2004-198 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development - Building-& Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20040198 Date Issued: Monday,'Apri119, 2004
This is to certify that work requested to be done as shown by Permit Number P20040198
has-been completed.
Tax Map Number: 523400-309-011-0002-019-000-0000
Location: 10 LUZERNE Rd
Owner: MICHAEL LIDDLE
Applicant: MICHAEL LIDDLE
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: P20040198 Application Number: A20040198
Tax Map No: 523400-309-011-0002-019-000-0000
Permission is hereby granted to: MICHAEL T,TDDT,F,
For property located at: 10 LUZERNE 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: MICHAEL LIDDLE
10 LUZERNE Rd Septic Alteration Residential
.Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
Plans&Specifications
2004-198
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday,April 20, 2005
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the wn of uee ?j4 ,April 20, 2004
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
_ Application for Permit--Septic Disposal System
Town of Queensbury 742 Bay Road ueerrsGury, NY 12804 (518) 761-8256
1. OWNER INFORMATION: . .......................................,..........................................,..,..,,................
✓1 (�Z � Office Use
Location of installation: t I�l
File Pennit No.�Q'7 9 g
Tax Map No.
Owner's Name: /`lC� � '�, hoe Paid
Address:_ ZY �(.f�� ' Art ........................................................... .........................................................................
-2. ��INSTALLER'S NAME : PHONE NO. �O
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate #bedroom(s) and multiply N of
bedrooms with applicable gallons per bedroom to equal total daily flow)
Year of House: No. of Bedrooms x Computation = Total Daily Flow
1980 or older x 150 gal/bdrm =
1980— 199.1 x. 130 gal/bdnn =
1991 —present x 110 gal/bdrm EIVED
Garbage Grinder Installed yes_ / no APR 112004
Spa or Whirlpool Installed yes_ / no
TOWN OF QUEENSBURY
4. PARCEL INFORMATION: (circle applicable information &indicate measurements BUILDING AND CODE
1JW
t11S9 57.tvund_V�alpr. _e9,d.rock.or�mporYi_4_u ir44ri.9tl_ _ :i44r.$upnly
plat ert wliert epth ert what efepth nrrr►rl<ao!!!ng feel feet ti
Steep slope clay. if well; water supply
slope other from any septic-system
depth: absorption is fl.
other
Percolation.Test: (To be completed by licensed professional engineer or archliec►)
!tale; minute per Inch
S. PROPOSED SYSTEM: For New Construction: All individual sewage disposal systems must be designed by a licensed
professional engineer or arcliitecl (unless installed in,a Planning Board approved subdivision). Add 250 gallons to the size
of the septic tank and leach field for cacti Garb,ige Grinder, Spa or Whirlimol Tub.
Septic Tank: Sallon(min. size 1,000 gcrl.)
Tile Field: each trench Total System Length: f1.
Seepage.Pit(s): number of size of each: ft. by ft.
Size of stone to be used:, tl / elemh or
Bed System.Size: x
Altemative 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 pursuaot.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 behalfofan 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 responsible person Efate
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection yeque c v d:
Queensbury Building&Code Enforcement Arrive: �j a epart: a pin
742 Bay Rd., Queensbuly,NY 12804 Inspector's Initial
NAME: t U. P IT NO.: v �l
LOCATION: y� [L,7 SPECT ON: —(>
RECHECK:
Comments and/or diagram
Soil Type/San Clay
Type of a er Municipal/WV11 Water
Waterline se ara ' e ft.
Well separation distance ft.
Other.wells: ft.
Absorption Field: Total length ft.
Length of each trench c�"
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 aration of Pits Z ft,
Conforms as per Plot Plan Y N
Location of System on Property:
Front Rear Left Side__Fight Side
Middle Frol Middle Rear
,stem 4Stus:Spproved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
LASueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
�UzIAJEX7 V
J"I have seen or observed, or believe I saw evidence of,
a!I objects such as houses, wells, trees, fences, etc.,
on d
also represent that
have
owi
phers0r all,.e orutt he l istances set forth enl the diagram."
SIGNATURE DATE.
fill
El RECEIVED
POW APR 1 � 2004
TOWN OF QUEENSBURY
j�� BUILDING AND CODE
� /
AM 6)a
f e
L
l
TOWN Orr- QUEEN— 'RY �
BUILDING
REVIEWED BY
DATE 114