2004-197 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community-Development - Building & Codes (518) 761-8256
C.E'jD_x'1vIFICATE0F COMPLIANCE
Permit Number: P20040197 Date Issued:. Friday, December 17, 2004
- This is to certify that work requested to be done as shown by Permit Number P20040197-
has been completed.
Tax Map Number: 523400-309-013-0001-058-000-0000
Location: 14 OHIO Ave
Owner: CRAIG RICHARD &DONNA LIPPS
Applicant: CRAIG RICHARD & DONNA LIPPS
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential 'TOWN OF QUEENSBURY
Director of Building&Code Enforcement
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20040197 Application Number: A20040197
Tax Map No: 523400-309-013-0001-058-000-0000
Permission is hereby granted to: CRAIG RTCHARD &DONNA LIPPS
For property located at: , 14 OHIO 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. Tyne of Construction Value
Owner Address: CRAIG RICHARD &DONNA LIPP
C/O DONNA BROE Septic Alteration Residential
Total Value
14 OHIO Ave
QUEENSBURY,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
FREDERICK SMITH
23 VERMONT Ave
OITEENSBITRY_ NY 12804
Plans&Specifications
2004-197
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday,April 21, 2005
(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 Ton nsbT Wednesday,April 21, 2004
SIGNED BY for the Town of Queensbury.
Director of Building& -ode E rcement
Application for Permit—Septic Disposal System
S 7oWii of Queensbury 742 Day lioad Queensbury, NY 12804 (518) 761-8256
1. OWNER INFORMATION: ..........................,..................................................................................
vz-"-
OOffice Usc
Location of installation: � d ��
File Permit No.
Tax Map No. / /
Owner's Name:(nargf4tci � � Fee Paid �J
Address: , 6hlj Poe
2. -'INSTALLER'S NAME "�'� � /� PHONE NO. -F d l
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 gaVbdnn = U�V
1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm = �V
Eu
Garbage Grinder Installed yes` / no O APR 7 `,
Spa or Whirlpool Installed yes / no pgl2004
TOWN OF QUEENSBURY
4. PARCEL INFORMATION: (circle applicable information & indicate measurements rUli-D`NG�,Np CODE
Q !s9 O.t.LQu11_d_W14.0.c _B4d.roGk_',p JA?pcl'1'iws MPt-Qdi1�_Dom slic Wltor.S��pl?ly
at Sall at Wulf depth (it what(lepth nucnlclpn
Rolling oanr feet feet
Steep slope clay if)vell; ivater supply
slope other front any septic-system
depth: absorption is f?.
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 n licensed
professional engineer or architect(unless ins(niled in a Planning Board approved subdivision). Add 250 gallons to the size
of the septic lank and leach field for each Garbage Grinder, Spa or Whirltx)ol Tub.
Septic Tank: /j�jj gallon (min. size 1,000 gal.)
Tile Field: each trench c50 ft. Total System Length:
Seepage Pit(s): number of size ofeach: ft. by fl.
Size of Stone to be used: 11 O�_ / depth or thickness
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 die 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 responslble person Date
Y
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/pm Depart: m/pI -
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials:
NAME: \� G ` PERMIT NO.:
LOCATION: INSPECT ON`. �I
RECHECK:
Comments and/or diagram
Soil Type: Sand/Loam/Clay
Type of Water: Municipal/Well Water ,
Waterline separation 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
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:
Front Rear 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
L:\.SueHemingway\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: am/pm
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials:
1�NAME: PERMIT NO.:
LOCATION: � — INSPECT ON:
RECHECK: C�c� •�
Comments and/or diagram
Soil T e Sand Loam/Cla
Type of Water:'Munici al/Well Water
Waterline separation distance ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length ft.
Length of each trench
Depth of trenches L ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank y" 1-1/(-
Tank to Distribution Box ./` - --
Distribution Box to Field/Pit V-1
Opening Sealed'Y� N/Partial
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan 0 Y N
Location of System on Property:
Front (ge Left Side Right Side
Middle Front Middle Rear ,
��e c C
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 28,2003
RECEIVED
APR 2004
TOWN OF QUEENSBURY
BUILDING AN
U A O
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"I have seen or observed, or believe I saw evidence of,
all objects such as houses, wells, trees, fences, etc.,
shown on this dog. ent. l also represent that 1 have
person sty, d ti distances set forth on th diagram "
SIGNATURETry
SAT
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BUILDING DEBT•
REVIEWED BY
DATE ��
J
(' "I have seen or observed, or believe I saw evidence of � V�
gJ �a11 objects such as houses, wells, trees, Fences, etc., i
shown on this document. l also represent that I have
i �}rso y m ure the distances set forth on the diagram.'
SIGNATURE DAT
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SIS
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