2003-021 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development - Building& Codes (518) 761-8256
: CERTIFICAT-E OF." COMPLIANCE
P20030021
Permit Number
Date,Issued: Friday, May02, 2003
._ _..... ;_This is to..certify.thatworkrequested-to`be done as showii.by Perrnit:Number P20030021
has been completed.
Tax Map Number; 523400-296-017-0001-050-000-0000
Location: 880 STATE ROUTE 9
w
Owner: CHARLES E. MOORE
Applicant:- . CHARLES E. MOORE
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: P20030021 Application Number: A20030021
Tax Map No: 523400-296-017-0001-050-000-0000
Permission is hereby granted to: CHARTYS F. MOORE
For property located at: STATE ROUTE 9
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. Tyne of Construction Value
Owner Address: CHARLES E. MOORE
30 GARRISON Rd Septic Alteration Residential
Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
GALUSHA & SONS
PO BOX 4787
OTJF,F,NSBTJRY.NY 12804
Plans&Specifications
2003-021
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Tuesday, January 27, 2004
(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 Queens ryi o ay,January 27,2003
SIGNED BY for the Town of Queensbury.
Director of Building&Code nforcement
Application for Permit—Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury, NY 12804 (518) 761-8256
1. OWNER INFORMATION: ....................... .................... .............I.................................................................
Office Use
Location of installation:
—��'
File Permit N
Tax Map No.
Fee Paid
Owner's Name: Mig6we--s F. Inpond
..................................................................................................
Address: 30 6414rrlS'
2. INSTALLER'S NAME : PHONE NO. �®
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate#bedrooin(s) and multiply #of
bedrooms with applicable gallons per bedroont to equal total daily flow)
Year of House: No. of Bedrooms x Computation = Total Daily Flow
980 or o Lld--eD x 150 gal/bdrrn = 300 rk
1980- 1991 x 130 gal/bdrrn = IVED.
1991 —present x 110 gal/bdrrn = -03
j N 2 72003
Garbage Grinder Installed yes no
Spa or Hot Tub Installed yes no TOWN OF QUEENSBURY
BUILDING AND CODE
4. PARCEL INFORMATION: (circle applicable information & indicate measurements)
Too p-rai)hv Soil Nature Ground Water Bedrock or Impervious Material Djoinestic Water Supply
(9'2� at what depth at what depth ci
'MoMng Ooa�n'i Z2.' feet w feet I 1U 1=7,i e
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: gallon (min. size 1,000 gal.)
Tile Field: each trench ft. Total System Length: ft.
I size of each: 9 ft. by ft.
Seepage Pit(s): number of
Size of Stone to be used: # depth or thickness Z 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
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 of Queensbury Sanitary Sewage Disposal Ordinance.
igy$ture of responsible person Da,(e
� tul
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received: .`.!flit,
Queensbury Building&Code Enforcement Arrive: am/p -D Part: am/pm
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials:
NAME: (� Ll PERMIT NO.: 0
LOCATION: J G v t) & 1��^ INSPECT ON: Z
RECHECK:
Comments and/or diagram
Soil Type: an / Clay
Type of Wat unic al/Well Water
Waterline separaborilistance 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 Si e Type
Building to tank
Tank to =r -�
Distribution Box to Field/Pit
Opening Sealed: Y/N/Partial
Location/Separations
Foundation to tank ft.
Foundation to absorption lqvft.
Separation of Pits craft.
Conforms as per Plot Plan Y N
Location of System i ty:
Front Rea Left Side Right Side
Middle F ont Mi dle Rear
S stem Use S tus•
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
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