2003-1991 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development- Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20030991 Date Issued: Wednesday, December 10, 2003
This is to certify that work requested to be done as shown by Permit Number P20030991
has been completed. '
Tax Map Number: 523400-296-006-0001-004-000-0000
Location: 59 BLIND ROCK Rd
Owner: DIANE COWAN
Applicant: DIANE COWAN
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY.
1-:
J-W
Director of Building&Code E orceme t
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20030991 Application Number: A20030991
Tax Map No: 523400-296-006-0001-004-000-0000
Permission is hereby granted to: DTANF, COWAN
For property located at: 59 BLIND ROCK 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: DIANE COWAN
59 BLIND ROCK Rd Septic Alteration Residential
Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
SANITARY SEWER
DAN DRELLOS
PO BOX 224
GLENS FALLS NY
Plans&Specifications
BP 2003-991
Septic System Alteration as per plot plan and specifications
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday, December 09, 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 Town of Queens ury; Tuesday, December 09, 2003
f/
SIGNED BY '��` for the Town of Queensbury.
Director of Building Co nforcement
RECEIVE
C£C d 8
Application for permit—Septic Disposal System
Town Of Queensbury 741 Bay.toad Queensbury, NY 12804 (S18) 761-8256
1. OWNER INFORMATION: TOWN OF Ql: ENSF3UFiY
Location of installation: 0`/ Ale,-,D g cfL`- J/
Tax Map No. o //�/ C�j��/+"7" File Permit No, U
Owner's Name: D 6 0 J
//_ 'a�J � _ l Fee Paid
�9 C�Go✓� /�� �� !_.__... __......_....._....
...
Address' ......___._ —....�_.._.._.....
2. INSTALLER'S NAME /V La o"I" Y PHONE NO) —/
3. RESIDENCE INFORMATION: (circle ear of dwelling,indicate#bedroom(s) and multiply#of
bedrooms with applicable gallons per bedroom to equal•total daily flow)
Year ofHouse: No. of Pedrooras x 9D=Zation = Total Daily Flow
1980 or older x 150 gal/bdrzn = lam 60L)
1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrim
Garbage Grinder Installed yes_ / no
Spa or Hot Tub Installed yes / no
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
PbUing
a and oc Ian ervi Wa Su 1and at what depth at what depth uni 'oam feet feet
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
S. 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 WhirlpooI Tub.
Septic Tank: ! � gallon(min. size 1,000 gal.)
'ISle Field: each trench ft. Total System Length: � 0
Seepage Pit(s): number size of each: ft. by ft.
Size 9f Stone to.be.used: # / 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 Townn of Queesbury, 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 rea egulatio with tet to this application and agree to abide by these and all
re, cuts of c Town Quc sbury S tary Sewage Disposal Ordinan
/,�
g a ure of retrponsible person /batk
T00/TOOO Xd3 C£:CT 3II.L COOZ/TO/LO
Septic Inspection Report
Office No. (518)761-8256 Date Inspection re •'eft recei / 1,9- (1 i
Queensbury Building&Code Enforcement Arrive: m/,m .part: ',_ am/ in
742 Bay Rd., Queensbury,NY 12804 Inspector's Initi s: r
NAME: ' �v fSPEC-T
NO.: v� �!
LOCATION: �� ,Lt; � f2o�l�c ON: G
RECHECK: 1
f r� Comments and/or diagram
Soil Type,,( Sandi arl Clay
Type of Wa Municip-d/Well Water j
Waterline separation distance ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length
Length of each trench
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 to Field/Pit +� �� l► , ������ ���
Opening Sealed: Y/N/Partial
Location/Separations
Foundation to tank
Foundation to absorption ) ft,
Separation of Pits ft.
Conforms as per Plot Plan Y N
Location of System on Property:
Front Rear Left Side Right Side
Middle Fro �t le Rear
S stem Use St us:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
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"! have seen' or a�sErved, r?r hElieve I saw Evidence of,
ai! objEcts such as houses; ..,ells t;eec ienCeS etc„
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DATE