2005-555 TOWN OF QUEENSBURY
742 Bay Road,Queensburv,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20050555 Date Issued: Wednesday, July 20, 2005
This is to certify that work requested to be done as shown by Permit Number P20050555
has been completed.
Tax Map Number: 523400-301-006-0002-083-000-0000
Location: 10 WESTLAND Ave
Owner: CHRISTINE MINER COULMAN
Applicant: CHRISTINE MINER COULMAN
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&Co a Enf ement
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: P20050555 Application Number: A20050555
Tax Map No: 523400-301-006-0002-083-000-0000
Permission is hereby granted to: CHRTSTTNE MTNF,R COT J ,MAN
For property located at: 10 WESTLAND 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: CMSTINE MINER COULMAN
10 WESTLAND Ave Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804
Contractor or Buddei s Name /Address Electrical Inspection Agency
T.B.S. SEPTIC
2 LOWER WARREN STREET
OTTEENSBTTRY. NY
Plans&Specifications
2005-555
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 date.)
Dated at thrZ of Qu nsbuOing
uesday, July 19, 2005
SIGNED B for the Town of Queensbury.
Director of B. de Enforcement
Application for Permit-Septic Disposal S stem
PP P P Y
Town Of Queensbury 742 Bay Road Queensbury,NY 12804 'i(518) 761-8256
1. OWNER INFORMATION: ......._........
Office Use
i
Location of installation: '
5
�o . �--
�-- 1 File Permit No.'
Tax 4ap No.
//� Fee Paid J� /
Owner's Name:-- r ti co CSC-/"t u, /c//
Address: w ��c S / t��M� ....................................................1....................... ...............
2. INSTALLER'S NAME : _I %r� PHONE NO.
3. RESIDENCE INFORMATION: (circle year o 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
i
1980 or older 3 x 150 gal/bdrm = ` v
1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm = -JUL
ZuO
Garbage Grinder Installed yes_ / no
Spa or Hot Tub Installed yes_ / no YO h `� ' DE
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
TAARduaDhv a e Ground Water Bedrock or jLnpervious Material . Do ater Supply
Flat sand wh t depth at w t epth unicipa
o ling eet -'feet
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.
Lktf% "s
Septic Tank: l l b 0 0- 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 qf 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
requirements of the T of Queensbury Sanitary Sewage Disposal Ordinance.
V <i
nature of responsible person Date
Septic Inspection Report /
Office No. (518)761-8256 Date Inspection requ t r e- ed: 7 g/ U
Queensbury Building&Code Enforcement Arrive: art: in
742 Bay Rd., Queensbury, 1/2804 Inspector's Initi
NAME: _ RMTT NO.:
LOCATION: SPECT ON: le
RECHECK:
Comments and/or diagram
Soil Type: a / a
Type of Wa er: unici ell Water
Waterlines arat1 ante 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 ell
Tank to Distribution Box
Distribution Box t ie!k it 11 Yj
Opening Sealed• Y /Partial
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.�
Separation of Pits ft.
Conforms as per Plot Plan N
Engineer Report and As-Built Y N
Location of System on Property:
Front Rear Left Right Side
Middle o Middl
System Use atus•
Approved
Partial Approved and needs to be re-inspected,please call the Building& Codes Office
Disapproved
Last revised 1/6/05
RECel—
JUL 1 4 2005
Po j C TOWN OF t��,wEIN BURY
1. 1t�C , N CODE
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To N OF QUEENSEURY
BUS DING & p T.
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