2003-863 'TOWN OF UEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518)761-8256
CERTI F I CATE -OF COMPLIANCE
Permit Number: P20030863 Date Issued: Tuesday, October 14,2003
- This is-to certif that wotictequested.to-be"done as shown,by Permit Number
has'npen completed,
Tax Map Dumber: 523400-295-013-0001,041.000.0000
Location: 920 WEST MT. Rd
Owner: ROBERT&DONNA PALMER
Applicant: ROBERT&DONNA PALMER
This structure may be occupied as a:
By Ordet of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
Director of Building&Coe 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: P200308 63 Application Number: A20030863
Tax Map No: 523400-295-013-0001-041-000-0000
Permission is hereby granted to: ROBERT&DONNA PALW.R
For property located at: 920 WEST MY Rd
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: ROBERT &DONNA PALMER Septic Alteration Residential
920 WEST MOUNTAIN Rd Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
I.B.S. SEPTIC
2 LOWER WARREN STREET
OIJEENSBITRY- NY
Plans&Specifications
1003-863
SEPTIC ALTERATION AS PER APPLICATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday, October 14, 2004
(Ifa 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 T October 14,2003
SIGNED BY mn for the Town of Queensbury.
Director of Building&Code Enforcement
Applibation for Permit-Septic Disposal System
Town of Queensbury'742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
...........
Offlee Use
Location of installation: C
File Permit Noc-q�,3=
Tax Map Noa% o13 --r
Owner's Name:
T-- .....................
Address: d CZ, -P003
Suit Q�'EFZJV-r)ftV0.ivo saUR,
2. INSTALLER'S NAME AH'%*
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 Comp
utation putation Total Daily Flo
1980 or older x 150 gal/bdrm =
-1980- 1991. x 130 galfbdrm =
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)
X-d6;6�ra-ohy SAiLZTature Ground Water Bedrock or Irni3ervious Material Do �esti, at,,SWDIV
CFI�� ,(sand at ha depth at what 4epth nicipal
)�—olling 11"affeet
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: jL1&d gallon(min.size.1,000 gal.)
Tile Field: each trench� ft. Total System Length:c--)L,9 C9
Seepage Pit(s): number of sizeI of each: —ft. by_ft.
to-to
Size of Stone to be used: W TA, 6
/ depth or thickness feet
Bed.System Size: x
Alternative System: length and/or size
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: t Size of each: gallons TOTAL Capacity: gallons
Mote: 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.
Signature of-respcMigfi e person Date
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Septic Inspection Report
Office No.(518)761-8256 Date Inspection requ c Date Inspect
ion n
Queensbuiy Building&Code Enforcement Arrive: a ppart: 4
742 Bay Rd., Queensbuiy,NY 12804 Inspector's Initials
NAME: T NO.:
LOCATION: S ECTON: 10& Cj3
RECHECK:
Comments and/or diagram
Soil DY Sandg lay
Type of unicipa jjWell Water
Waterline se par �Tance
Well separation distance ft.
Other wells: ft,
Absorption Field: Total length --ft.
Length of each trench
Depth of trenches
Size of Stone P-M b Q--L,
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box.
Distribution BoxP6-Vield git W. 8DEZ55
Opening Seale)K IV/-wpartial
Location/Separations
Foundation to tank ft.
Foundation to..absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan V Y N
Location of System on Property:
Front Rear Left Side Right Side
Middle Front Middle Rear
System Use Sta s-:_
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
--Disapproved
L:\SueHomingway\Btiilding.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
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