft.
M absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Engineer Report and As-Built Y N
Location of System on Property:
Fron ear eft S* Ri t Side
MiddleZFrontiddle Rear
S stem Use St
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
Last revised 1/6/05
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