2004-565 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CEllTIFICATE OF COMPLIANCE
Permit Number: P20040565 Date Issued: Thursday, July 22, 2004
This is to certify that work requested to be done as shown by Permit Number P20040565
has been completed.
Tax Map Number: 523400-308-016-0001-078-000-0000
Location: 4 MINNESOTA Ave
Owner: TERESA K NICHOLSON
Applicant: TERESA K NICHOLSON
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
r:
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: P20040565 Application Number: A20040565
Tax Map No: 523400-308-016-0001-078-000-0000
Permission is hereby granted to: TERFSA K NIC;HOLSON
For property located at: 4 MINNESOTA 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: TERESA K NICHOLSON
4 MINNESOTA Ave Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
FRED SMITH
23 VERMONT Ave
OITEENSBITRY_ NY 12804
Plans&Specifications
2004-565
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday, July 22, 2005
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at th of QnffAnsIbury, hursday, July 22, 2004
SIGNED BY for the Town of Queensbury.
Director of Buil mg&Ade Enforcement
Application for Permit—Septic Disposal System
Town of Queensbury 742 Bay lioad Queensbury,NY 12804 (518).761-8256
1. OWNER INFORMATION: If YYI� n1�
�So ..Orficc Use
.................
Location of installation: �'1` �� t A,
Tax Map No. / / ,
File Permit No.
' h / H Z t'C�/1tJlsv�� Fee Paid
Owner's Name:
Ave
2. INSTALLER'S NAME vll PHONE NO.
.. 3. -RESIDENCE INFORMATION: (circle year of dwelling, indicate#bedroom(s) and multiply N of
bedrooms with applicable gallons per bedroom to equal total daily flow)
Year of House$ No of Bedrooms x Computation = Total Daily Flow
1980 or-older %{. x 130 gaVbdnn _ 3w
1980— 1991 x 130 gal/bdrm =
_. 1991 —present x _110 gaVbdrm =
Garbage Grinder Installed yes / no
Spa or Whirlpool Installed yes / no CEwE®
4;, PARCEL INFORMATION:" (circle applicable informak�ippn td�o&measurements)
4.il Np&j_t9 Q.�QU�t4I atv.r_1!004
DAB � M. IV Ot!;'MA(.Qd,t1 ...... _. :ttor_$uprly
Yat sal at what depth '�lVf�Rolling loam Jcet UIL fc�ctr we
Steep slope clay if well; water supply
slope other from any septic-system
depth: absorption is f1.
other
Percolation Test: (To be completed by licensed prr fesslonal engineer or architect)
Rate: minute per Inch
S, PROPOSED SYSTEM: For New Construction: All individual sewage disposal systems must be designed by n licensed
professional engineer or architect(unless installed in a Planning Board approved subdivision). Add 250 gallons to the size
of the septic lank and Icach field for cacti Garbage Grinder, Spa or Whirlimol 7'ub.
Septic Tank: gallon (min, size 1,000 gal.)
Tile Field: each trench _J?. Total System Length t f?.
Seepage Pit(s): number of size vfeach: J?. by J?.
Size of Stone to be used: tl ��_ / �lrpth or,thickness
Bed System Size: x
Ahemadve 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 those and all
requirements o T of Queensbury Sanitary Sewage Disposal Ordinance.
Slg ature o responsible person Date
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received: �( 99�
Queensbury Building&Code Enforcement Arrive: amlk4e
art: am/pm
742 Bay Rd., Queensbuly,NY 12804 Inspector's Initials:
NAME: PERMIT NO.:
LOCATION: UMMp 6 b: INSPECT ON: 1221dj () JL
RECHECK:
Comments and/or diagram
Soil T Sa la
T e of Vva—terk Munic /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 7--
Seepage Pits: Number
Size: x
Stone Size:
Pipin2 Size Type
Building to tank VSc
Tank to Distributi n Box tt 5 rL 3S--
Distribution BoxtONield/Pit tlfj Zd
Opening Sealed Y N/Partial
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Confornis as per Plot Plan Y N
Location of Syste on Property:
Front e Left Side Right Side
Middle Front iddle Rear
S stem Use
Stat
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
LAS ueHemingway\Building.Codes.Inspection.FORMS\S ep tic Inspection Report.doc January 28,2003
(Mlml
"I have seen or observed, or believe I saw evidence of,
ail objects such as houses, :ie!ls, trees, fences, etc.,
shown oil this OCUrilent. i also represent that I have
perso��aliy ;r d t1.e istances set forth on the diagram."
SIGNATURE DATE
v_
RE EIV y
' JIIL� 200
U TOWN F
--!U_1L1 f NG AND CO E Y
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