2001-042 TOWN OF QUEENSBURY
Fos 2 B Road ueensb NY 12804-5902 518 761-8201
74 aY ,QY, )
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20010042 Date Issued: Tuesday, February 06, 2001
This is to certify that work requested to be done as shown by Permit Number P20010042
has been completed.
Tax Map Number: 523400-101-000-0002-013-000-0000
Location: 1 BULLARD Ave
Owner: ROGER PALMER
Applicant: ROGER PALMER
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
( eleta 4
Director of Building&Code Enforcement
" TOWN OF QUEENSBURY
Foo 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20010042 Application Number: A20010042
Tax Map No: 523400-101-000-0002-013-000-0000
Permission is hereby granted to: ROGER PALMER
For property located at: 1 BULLARD Ave
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: ROGER PALMER Septic Alteration Residential
LOIS TEDESCO PALMER Total Value
1 BULLARD Ave
QUEENSBURY,NY 12804
Contractor or Builder's Name/ Address Electrical Inspection Agency
I.B.S. SEPTIC
2 LOWER WARREN STREET
OUEENSBURY.NY
Plans &Specifications
2001-042
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID - THIS PERMIT EXPIRES: Sunday,February 02,2003
(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 f Que sb rid. , Fp ruary 02,2001
SIGNED BY irl .I 41, for the Town of Queensbury.
Director of Building&Code Enforcement
Application for Permit— Septic Disposal System
Town of Queensbiny 742 Bay Road Queensliury,NY 12804 (518) 761-8256 '
1. OWNER INFORMATION:.' 2
#,
Location of installation: /-3C--- � Office Use
((-0t � ��C
Tax Map No. / ' I, File Permit No. / ` D--
•
Owner's Name;, -ro 1/4, (' � c .� Fee Paid- JC,
Address: / - / i 6> (CFr---cI 6t C�c,
2. • INSTALLER'S NAME : • J— t , SpIG p_� PHONE NO. ��� (��j Y • •
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate #bedroom(s) and multiply II 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 3 x -150 gal/bdnn = VI-0
1980- 1991 x 130 gal/bdrm =
1991 —present - - x 1.10 gal/bdrm =
Garbage Grinder Installed yes / no _
Spa or Whirlpool Installed- yes / no
4. PARCEL INFORMATION: (circle applicable information &indicate measurements)
�,•,..grnolly S.,:.,I.atm) grsa ndV.4!alo.C_.__PCSir.gck.or ImperykonsAtaterkalUompslic W.atcr_S11pply
ep .:, ere at titer depth al II' a eplk insaticlpal
oiling n .. . feel . ' . eel well
Sleep slope clay if well; water.supply
,__/o slope other from any septic-system
• depth: absorption is fl.
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 ii licensed
. professional engineer or architect(unless installed in a Planning Board approved subdivision). Add 25O gallons to Ike size ' _,,`,,
of the septic tank and leach field for each Garbage Grinder, Spa or Whirlixwl Tub. . -
Septic Tank: 4 5-0 gallon (min. size_1,000 gal)
Tile Field: each trench�� ft. Total System Length::22a_____. i. . .
Seepage Pit(s): number of size ofecich: ft. by fl.
i •Size of Stone to be used: ll a- • % depth or thickness feel
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.
s
1: 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 those and all
requirements of the To of Queensbury Sanitary Sewage Disposal Ordinance.
V .
.6./e • .
_. , o�
nature of responslb a person '. ' Date:
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TOWN OF QUEENSBURY
BUILDING &_CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804 •
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name 1:)--.125 ac2fry\,97/
Location _ \ o y
Date r —ac()J Permit #1 ,1e1))-OLPN-
SOIL TYPE: San -Lo `-Clay-
Results of Percolation -st-
(if applicable) Rate- inut- Inch
TYPE OF SYSTEM:
ABSORPTION FIELD: Tot. l Lengt
Length of each trench �b efj /Q5eJ'
Depth of trenches /-Z.'
Size of stone
SEEPAGE PITS: Number-IIW
Size - ft. x mar ft.
Stone size
PIPING: Size Type
Bldg. to Tank
Tank to Dist. Box ,gam
Dist. Box to Field/Pi " (
Openings Sealed? OP No Partial
LOCATION/SEPARATION .
Foundation to Tank /0 feet
Foundation to Absorption zj feet
Separation of Pits
Conforms as per Plot Plan ers No
LOCATION OF SYSTEM ON PROPERT
(circle one)
Front - Rear - Left Side - Right Side
Middle Front - Middle Rear
COMMENTS:
for,/ eft fro"-
SYSTEM USE APPROVED: NO
Arrived: //. 5'r
Departed:
Building Inspector
TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
531 Bay Road
Queensbury NY 12804
518-745-4447
SEPTIC DISPOSAL SYSTEM INSPECTION
Name
u eh'1
Location v/
Date 0/4 Permit # 01 DLO--
SOIL TYPE: Sand-Loam-Clay-
Results of Percolation Test-
(if applicable) Rate-Minute/Inch
TYPE OF SYSTEM:
ABSORPTION FIELD: Total Length
Length of each trench
Depth of trenches
Size of stone
SEEPAGE PITS: Number-
Size - ft. x ft.
Stone size
PIPING: Size Type
Bldg. to Tank
Tank to Dist. Box
Dist, Box to Field/Pit
Openings Sealed? Yes No Partial
LOCATION/SEPARATIONS:
Foundation to Tank feet
Foundation to Absorption _ feet
Separation of Pits _ feet'
Conforms as per Plot Plan Yes No
LOCATION OF SYSTEM ON PROPERTY:
(circle one)
Front - Rear - Left Side - Right S:ide
Middle Front - Middle Rear
COMMENTS:
s-ep Ls-L �r h
�v
SYSTEM USE APPROVED: YES NO
Arrived: icW
Departed:
. ,
"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/asured thit distances set forth on the diagram."
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