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2004-442 TOWN OF QUEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201 Community Development -Building & Codes (518) 761-8256 CERTIFICATE OF COMPLI-ONCE Permit Number:. P.20040442 _ .Date Issued: Thursday; June 17, 2004 - This.is to certify:ahat.work requested to be-done as-shown by Permit Number = P20046442 has been completed. Tax Map Number: 523400-302-014=0002-065-000-0000 Location: 18 LINDEN Ave Owner: THOMAS HARVEY Applicant: THOMAS HARVEY This structure may be occupied as a: By Order of Town Board Septic Alteration Residential of Qu NSBURY 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: P20040442 Application Number: A20040442 Tax Map No: 523400-302-014-0002-065-000-0000 Permission is hereby granted to: THOMAS HARVRY For property located at: 18 LINDEN 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. Type of Construction Value Owner Address: THOMAS HARVEY TAMMY KOEPPEN Septic Alteration Residential Total Value 18 LINDEN Ave QUEENSBURY, NY 12804 Contractor or Builder's Name /Address Electrical Inspection Agency I.B.S. SEPTIC 2 LOWER WARREN STREET 01 TEENSBi TRY. NY Plans&Specifications 2004-442 SEPTIC ALTERATION $25.00 PERMIT FEE PAID -THIS PERMIT EXPIRES: Wednesday, June 15, 2005 (If a longer period is required,an application for an extension mast be made to the code Enforcement Officer of the Town of Queensbury before the expiration date.) Dated at the 1F0wn Quee u sday, June 15, 2004 SIGNED BY for the Town of Queensbury. Director of Building&Co 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: 4t j 9 File Permit No. "7'— yo� Tax Map No. Fee Paid Owner's Name: UIA.T LIC Address: 2. INSTALLER'S NAME PHONE NO. 3. RESIDENCE INFORMATION: (circle year of dwelling, indicate 4 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 gal/bdrm = C� 1980- 1991 x 130 gal/bdrm = 1991 -present x 110 gal/bdrm = \/E D Garbage Grinder Installed yes— / no /> �/ Spa or Whirlpool Installed yes_ / no JUN 2004 TOWN OF QUEENSBURY 4. PARCEL INFORMATION: (circle applicable information &indicate measure4i i1DING AND CODE T a h 01 ure Ground Water Bedrock or Impervious-Material Water SUDDIV Flat s nd at depth at what e th . municipal ing oam 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: 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). Add250 gallons to the size of the septic tank and leach field for each Garbage Grinder,Spa or Whirlpool Tub. Septic Tank: /40-0-gallon (min. size 1,000 gal.) Tile Field: each trench _ft. Total System Length• ft. Seepage Pit(s): number of size of each: ft by ft. 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 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 ib a person Dat Septic Inspection Report Office No. (518)761-8256 Date Inspection reque re eived: Queensbury Building&Code Enforcement Arrive: a �/ Depart: 1 am/pm 742 Bay Rd., Queensbury,NY 1,2804 Inspector's Initials: NAME: &Pwey PERMIT NO.: 'LOCATION: - INSPECT ON: .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 MiddlIs: Middle Rear System Use Stpproved 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 Septic Inspection Report Office No. (518)761-8256 Date Inspection request received: Queensbury Building&Code Enforcement Arrive: am/p D art: /pm 742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials: NAME: PERMIT NO.: LOCATION: IAJ INSPECT ON: / D RECHECK: Comments and/or diagram Soil Type: Sand/Loam/Clay _ Type of Water: Municipal/Well Water 7 Waterline separation distance ft. Well separation distance ft. Tr PC_ --Q 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 O ening 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(J � � l Middle Front Middle Rear System Use StaXartial. oved Approved and needs to be re-inspected,please call theBuilding&Codes Office pproved LASueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003 pf Septic Inspection Report Office No. (518) 761-8256 Date Inspe, tion request received: Queensbury Building&Code Enforcement Arrive: /' t7 f am/pm Depart: am/pm 742 Bay Rd., Queensbury,NY 12804 Inspector's Initials: NAME: Y if PERMIT NO.: / Il � LOCATION: INSPECT ON: RECHECK: Comments and/or diagram Soil Type: 6ancjJ L9mnW,,Clay Type of Wa'fe-r-igunicip&Well Water Waterline separa ' istance ft. Well separation distance ft. Other wells: ft. Absorption Field: Total length ft. Length of each trench ft. �` L Depth of trenches ft. Size of Stone ..Seepage Pits: Number Size: x Stone Size: Piping Size Type Building to tank Tank to Distribution Box k Distribution Box to Field/Pit 1 l� -Opening Sealed: Y/N/Partial Location/Separations Foundation to tank ft. Foundation to absorption I— 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 �L _System Use Status: Approved Partial Approved and needs to be re-inspected,please call the Building&Codes Office Disapproved LASueHemingwayU3uilding.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/�prn Depart: am/pm 742 Bay Rd., Queensbury,NY 12804 Inspectors Initials: �� NAME: r c _ PERMIT NO.: -,)' LOCATION: INSPECT ON: 5 RECHECK: Comments and/or diagram Soil Type: Sand/Loam/Clay Type of Water: Municipal/Well Water Waterline separation distance ft. Well separation"distance Other,wells: ft. Absorption Field: Total length Length of each trench ft. 1Te- //Wh' Depth of trenches ft. Size of Stone � Seepage Pits: Number Size: x / G�� or 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 I 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 LASueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003 ,�+�/jM. J