2004-230 TOWN OF QUEENSBUIRY
742 Bay Road,.Queensbury,NY 12804-5902 (518)761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE- OF-COMPLIANCE.
Permit Number: P20040230- Date Issued: Friday, April 30, 2004
ry This=is to,certifythatwork°requested to bez done as shown by Permit Number P20040230
has been completed.
Tax Map Number: 523400-308-008-0002-042-000-0000
Location: 12 LEO St -
Owner: GLENNAN & SHERRY HUGHES
Applicant: GLENNAN& SHERRY HUGHES
This structure may be occupied as a:
By Order of Town BoardW
Septic Alteration Residential TON OF QUEENSBURY.
r
Director of Building&Code Enforcement
T TOWN OF QUEENSBURY
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742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20040230 Application Number: A20040230
Tax Map No: 523400-308-008-0002-042-000-0000
Permission is hereby granted to: CTLENNAN& WERRY H[JCTHF,S
For property located at: 12 LEO St
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: GLENNAN& SHERRY HUGHES
12 LEO St Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans&Specifications
2004-230
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday,April 27, 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 To o eensb s y,April!27, 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: ..........................................................................................................:............................:
Office Use
Location of installation:
File Permit No.Z!Mq- Q30
Tax Map No.
` Fee Paid SQ
Owner's Name: '-
�a .......................................................................................................................................
Address: I
2. INSTALLER'S NAME ' . � t PHONE NO.
3. RESIDENCE INFORMATION: (circle year of dwelling, indicaedroom(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=19 1 x 130 gal/bdrm =
1991—present x 110 gal/bdrm =
C7,
Garbage Grinder Installed yes_ / no p
Spa or Hot Tub Installed yes_ ./ no
4: PARCEL INFORMATION: (circle applicable information&indicate measurements)
ToDojzrVhy Soil Nature Ground Water Bedrock or Impervious Material Domestic Water Su 1
lat a
n at what depth at what depth'Ru munici al
Bing et �. --feet
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: ' A. 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: (7 gallon (min. size 1,000 gal:)
Tile Field: each trench--�=ft. Total System Length: c� ft.�
Seepage Pit(s): number of size of each: ft. by ft.
Size of Stone to be used: #2, _ / depth or thickness feet
.i
Bed System Size: x
Alternative System: length aid/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 respon ible person `� Date
l'ov it of Qw-.01181lllf-v
S(nVel m -Intl Sews ge I)'csposal (.Ilse t)(el.
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7. SIGNATURE INFORMATION FOR.USk'VNUO M rT9AzVb`1 w"090%,• 0--p r
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Septic Inspection Report
Office No. (518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: Depart� �m�--
742 Bay Rd.,Queensbury,NY 12804 Inspector's InitidQ9
NAME: 4 PERMIT NO.: Z' c4-3 D
LOCATION: INSPECT ON: - C13(-
RECHECK:
Comments and/or diagram
Soil Type: a / Clay
Type of Water: unicip /Well Water
Waterline sepa tion ' ance 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 SizP1 P Type Ik
Building to tank GYJ
Tank to Distributioi Box
Distribution Box 'eld/Pit P%
Opening Sealed Y/ /Partial
Location/Separations
Foundation to tank ft.
Foundation to abso tion ft.
Separation of Pits ft,
L.Conforms as per Plot Plan Y N
Location of SygRea
n Property:
Front Left Side Right Side
Middle Fr t Middle Rear
System
Use St
s:
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.doe January 28,2003
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_ have seen or obser
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objects such as houses' alslo represent that�l have —
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rs ally measured the distances t forth on the-diagram.
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