2004-634 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development- Building & Codes (518) 761-8256
CERTIFI CATE OF COMPLIANCE
Permit Number: P20040634 Date Issued: Monday, August 16, 2004
This is to certify that work requested to be done as shown by Permit Number P20040634
has been completed.
Tax Map Number: 523400-302-018-0002-007-000-0000
Location: 217 SHERMAN Ave
Owner: STANLEY & CANDY PRATT
Applicant: STANLEY & CANDY PRATT
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: P20040634 Application Number: A20040634
Tax Map No: 523400-302-018-0002-007-000-0000
Permission is hereby granted to: STANLEY& CANDY PRATT
For property located at: 217 SHERMAN Ave
in die Town of Queensbury, to construct or place
at die above location in accordance with application together with plot plans and other information hereto filed
and approved and in compliance with tie NYS Uniform Building Codes and the Queensbury Zoning
Ordinance. Type of Construction Value
Owner Address: STANLEY& CANDY PRATT
217 SBERMAN Ave Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
SANITARY SEWER
DAN DRELLOS
PO BOX 224
GLENS FALLS NY
Plans&Specifications
04-634
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Saturday, August 13, 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 Tov` :r;�n of e f a ,August 13, 2004
SIGNED BY for the Town of Queensbury.
Director of Building&Code&forcement
RECEIVEDApplication for Permit=Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256 AUG 12 2004
1. OWNER INFORMATION:
.•................................................r............•
... ..............
UEENSBURY
Location of installation:2�� A&-IL-lU AA— AND CODE
Tax Map No. / / : File Permit No. V�' `-:( 3
Owner's Name: ( CL C.A-ND P��-- ' Fee Paid ��� 00
r/
Address: , 17 I • 1 e,L44 lh',J l �
2. INSTALLER'S NAME ���,� _ 1-k v PHONE NO. 79� -7 a�
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 J x 150 gal/bdrm = y�0
1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm =
Garbage Grinder Installed yes_ / no
Spa or Hot Tub Installed yes— / no
4: PARCEL INFORMATION: (circle applicable information&indicate measurements)
TUography Soil Nature Ground Water Bedrock or Im ervious Material . Domestic Water Su 1
at sand at what depth at what depth munici al
Rolling loam feet feet we
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). Add 250 gallons to the size
of the septic tank and leach field for each Garbage Grinder, Spa or Whirlpool Tub.
Septic Tank: 1 000• gallon (min. size 1,000 gal.)
Tile Field: each trench ft. Total System Length: 2,00 ft.
Seepage Pit(s): number of /v' - size of each: ft. by ft.
Size of Stone to be used: # A- / depth or thickness feet
i
Bed System Size: x
Alternative System: length and/or size
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: 1 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
require of the Town of Q sbury Sanitary Sewage Disposal Ordinance.
L ( Z/0 }
Si ature of responsible'person Date
- •'I'awtt of (2ttcetlsbury
Kr,.tiV(.I.s and 5cwilge Disposal (.1131plet•
Appfind ix
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7. SICGN,ATURE &INFORMATION FOF,IZSx'ul4=LZ rlrg--avL'4 w„va-%o•.m• ,r
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Septic Inspection Report
Office No. (518)761-8256 Date Inspection reques received: dt 00�6n-
Queensbury Building&Code Enforcement Arrive: am/ epart: am/pm
742 Bay Rd., Queensburyy,NY 1,2804 Inspector's Initials. 1�-
NAME: L T _ PERMIT NO.:
LOCATION: { INSPECT ON: 6 0 -
RECHECK:
Comments and/or diagram
Soil Type: Sa lay
Type of Wate • MunicipaJ Well Water
Waterline separ tance ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenche ft.
Size of Sto IN 4 U v
-Seepage Pits: Number
Size: x
Stone Size:
Piping Size T e
Building to tank Gp
Tank to Distribution Box w ��
Distribution BoxN Field/Pit H ��
Opening Sealed:(YA N/Partial
Location/Separations
Foundation to tank V ft.
Foundation to absorption ft.
Separation of Pits ft.
Confonns as per Plot Plan VY N
Location of System on Property:
Front Rear Left Side ®RightSi
Middle Front Middle Rear
S 'stem Use Stat s•
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
o 9-G3
"I have seen or observed, or believe I saw evidence of, RECEIVED
all objects such as houses, wells, trees, fences, etc.,
shown on this docum?nt. I also represent that I have AUG 12 2004
personally meaSffed the distances set forth on the diagram." TOWN OF QUEENSBURY
v BUILDING AND CODE
t SIUATURE DATE
BUILDING
REVIEWED BY
IDATE 3 6y
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