2005-699 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: P20050699 Date Issued: Wednesday, August 31, 2005
This is to certify that work requested to be done as shown by Permit Number P20050699
has been completed.
Tax Map Number: 523400-301-017-0002-051-000-0000
Location: 841 SHERMAN Ave
Owner: JOSEPH &ALTHEIA WILLIAMS
Applicant: JOSEPH & ALTHEIA WILLIAMS
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: P20050699 Application Number: A20050699
Tax Map No: 523400-301-017-0002-051-000-0000
Permission is hereby granted to: JOSEPH& ALTHEIA WILLIAMS
For property located at: 841 SHERMAN 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: JOSEPH& ALTHEIA WILLIAMS
841 SHERMAN Ave Septic Alteration Residential
QUEENSBURY, NY 12804 Total Value
Contractor or Builder's Name /Address Electrical Inspection Agency
MORNING STAR SEPTIC
Plans&Specifications
2005-699
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday, August 30, 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 Queensbury; Tuesday,August 30, 2005
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
KI
Application for Permit— Septic Disposal System '` _
Town of Queensbury 742 Bay Road Queensbun,, NY 12804 (518) 761-8256
1. OWNER INFORMATION:
C/���
Location of installation: � �/ / u ol ✓"� Office Use 1^
File Permit No, �o5 lL q
Tax Map No.
e Fee Paid
Owner's Name: ��'��(��S
Address: LI
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of
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2. INSTALLER'S NAME : 4//10n� 1 ' 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 q x 150 gal/bdrm =
1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm =
Garbage Grinder Installed yes / no V<
Spa or Hot Tub Installed yes_ ; no
4. PARCEL INFORMATION: (circle applicable information& indicate measurements)
aphy S ature Ground Water Bedrock or Impervious Material ater Supply
Flat Can at what depth at what,depth municip
in loam feet Z G feet
Steep slope clay if well; water supply
^%slope other from any septic-system
depth: absorption is f t.
other
Percolation Test: (To be completed by licensed professional engineer or architect)
Rate: minute per inch
S. 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: &5-11lon (min, size 1,000 gal.)
Tile Field: each trenchft. 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 t plication and agree to abide by these and all requirements of
the Town of Quee ury Sanitary Sewage is oral Ordinance.
5 -0
Signature r ponsib rson Date
1
ROAD
Appendix C
ABSORPTION FIELD
SEPARATION REQUIREMENTS
PON
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Septic Inspection Report
Office No. (518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/pmDepart: V
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials: /f IU
NAME: �T -``A'► PERMIT NO.: �- 7
LOCATION: LJ �„ INSPECT ON: d .
RECHECK:
Comments and/or diaeram
Soil Type: Sand/Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft.
Well separation distance ft.
Other wells:
Absorption Field: Total lengthLength of each trench
Depth of trenches ft.
Size of Stone �`�Z, 1 `
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 abso tian ft.
Separation of Pits ft.
Conforms as per Plot Plan I Y N
Location of System on Property:
Front Rear Left Side Right Side
Middle Front Middle Rear
system Use St us:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:'aSueHemingway\Building.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 Depart: in
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials: ir-m
NAME: PERMIT NO.: D S -�j
LOCATION: Q-n4 W n/ Av-l— INSPECT ON:
RECHECK:
Comments and/or diagram
Soil Type: and Loam/Clay
Type of Water. umci 1 at
Waterline separation distance ft. ����•�`Jr .� ��
Well separation distance ft.
Other wells: ft. &--� '
Abso tion Field: Total length ' - ft.
Length of each trench ft.
Depth of trenches
Size of Stone Z
seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box ('
Distribution Box tgkield/Pit ';
Opening Sealed:tV 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 System on Property:
Front _ ar Left Side Right Side
Middle Front Middle Rear
System Use Status:
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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TOWN OF QUEENS URY
BUILDING T.
REVIEWED _ - -
DATE____._- �
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