2004-735 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. P20040735 Date Issued: Wednesday, September 29, 2004
This is to certify that work requested to be done as shown by Permit Number P20040735
as been comp ete
Tax Map Number. 523400-290-006-0001-064-600-0000
Location: 36 SUNNYSIDE EAST
Owner. ROBERT &ANNA DOUGHER
Applicant: ROBERT &ANNA DOUGHER
This structure maybe 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: P20040735 Application Number: A20040735
Tax Map No: 523400-290-006-0001-064-000-0000
Permission is hereby granted to: ROBF.RT & ANNA DOT TCTWR
For property located at: 36. SUNNYSIDE EAST
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. Tyke of Construction Value
Owner Address: ROBERT &ANNA ROUGHER
36 SUNNYSIDE EAST Septic Alteration Residential
Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
Plans&Specifications
2004-735
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Saturday, September 17, 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
TQuee , eptember 17,2004
u
SIGNEDBY -/I for the Town of Queensbury.
Director of Building&Code 4Enforcement
Application for Permit=Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,IVY 12804- (518) 761-8256
1. OWNER INFORMATION:
j.....................................«............................................................ ...................,
. '
Location of installation: Office Use_r
File Permit NdDA
/ -
Tax Map No.
Owner's Name: Fee Paid
.............................................................................................................
Address: 4r�l� ;............,....,.....
2. INSTALLER'S NAME �� /� �.,a �- PHONE NO.
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 Dailv Flow
1980 or older x 150 gallbdrm =
1980- 1991 x 130 gaUbdrm �
1991 -present x 110 gaVbdrm =
SffP 16 2004
Garbage Grinder Installed yes_ / no ✓ TOWN OF Spa or Hot Tub Installed yes! ./ no BUILDING QAND CODS Y
4: PARCEL INFORMATION:. (circle applicable information&indicate measurements)
T o a h 1 Nature Ground Water Bedrock or Irn ervious Material Domestic Water Su 1
Flat sand at what depth at what depth municipal
olling oam �eet _ . eet e
Steep slope . clay if well;water supply
slope other from any septic-system
depth: absorption is
other jC�
Percolation Test: o be completed by licensed professional engineer or architect)
Rate: minute per inch
S. PROPOSED SYSTEM: For Thew 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: Q CQgallon(min.size 1,000 gal)
Tile Field: each trench En.. ft. Total System Length:
Seepage Pit(s): number of size of each: fi.'by ft,
Size of Stone to be used: # I 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
^----
=- -- 1Vote.�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
requiremen of the Town of Queensbury Sanitary,Sewage Disposal Ordinance.
Signature of responsible person Date
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Septic Inspection Report
Office No. (518)761-8256 Date Inspection re est re e' ed-
Queensbury Building&Code Enforcement Arrive: any/ art: a pm
742 Bay Rd., Queensbury,NY 12804 Inspector's Init
G
NAME: PE IT NO.:
LOCATION: _ � ,� _, P CT 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 Kield/Pit
Opening Sealed Y/ /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
Middle Front Middle Rear
System Use S/atus:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
U\Sueliemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
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Septic Inspection Report
Office No. (518)761-8256 Date Inspectiop request received:
Queensbury Building&Code Enforcement Arrive:' '.'S am/pm Depart: am/pm 1
742 Bay Rd., Queensb�ury, lNY 12804r Inspector's Initials:
NAME: PERMIT NO.: C 7-- 3�
LOCATION: } � i , INSPECT ON:
RECHECK:
Comments and/or diagram
Soil T e: and, o /Clay
_Type of Water: Municipal/ ell Water
Waterline separation distance ( ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length c! ft.
Length of each trench ft.
Depth of trenches 2 ft,
Size of Stone
.Seepage Pits: Number
Size: x
Stone Size: .
Piping Size Type
Building to tank
Tank to Distribution Box
Distribution Box t _ ield/Pit
Opening Sealed: 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: e
0
Front 0earLeft Side Right Sidv, fti le/1 bGc��.
Middle Front Middle Rear
_System Use Status: i'zY�[�li y��I� 's luvs-e—
Approved d
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:\.SueHemingway\Huilding.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003