2004-650 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: P20040650 Date Issued: Thursday, August 26, 2004
This is to certify that work requested to'be done as shown by Permit Number P20040650
has been completed.
Tax Map Number: 523400-302-014-0002-060-000-0000
Location: 21 BULLARD Ave
Owner: DANIEL & CAROL NIZOLEK
Applicant: DANIEL & CAROL NIZOLEK
This structure may be occupied as a:
By Order of Town-Board
Septic Alteration Residential TOWN OF QUEENSBURY
Director of Building&Code Enforcement
T OWN:OF QUEENSBURY
G-
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20040650 Application Number: A20040650
Tax Map No: 523400-302-014-0002-060-000-0000
Permission is hereby granted to: DAWT,& C;AROT,NT7,OT,F,K
For property located at: 21 BOLLARD 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: DANIEL& CAROL NIZOLEK
Septic Alteration Residential
21 BOLLARD Ave
QUEENSBURY,NY 12804 Total Value
Contractor or Builder's Name /Address Electrical Inspection Agency
SANITARY SEWER
DAN DRELLOS
PO BOX 224
GLENS FALLS NY
Plans&Specifications
2004-650
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday,August 25, 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=w;
e b . W dnesday,August 25, 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:
I File Permit No. 10
Tax Map No.
O
Fee Paid
Owner's Name: /V
................I...............I................................................................................. .............
Address: Mg f"D/ V e-
2. INSTALLER'S NAME 4V/re PHONE No. 7 9-7- 7,26-7
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 x 150 galibdrin =
1980- 1991 x 130 galibdrin = 0
1991 -present x 110 gaAdrr I n =
Garbage Grinder Installed yes / no'
Spa or Hot Tub Installed yes_ / no
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
Too graphy Soil Nature Ground Water Bedrock or Im 2envious Material Domestic Water SuRply
C-7Plat <---ya-n at what depth at what depth (-m--un—iciPa1--)
Xot n g oam feet feet well
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.
Wo -"urm./6
Septic Tank: -gallon (min. size 1,000 gal.) -Z- Q- 7-01
Tile Field: each trench Total System Length: S5 ZO- ft.
Seepage Pit(s): number of I-J size of each: ft. by r1j11r----CE1VED
Size 9f Stone to be used: # depth or thickness feet AUG 2 4 2004
Bed System Size: x TOWN OF QUEENSBURY
BUILDING AND CODE
Alternative System: fz-ja eill) length and/or size 20
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 ofQpeensbury Sanitary Sewage Disposal Ordinance.
Wqig a-ture of respInsible person Date
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Septic Inspection Report
Office No. (518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/NZrt: e am/pin
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials:
NAME: , PERMIT NO.: ' GSTO
LOCATION: INSPECT ON: --
RECHECK:
Comments and/or diagram
Soil T e: San lay
Type of Water: &1unicipaV Well Water
Waterline separa • ance
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenches ' ft.
Size of Stone L CAA _
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank (�
Tank to Distributioi Box Sn,2
Distribution Box t ield/Pit K LA
opening Sealed: N/Partial
Location/Separations
Foundation to tank /1 ft.
Foundation to absorption ft.
Separation of Pits ft.
Conform s per Plot Plan Y N
Location of stem on Property:
Front Rear Left Side Right Side
dle Front Middle Rear
Svstem Use 4Stat :pproved
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 que ce' :
Queensbury Building&Code Enforcement Arrive: VSPECT
part: '.L�s a m
742 Bay Rd., Queensbury,NY 1,2804 Inspector's Initi
NAME: �� .Z V, :
LOCATION: ` �,�L�� :
RECHECK: t
F- Comments and/or diasram
Soil Type: Sand/Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft.
Well separation distance ft. �N�
Other wells: ft.
Absorption Field: Total length
Length of each trench ft.
Depth of trenches ft.
Size of Stone t9-
See a e Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box `� y
Distribution Box to Field/Pit
Opening Sealed: Y/N/Partialj �
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
Middle Front Middle Rear
System Use Status:
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.doc January 28,2003
I have seen or observed, or believe I saw evidence of,
all objects such as houses, wells, trees, fences, etc.,
shown on this document. I also represent that I have
personally measured the distances set forth on the diagram."
IGNATURE DATE
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