2003-583 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902. (518)761-8201
'Community Development-Building&Codes (518)761-8256
CERIT IFIC.A1fE
OF COMPLIANCE
Permit'Number: P20030583 Date Issued: Tuesday,July 29,2003
This is to certify that work requested to be done as shown by Permit Number P20030583
has been completed.
Tax Map Number: 523400-296-010-0001-062-000-0000
Location: 7 ST.ANDREWS Dr
Owner: SAMUEL&TERRY GOTTESMAN
Applicant: SAMUEL&TERRY GOTTESMAN
This structure may be occupied as a:
By Order of Town Board
Septic Alteration:Residential TOWN OF QUEENSBURY
Director of Building&Code Enforcement
W
Application for Permit—Sepik Disposal System
Town of Queensbury 742'Bajl Road Queeh:sbury,NY,`I2804 (518) 761-8256
1. OWNER INFORMATION: iF,,
<
Location of installation: `7 Sf +LLc7S �/ ; •':; 5..................................................Office Use
hn ..................................................j
Tax Map No.
File Permit No.
€ Fee Pai
s� }<
Owner's Name: �'lcQ ..... ......................................................
1 ,
....t.. ........»....».».............»....----------
Address:
2. INSTALLER'S NAMES O # PHOCail
?4'oZ G
3. RESIDENCE INFORMATION: (circle year:.of dwelling,*indicate#!bedroom(s) ay#of
bedrooms with applicable gallons per bedroom to equa ow
�.
Year of House: No. of Bedrooms x Com `utation Total Dail Prd�
EiVELJ
(Moor older x 150 gal/bdrm _
1980— 1991 x 1.30,gal/bdrm JUL 2 5 2003
1991 —present x 110 gaUbdrm
Garbage Grinder Installed I no
yes
BUILDING Ai�VD CO®�Y
—
Spa or Hot Tub Installed yes— t no
4: PARCEL INFORMATION: (circle applicable information&indicate measurements)
ToDoaranhv Soil Nature Ground V4Tater Bedrock or hi"ervious Material Domestic Water Supi3ly
laf an at what,depth at,what depth municipal
Rolling loam eel �' ' "'
}.' feet well
Steep slope clay a if well; water supply
_/o slope other t from any septic-system
depth: absorption is ft.
other
Percolation Test: (To be completed by Incensed professional'engineer or architect)
Rate: minute per inch 1
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, spat',Whirlpool Tub.
Septic Tank: 1Z-5`Gf gallon(min. size 1`000 gal.) is Id d/ LC x-0 r �O
Tile Field: each trench ft. Total SystemLength: ft.
v(Do
Seepage Pit(s): number of c/} size of each: '`. ft. by 9 ft. Jam,j 94
�ry Le-�_ _,J Zcc v fit-o(�t,c.� `+
Size�Stone to be used: # �'" l depth or thickness feet /
Bed System Size: ��' Ya�S
Alternative System: length andtor size
6. HOLDING TANK SYSTEM: (if required) �y �` i>• �Z�
i e115 !9 s6"
Number of tanks: / Size df'each: gallon s' %;TOTAL Capacity: gallons
Note: Alarm System and associated'electrical work must lie 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 br failui e to make a material fact or
circumstance known by or oil behalf of ail applicant;shall be void.
, I
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 bisposat Ordinance.
001
Sign ure of r sponsi,?!, person+ 3 e
Septic Inspection Report
Office No. (518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive:..9NIV am�/�D art: afil/pin
742 Bay Rd.,Queensbuiy,NY 12804 Inspector's Initials:
NAME:
PERMIT NO.:
LOCATION: INSPECT ON:
RECHECK:
Comments and/or diagram
Soil Type: Sand J Loam Clay
Type of Water: Municipal/Well Water
Waterline separation distance
Well separation distance ft.
Other wells:
Absorption Field: Total length
Length of each trench ft.
Depth of trenches
Size of Stone
Seepage Pits: Number
Size: X=
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box
Distribution Box ,,Field/Pit
Opening SealedLVN/Partial
Location/Separations
Foundation to tank
Foundation to absorption
Separation of Pits
Conforms as per Plot Plan Y N
Location of System on Property:
Front Rear Left Side Right Side
t Middle Rear
System Use Etatus:
Approved'
Partial Approved and needs to be re-inspected,please call the'Building&Codes Office
Disapproved
L:\SucHemingway�uilding.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
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