2004-906 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:- P20040006 Date Issued: .Tuesday, November 16, 2004 .
This.is to certify that work requested to be done as shown by Permit Number P20040906
has-been completed. -
Tax Map Number: 523400-308-018-0002-004-000-0000
Location: 26 BRICKOVEN Rd
Owner: PAUL & CONNIE GERARDE
Applicant: PAUL & CONNIE GERARDE
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
Director of Building&Code Enforcement
T TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20040906 Application Number: A20040906
Tax Map No: 523400-308-018-0002-004-000-0000
Permission is hereby granted to: PAIJL& C ONN ,, CTF,RARDF,
For property located at: 26 BRICKOVEN Rd
in die Town of Queensbury,to construct oriplace,
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.
Tune of'C6ni iruction Value
Owner Address: PAUL& CONNIE GERARDE
26 BRICKOVEN Rd Septic Alteration Residential
Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name /Address ! Electrical Inspection Agency
T.B.S. SEPTIC
is
2 LOWER WARREN STREET
OTTEENSBTTRY_ NY
Plans&Specifications
2004-906
SEPTIC ALTERATION
I
$25.00 PERMIT FEE PAID -THIS PERMIT EXPIRES: Wednesday, November 16, 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 To of Qu nsbu T e .d , November 16, 2004
SIGNED BY ® for the Town of Queensbury.
Director of Building&Code Enforcement
Application for Permit=Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION: w..................................;,,....;,�;,:.,..,,..,,,,.,..,.,.,,-.......,.....,..,.,..........,..�.,.......
Offlee Use
Location of installation. f �2 0
' File Permit No — 0.
Tax M•ap No.
f Fee Paid
Owner's Name: _fff !vt!C ...._....-..................................--,...,,-,.,,u.,,.,,,.,,,.,.,u,,...,.,,,,.,,N;w„,,,,,,�„-,,,,
Address•
2. INSTALLER'S NAME 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)
YYcar of House NQ,of Boskoom s x C==At Zn_ Total Daily Flow
�- RECEIVED
1980 or older x 150 gal/bdrm =
1980-1991 x 130 gal/bdrm NOV 15 2004
1991—present x 110 gal/bdnn =
Garbs a Grinder Installed es / no TOWN OF QUEENSBURY
S Y ._. BUILDING AND CODE
Spa or Hot Tub Installed yes ! no
4: PARCEL INFORMATION: (circle applicable information&indicate measurements)
e _Materi(�
a
.FlFing
sand at w at depth at w at d" th municipal
am feet et we
Steep slope clay dwell; water supply
_%slope other from any septic-system
depth: absorption`is
other
Percolation Test: (To be compieW by.licensed professional engineer or architect)
Rate: minute per inch
5. PROPOSED SYSTEM: Ea 1492 Constriction: 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: gallon(min,size 1,000 gal)&el %( 7
Tile Field: each trench v. A. -Total'System Length-
Seepage Pit(s): number of size of each: _ fl. by ft:
Size�f 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: $allons_lSOTAL Capacit,:— gallazzs= - `
^ 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 Tow_ n
of Queensbmy,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.
1 have read the regulations with respect to this application and agree to abide by these and all
requirements of the wn of Queensbury Sanitary Sewage Disposal Ordinance,
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Signature of responsible person Date
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Septic Inspection Report
Office No. (518)761-8256 Date Ins ectio} re t r e' ed:
Queensbury Building&Code Enforcement Arrive: s a e rt: am/
742 Bay Rd., Queensbury,NY 12804 Inspector's Initia 77
NAME: C-4 C\t'� 1 E IT NO.: / O
LOCATION: ' i PECT 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
Depth of trenches s ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box
Distribution Box t i d/Pit
Opening Seale Y /Partial
Location/Separations
Foundation to tank
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
Mid/FrS stem Use proved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:1SueHemingway\Building.Codes.Inspection.FORMS1Septic Inspection Report.doc January 28,2003
r
RECEIVED
NOV 1 2004
TOWN GNG AND QUEENSBURY
BUILDI
O
L,4 -
TOWN R QUE ENO
BUILDING & T.
REVIEWED.8Y
DATE-
C
k 0 UCt-�
"1 have seen or observed, or believe I saw evidence. of,
all objects such as houses, wells, trees, fences, etc., n ��VC_
shown on this document; I also represent that I have
person red th? d• Lances set forth on the diagram." AC
---7- L ff-0 L10
SIGNATU E DATE