2002-257 TOWN OF OUEENSBURY ,
742 Bay Road,Queensbury,NY 12804-5902. (518)761-8201
Community Development-Building&Codes (518)761-8256
CEIRTA IFICA"I"E OF COMPLIANCE.
Permit Number: P20020257" Date Issued: Friday,April 12,2002
This is to certify that work requested to be-done as shown by Permit Number P20020257
has been completed.
Tax Map Number: 523400-308-016-0001=011.000-0000
Location: 17 STEPHANIE Ln
Owner: PAUL&MIGDALIA LEMKE
Applicant: MICKEY BAEZ
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 QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902. (518)761-8201
Community Development-Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20020257 Application Number: A20020257
Tax Map No 523400-308-016-0001-011-000-0000
Permission is:;hereby granted to: MICKEY BAEZ
For property located at: 17 STEPHANIE Ln
in the Town of Queensbuty,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: PAUL&MIGDALIA LEMKE Septic Alteration Residential
15 STEPHANIE Ln
Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name Address Electrical Inspection Agency
OUEENSBORY SEWER
JAY SWEET
Plans &Specifications
2002-257 MICKEY BAEZ
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 1 PERMIT FEE PAID- THIS PERMIT EXPIRES: Saturday,April 12,2003
(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 To BY
w t2y; Qrr.,ay,,;&fQ April 12,2002
,Vnsbu
SIGNED d W, for the Town of Queensbury.
Director of Building& ode Enforcement
Application for-Perinit—Septic Disposal System '
Town of Queensbivy 742 Bay Road Queeirsbury,NY 12804 (518)761-8256
1. OWNER INFORMATION:
.....:..................................................:.............................................................................
Office Use '
Location of installation:'
' File Permit No—�ZQQ a-S7
Tax Map No.
Owner's Name:
Fee Paid
Address:
2. INSTALLER'S NAME PHONE NO. r. �v01K,y�
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate#bedrooin(s)and multiply# of
bedrooms with applicable gallons per bedroom to equal total daily flow)
Year ofHouso: No of Bedrooms x Computation - Total Daily Fiow
1980 or,older _ _ x 150 gal/bdrm =
1980- 1991 - x 130 gal/bdrm- =
1991 -present x 110 gal/bdrm = @i
7.
Garba6 D_
Grin ^� Y g . der Installed yes_ /�' �P� 1 .t
Spa or Whirlpool Installed yes
TOWN OF Qi}EEN ;URY
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
}
o era by Soil Nature Ground Water Bedrock or Impervious Material Domestic Water Suave
Ma s to at what depth at what depth < nirinici is
Rolling loam feet feet well
Steep slope clay if well; water supply
Tio slope other - - from any septic-system
depth: absorption is A
ether _
-- -Percolation Test: (7o be-coinl)leied by'Iicensedlprofessiot?al elgineer or architect)
Rate: - minute Pei-inch
5. PROPOSED SYSTEM: For New Constniction: 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 s&c
of the septic,tank and leach field for each Garbage Grinder,Spa or Whirlpool Tub.
#�7
Septic Ta)ok: g zr_z5 gallon (min. size 1,000 gal.)
Tile Field: each trenchft. Total System Length:,-,a
Seepage Pit(s): number of_ size of each:
Size of Stone to-be used: # / depth or thickness feet
Bed System Size: x
Alternative System: `-i") 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 pennit 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 regulation4 with respect to this application and agree to abide by these and all
i
requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance.
Sift re of responsible person Date
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e all objects such as houses, loells, trees, fences, etc.,
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personally measured the distances set forth Wo the diagram."
IGNATURE DATE
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