2005-860 TOWN `OF QUEEN-SBU-RY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20050860 Date Issued: Tuesday, November 08, 2005
This is to certify that work requested to be done as shown by Permit Number P20050860
has been completed.
Tax Map Number: 523400-301-014-0001-053-000-0000
Location: 8 LADY SLIPPER Dr
Owner: SHIRLEY & BRUCE PARENT
Applicant: SHIRLEY &BRUCE PARENT
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 llir ctor of Building 8r3 e rcement
Planning Board or Zoning Board of Appeals.
f, TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building&Codes (518) 761-8256
- BUILDING PERMIT
Permit Number: P20050860 Application Number. A20050860
Tax Map No: 523400-301-014-0001-053-000-0000
Permission is hereby granted to: SHIRLEY&BRI CE PARENT
For property located at: 8 LADY SLIPPER Dr
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: SHIRLEY &BRUCE PARENT
8 LADYSLIPPER Dr Septic Alteration Residential
Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans &Specifications
2005-860
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Thursday,November 02,2006
(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 then of Queer bu r Wednesday,November 02,2005
0
SIGNED BY !• d f/ a� for the Town of Queens
bury.
ury
Director of Building&Coo e Enforcement
Application for Permit— Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury, NY 12804 (518) 761-8256
1. OWNER INFORMATION:
Office Use
Location of installation:
12
F Permit Y
File 60
Tax Map No.
Fee Paid
Owner's Name: C,_ P_1CV'e_-1-u t
.....................................................................................................................................
Address: ccd is S I c 042,,.-
U V c ECEIVEU
2. INSTALLER'S NAME N 0 V 0 1 45NE NO.
3. RESIDENCE INFORMATION: (circle year OUArelling, indiTQWN MKINIultiply #of
bedrooms with applicable gallons pJ3&MMQ,29L I daily flow)
Year of House: No. of Bedrooms x Computation = Total Daily Flow
1980 or older x 150 galfbdrm =
I_P9�_ 19�__-) — _�2_ x 130 gal/bdrm
91�-present x 110 gal/bdnn
Garbage Grinder Installed yes no
Spa or Hot Tub Installed yes no S-3
4. PARCEL INFORMATION: (circle applicable information& indicate measurements)
Topography Soil Nature Ground Water Bedrock or Impervious Material Domestic Water Supply
at what depth at what depth
_75"lling loam —feet feet well
Steep slope clay if well; water supply
%slope other from any septic-system
depth: absorption is
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.
Sgtic Tank: /,Z5_D gallon (min. size 1,000 gal)
mod-F'r-+d- q�uch tre-n-Ich Total System Length:
11,— �� - /-,-4
Seepage Pit(s): number of size of each: _ft. by
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 atown 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.
Si at re P responsible person Date
Town of Queensbury
Sewers and Sewage Disposal Chapter
Appendix C
ABSORPTION FIELD
SEPARATION REQUIREMENTS
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Appendix C
ABSORPTION FIELD
SEPARATION REQUIREMENTS
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Septic Inspection Report A f/
k
Office No. (518) 761-8256 Date Inspection rVSPECTON:
d�
Queensbury Building&Code Enforcement Arrive: .41� art:
742 Bay Rd., Quee bury,NY 12804 Inspector's Initia
NAME: P v coo
LOCATION: c,
RECHECK:
Comments and/or diagram
Soil Type- San airilay
Type of r• unicipal ater
Waterline sepa n istance V_ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length ft. "
Length of each trench
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 field/Pit
Opening Seale Y /Partial
End Caps
Location/Se arations
Foundation to tank r 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 Prope
Fron Rear ft e---Right Side
4St
t Middle Rear
System pproved
Partial Approved and needs to be re-inspected, please call the Building&Codes Office
Disapproved
Last revised 1/6/05
V/ 64
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TOWN OF t?U ' Y
BUILDING &
REVIEWED B
_— - DATE I
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)PIrn CA
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y �\ "I have seen or observed, or believe I saw evidence of,
all objects such as houses, wells, trees, fences, etc.,
D shown on this document. i also represent that 1 have
;�ersonaiiy measured the d' 1. nces se T4orth on the diagram."
1/- o s-
SIGNATURE DATE