2005-852 TOVN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development- Building &Codes (518) 761-8256
CERT IFICATE OF COMPLIANCE
Permit Number. P20050852 Date Issued: Friday, October 28, 2005
This is to certify that work requested to be done as shown by Permit Number P20050852
has been completed.
Tax Map Number. 523400-302-014-0001-015-000-0000
Location: 21 PERSHING Rd
Owner. MARY MORIARTY
Applicant: MARY MORIARTY
This structure maybe occupied as. as
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&Mde Ei&rcernent
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: P20050852 Application Number: A20050852
Tax Map No: 523400-302-014-0001-015-000-0000
Permission is hereby granted to: MARY MORIARTY
For property located at: 21 PERSHING 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: MARY MORIARTY
21 PERSHING Rd Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
nT TEENSBT TRY SEWER
JAY SWEET
Plans&Specifications
2005-852
SEPTIC ALTERATION
i
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday, October 27, 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.) i
Dated at the wn of Qu " nsbury; hursday, October 27, 2005
SIGNED B� for the Town of Queensbury.
Director of Building& de Enforcement
Application for Permit— Septic Disposal System Town of Queensbury 742 Bay Road Queensbwy, ArY 12804 (518) 761-8256
1. OWNER INFORMATION:
.................I.............................................. .....................................................
Office Use
Location of installation: � � `�
File Permit I I
Tax Map No.
Fee Paid
Owner's Name..
.........................
Addr
ess:
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. =
1980- 1991 x 130 gal/bdn-n =
1991 -present x 110 gallbdrin =
ocr 9
Garbage Grinder Installed yes
J�' J Spa or Hot Tub Installed yes_ 3Q 6 Or 1005
EFh
4. PARCEL INFORMATION: (circle applicable information& indicate measurements)
Topura-phy Soil Nature Ground Water Bedrock or Impervious Material Domestic Water Supply
at <::sjnN:) at what depth at what depth <: M—um—c t -
pa7D
----7011ing loam —feet feet c:--W:�—e �
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). Add25O gallons to the size
of the septic tank and leach field for each Garbage Grinder, Spa or Whirlpool Tub.
Septic Tank: gallon (min. size 1,000 gal.)
-444e Field: each trench Total System Length: A V-6 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 &IN-FORMATION 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.
Sibna_tur �_f responsible personDate
Town of Queensbury
Sewers and Sewage Disposal Chapter
Appendix C
ABSORPTION FIELD
SEPARATION REQUIREMENTS
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Appendix C
ABSORPTION FIELD
SEPARATION REQUIREMENTS
PO
pain.
4
TIt PsRJVCWAY �R'
Septic Inspection Deport
A
Office No. (518)761-8256 Date Insh:�
pection&receiv O o2
Queensbury Building&.Code Enforcement Arrive: rt:742 Bay Rd., Queens NY 12804 Inspector's Init
NAME:, CUy9-1 P IT NO.: CC45—
LOCATION: �- r�� SPECT ON:
RECHECK: ,
Comments and/or diagram
Soil T : San L- aim" 1
Type o y: unic' /Well Water
Waterlines n 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: x
Stone Size:
Piping Size Type
Building to tank W
Tank to Distribution Box !A 11
Distribution Box o Field/Pit
Opening Seale Y /Partial
End Caps
Location/Separations
Foundation to tank
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan VY N
Engineer Report and As-Built Y N
Location of System on Property:
Fro Rear Left Side Iht Side
Middle Front Middle Rear
System Use St s•
Approved
Partial Approved and needs to be re-inspected,please call the Building& Codes Office
Disapproved
Last revised 1/6/05
ti
THIS PLAN TO BE ON
PROJECT SITE AT
ALL TIMES F R
r
TIMED �z;'
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i CONSTRUCT
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TOWN OF UpEEN88uRy QLAG DEP RNEN T c,
Based on our iirnw examination,
comppliance with our comments shall
not he construed as-indicating the
plans and spReations are in full
compliance nth the Building Codes
of New York State,