2003-610 TOWN OF QUEENSBURY
l
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518)761-8256
C E RT I F I CATE OF COMPLIANCE
Permit Number: P20030610 Date Issued: Tuesday,August 05,2003
This is to certify that work requested to be done as shown by Permit Number P20030610
has been completed.
Tax Map Number: 523400-309-009-0001-016-000-0000
Location: 38 INDIANA Ave
Owner: TAMMY DE BLOIS
Applicant: TAMMY HARRINGTON
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 OUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20030610 Application Number: A20030610
Tax Map No: 523400-309-009-0001-016-000-0000
Permission is hereby granted to: TAMMY T4ARRTNCTTON
For property located at: 38 INDIANA Ave
in the Town of Queensbury,to construct or'plk�
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.
Ty
pe of Construction Value
Owner Address: TAMMY DE BLOIS Septic Alteration Residential
38 INDIANA Ave QUEENSBIfRY,NY 12804 Total Value
Contractor or Builder's Name Address Electrical Inspection Agency
T.B.S. SEPTIC
2 I.OWFR WARREN STREET
OIJFFNSBIJRY.NY
Plans&Specifications
2003-610
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday,August 05,2004
(If a longer period is required,an application for an extension must be"made to the code Enforcement.Officer
of the Town of Queensbury before the expiration date-)
Dated at the da ,August 05,2003
SIGNED BY Q�V W; &221 -----.for the Town of Queensbury.
Director of Building&Code Enforcement
Application for Permit=Septic Disposal System
Town of QueensburV 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
Office Use
Location of installation:
File Permit No.0
Tax Map No.
c�C)
Fee Paid
Owner's Name: 4,!�j
...................... ........................................................................
Address:
2. INSTALLER'S NAME PHONE NO.
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate#bedroom(s) and multiply #of
bedrooms with applicable gallons per bedroom to equal total daily flow)
Year of House: No. of Bedrooms x Computation = Total Daily Flow
1980 or older t x 150 gal/bdrm = A-
1980- 1991 x 130 gal/bdrm =
1991 -present x 110 gal/bdrm =
Garbage Grinder Installed yes.— no'
Spa or Hot Tub Installed yes— no
4: PARCEL INFORMATION: (circle applicable information&indicate measurements)
/aW4aaRhy—-$RI-Nature Ground Water Bedrock or Impervious Material D=ZRiiMater Su13Dlv
Fl sand t_t tdepth at ha depth unicipal
olling am feet feet Steep slope clay if well; water supply
%slope other from any septic-system
depth: absorption is_j?.
Percolation Test: .(To be completed by licensed professional engineer or architect) ot-her
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:
Seepage Pit(s): number of—LVe— size of each: -ft, 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
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 th own of Queensbury Sanitary Sewage Disposal Ordinance.
'79ignature of responsible person Date
'I'c�wi♦ cif (I'ma-^u�I)IL 'ry
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7. SICGNXTURE 8r IIFORMATISJTS FO.L IC1:5�T'VP4�`sJUCSL '• '� v� tyaor+�••:w•:% `•:
Septic Inspection Report
Office No. (518)761-8256 Date Inspection r uest c d:
Queensbury Building&Code Enforcement Arrive: am/p D a
742 Bay Rd., Queensbury,NY 12804 Inspector's Initia
NAME: VVx n E IT NO.:
LOCATION: INS ECT ON:
RECHECK:
Comments and/or diagram
Soil jy2e: an ay
)Bj4We11 Water
Waterline sep� nce ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length
Length of each trench
Depth of trenches ft.
Size of Stone
Seepage Pits: Number
Size:
J..Stone Size:
Piping Size T e
XA1A j'N
Building to tank �kw �-�uA i2_1)
.e " V —
Tank to D&itW6aW6x ,ml.'Iz
Opening Seale : V artial
Location/Separations
Foundation to tank
Foundation to�absorption
Separation of Pits
Conforms as per Plot Plan Y N
Location ystem on Property:
rty`r I ear eft Si- ft.
Foundation
Middle F n Middle Rear
S stem Use St tus:
Approved
Partial Approved and needs to be re-inspected,please call the*Building&Codes Office
Disapproved
L:\SueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Rep ort.doc January 28,2003
TOWN"OF QUEENS RY
BUILDIN•Q 0
REVIEWED BY
DATE
"I have seen or observed, or believe I saw evidence of
all objects such as houses; wells, trees, fences, etc.,
shown on this document. I also represent that I have
personall measured the distances set forth on the diagram."
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SIGMA U �---�=.-�
DATE
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