2004-173 TOWN OF QUEENSBURY
Lid 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20040173 Application Number: A20040173
Tax Map No: 523400-309-015-0001-068-000-0000
Permission is hereby granted to: KAY, ROBERT AND SHARON
For property located at: 63 HAVILAND 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 1
Ordinance. Type of Construction Ya1
Owner Address: KATHERINE SCRIPTURE
C/O STACEY SCRIPTURE Septic Alteration Residential
88 AIRLINE Rd Total Value
CLINTON, CT 06413
Contractor or Builder's Name /Address Electrical Inspection Agency
MCGUIRE, RICK
NY 12804-0000
Plans&Specifications
BP 2004-173 Rob Roy LLC Robert and Sharon Kay
Septic Alteration, Residential
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Tuesday, April 12, 2005
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbu efore the exp° ation date.) �
Dated at the Town AQue s xt
M pril 12, 2004
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: .....................................................................................................................................
3 4VI
, Office Use
Location of installation: l�„ 1I
3Q�y����- ,(off nG File Permit No "7
�U J Tax Map No. �/ ! O P,
Fee Paid 0 >
RIO v,, Owner's Name: 1i4
:...................................................
...............
...............................................................
Address:
2. INSTALLER'S NAME G,h'! /V!�41v Ar C 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 yf. 1967 ' 3 x 150 gal/bdrm =
1980—1991 x 130 gandrm =
1991—present x 110 gal/bdrm =
Garbage Grinder Installed yes_ / noj��` 3
Spa or Hot Tub Installed yes_ ./ no /'wt q �""'
4: PARCEL INFORMATION: (circle applicable information&indicate measurements)
ToDogrVhy Soil Nature Ground Water Bedrock or Impervious Material tic Water Su 1
lat sand at what depth at what depth municipa
Rolling oam feet feet we
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: 1.ao gallon (min. size 1,000 gal)
Tile Field: each trench _-D ft. Total System Length: 6C) ft.
Seepage Pit(s): number of size of each: ft. by ft.
Size of Stone to be used: # / depth or thickness feet
r
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.
Signature of re onsible person Date
' , • • :i
• . . � ;►I�gtVit t)f �Ztt(;�'it.�Rl3ttf'y '
.�rtvc:rs :ut(I Sewsi);c� 1)i��sc►�st1 t:ltst�ilt•:•
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7. SION,ATURE &INFORMATION FM USllUrl;$.Tsl r,rzr< ovx,-,
Septic Inspection Report
Office No. (518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: a am/pm Depart: am/pm
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials: --AE
(J NAME: PERMIT NO.:
CEO C�
LOCATION: C INSPECT ON: / -G-v
RECHECK:
` Comments and/or diagram
Soil Tye: Sand/Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft•
Well separation distance ft
Other wells: ft
Absorption Field: Totallengt4 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
Tank to Distribution Box
Distribution Box to Field/Pit
Opening Sealed: Y/N/Partial
Location/Separations
Foundation to tank ft•
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Location of System on Property: n
Front Rear Left Side Right Side b n�� S L����I"
Middle Front Middle Rear
System Use Status:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:\SueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 29,2003
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received:
'Queensbury Building&Code Enforcement Arrive: am/ in art: am/pm
742 Bay Rd., Queensbuly,NY 12804 Inspector's Initials:
NAME: Ro ��Ri7o P PERMIT NO.:
LOCATION: INSPECT ON: 6
RECHECK:
Comments and/or diagram
Soil Type: SandPuni%cip
Clay
T e of Water: /Well Water
Waterline separate tance 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 Siz T e
Building to tank b
Tank to Distribution Box
Distribution Box to Fi ld(Pit K
Opening Sealed: Y/ Partial � ��.b
Location/Separations
Foundation to tank ft•
Foundation to absorption ft.
Separation of Pits ft•
Conforms as per Plot Plan Y N �
j A-Ge--
Location of Sy on Property:
Front Rear Left Side Right Side
Middle Front Middle Rear
System Use Status:
roved
artial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
LASueHemingway\Buildino.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
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