2003-386 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518)761-8256
Crn.TIFICATE OF COMPLIANCE
Permit Number: P20030386 Date Issued: Tuesday, June 10, 2003
This is to certify that work requested to be done as shown by Permit Number P20030386
has been completed,
Tax Map Number: 523400-302-017.0003-053-000-0000
Location: 34 OAK TREE Cir
Owner: MARK&KAREN DE SIMONE
Applicant: MARK&KAREN DE SIMONE
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
Director of Building&Code EnfoicAnent
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community.Development-Building&Codes (518),761-8256
BUILDING PERMIT
Permit Number: P20030386 Application Number: A20030386
Tax Map No: 523400-302-017-0003-053-000-0000
Permission is hereby granted to: MARK &KAREN DF, SIMONE
For property located at: 34 OAK TREE Cir
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: MARK,&KAREN DE SIMONE
34 OAK TREE Cir Septic Alteration Residential
Total Value"
QUEENSBURY,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
SANITARY SEWER
DAN DRELLOS
PO BOX 224
CTT,FNS FALLS NY
Plans&Specifications
2003-386
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25,00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Saturday;June 05,2004
(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 Taw ueensb ; r ay,June 05,2003
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
516 745.,4437,
No.638 04,62 '02 AN 11.25`I M TOWN OF QUEENSBURY FAX;518..745 4437 PAGE 1
Application far Permit—8eptio Dispbsstl System:
f Town of Qiteensbury'742 Bay Road QueVnsbury,NY 12804 (518) 76I-8236
j 1. to`C7s%
Location of installation.
File Pomtit No. .
i-Tax Map No. �.,,;/ / Z- C1G
- Feo Paid
t?wnor"a Nrune .......... ....
Addtoss: p�-r2 e Wi t,, . �..
2. INSTALLER'S NAME den f//C., PHONE NO.
3.. RESIDENCE INFORMATION: {circle year of dwelling,.indicate#bedroorn(s) and multiply# of
bedrooms with applicable_gallons per bedroom to equal total daily flow).
Year of House- 'ok]ft.j2dro- orns k C=dzutati= xgw- NEU,
1980 or older x 150 gal/bdrm 2003
x - 130 gal/bdrm a
1991--present x 110 gallbdrm =
TOUVN OF QUESNSSURY
Qarbage Grinder Installed yes._ ! ,no BUILDING ANQ CODE
Spa or Whirlpool Installed yes / no
4, PARCEL INFORMATION:..(circle'applicable inforrmttionA indicate,measurernentO
at a at what depth at what depth rnunic/pal
ling. cam ' feet feat well
Steep slop (fwell.water"supply
e clay
_ %slope other from any septic-system.
depth: absorption Js ff.
other
Percolation Tent, (710 be completed by licensed peofesetonal engineer or architect)
Rate: minute per-inch
S. .: PROPOSED SYSTEM; V6r Netr.Consttncticlri:- All,badividuai sewage disposal"otns must be designed by a licensed
professional engineer or architect(unless installed in a Planting Hoard approved subdivision). Add 250 `gallons w the size
of the soptic tank and leach field fbr each Oarbago Chinder,Spa or Whirlpool Tub.
Septic Tank: / gallon(min. size 1,000 gal.)
Tile Field: each trench . fl. Total System Length:
Seepage Pit(s): number of size of each: fr by eft
Size of Stony to be axed: # /:depth or thickness Feet
Bad System Size: x
Alternative System: length-and/or size
6. HOLDIN4 TANK SYSTEM: (if required)
Number of tanks: / Six*of each: gallons /TOTAL Capacity. gallons
Note: Alarm System and associated electrical work-must be inspected by a Town,approved
electrical iusp06d ',agency. .
7. SIC•I•NATUR:L da INFOIt.MAATION FOR•RESPONSIBLE PERSON(please read) .
For your protection,please trots that pursuant to Section 136-29 ofthe Code of the Town-
'approval granted which is based upon or is granted in
of Queensbum any permit-or
reliance upon any material misrepresentation or failure to make*:material fact or
circumstanceknown-by or on behalf'ofan.ap'plic=4 shall be void.
I heva r regulations with respect to this application and agree to abide by these and all
raquir cnts o_ 4-Town of t2u ury Sanitary Sewage Disposal Ordinance,
6 .�
lg i tore of.res o ble pars De
Septic Inspection Report
Office No. (518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am./pria Depart: am/pm
742 Bay Rd.,Queensbury,TkY 12804 Inspector's Initials: �A� 7 -Q 3
NAME: M 61T�PERMIT No .: I
LOCATION: -INSPECT ON:
LOCATION:
RECHECK: I
Comments and/or diagram
Soil Type: San ay
Type of Water Municipal Water
Waterline sepa?Miog-4isrrance
Well separation distance
Other wells: ft.
Absorption Field: Total length
Length of each trench
Depth of trenches 2 .
Size of Stone A)rA 14
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank 6-x f 4 r/,t�
Tank to Distribution Box
14-" -20 A-
Distribution Box 4 Field Pit lk
Opening Sealed N/Partial
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits
Conforms as per Plot Plan Y _N
Location of ste on Property:
Front nRear Left Side Right Side
Middle Front Middle Rear
System Use Stat sf
Approved
Partial Approved and needs to be re-inspected,please call the'Building&Codes Office
Disapproved
L:1.SueHemingway\13uilding.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
0/9
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RECEIVED
JUN U 3 2003
lLDIR4C AND CODE
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