88-082CERTIFICATE OF OCCUPANCY
TOWN OF QUEENSBURY
WARREN COUNTY, NEW YORK
Date October 16 19 89
'Ibis is to certifythat work 88-82
requested to be done v shown by Permit No.
has been completed.
This structure may be occupied as a One Family Dwelling
LocationLot 22 Briggs Court (St. No. 9) Queensbury Forest
Owner Masullo Brothers Builders Inc.
By Order Town Board
TOWN OF QUEENSBURY
Building & Zoning Inspector
BUILDING PERMIT
TOWN OF QUEENSBURY
WARREN COUNTY, NEW YORK
PERMISSION is hereby granted to
Masullo Brothers Builders Inc.
OWNER of property located at Lot 822 Briggs Court (St. No. 9) Street, Road or Ave.
in the Town of Queensbury, To Construct or place a One Family Dwelling
at the above location in accordance to application together with plot plans and other information hereto filed and
approved and in compliance with the Town of Queensbury Building and Zoning Ordinance.
t.
OWNER'SAddressis 3049 Broadway
Schenectady, N.Y.
2.
CONTRACTOR or BUILDERS Name
Same
3.
CONTRACTOR or BUILDERS Address
Same
4.
ARCHITECT'S Name
5.
ARCHITECT'S Address
6.
TYPE of Construction — (Please indicate by X)
U Wood Frame ( 1 Masonry ( 1 Steel ( 1
7.
PLANS and Specifications
No 34' x 48' as per plot plan, specifications and application including
septic system and attached garage.
8.
Proposed Use
One Family Dwelling
�5.UU C/o
$ 129.00 PERMIT FEE PAID —THIS PERMIT EXPIRES October 1, ig 88
(If a longer period is required an application for an extension must be made to the Building and Zoning inspector of the
town of Queensbury before the expiration date.)
Dated at the Town of Queensbury this 21st Day of
SIGNED BY
Building and Zoning Inspector
March
mum
the Town of Queensbury
H
w
w
w
b
0 0
r
0
rt
rt tQ
rt N
• N
z od
on
H.
av
0 ov
� m
-own of Vueenibury
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road, R.D. 1 Box 98
Queensbury, Now York 12801
�a�
I a I �� APPLICATION FOR
appt.t.cauon r+u.
Permit.Issued 19
Permit Expires 19
Zoning Designation
Variance No.
Site Plan Review No.
Approved
BUILDING AND'I.ONING PERMIT I '
a e r r e �► r +► ar r. • li .e ar r ♦ • at ar +► • lr r r r • r
TOWN OF QUr`.civ�G:::
MAR 181988
IZUILUING Csc i:(:uc UEPT
/4�
.S' /3s/ 00 .
a ar • * ar ar a r r ■ :; r
A PERMIT MUST BE OBTAINED BEFORE BEGINNING CONSTRUCTION. ANSWER ALL OF THE FOLLOWING.
The undersigned hereby applies for a Building Permit to do the following work which will
be done in accordance with the description, plans and specifications submitted, and such
special conditions as may be indicated on the Permit.
The owner of this property is% Misullo Brothers builders. Inc.
P.O. Address anGq Rrn �` j�an'�olr):ady Nowt' Ynrlr Tel.370-I OSR
Property Locatiorls�. _ot f 22 / /�/OU,SC �/ ��/�i CT Tax Map No.
Street number or building lot number
Subdivision name (if applicable) oueensbury Forest
THE PERSON RESPONSIBLE FOR SUPERVISION OF WORK AS REGARDS BUILDING CODES IS:
.Masu11Q ix"bers-Build-ar"Fc• IW-J-rpadwav•.fichenectady. New York 518-370-1058
Name P.O. Address Tel. No.
Namo'cf builder Same Address Same as Abobe Tel. Sams
Na"!; of plumber_mR plulbing Address 88 Newton Strepa Albam.N.y. Tel .459-5811
Name' of mason lIo Bxoa, g,;irlo.a Address Swe Tel. Same
MATURE OF PROPOSED WORK: " ZONING INFORMATION:
a'Construction of a new building " A PLOT PLAN MUST BE PREPARED AND SUBMITTED,
_Addition to a building, " drawn reasonably to scale and attached hereto,
Alteraihion.to.a building " showing clearly and, distinctly all buildings,
(nO.phange to exterior dimensions) " whether existing or proposed and indicate all
Other work (describe) " set -back dimensions from property lines. Give
" street and number or lot number and indicate
FOR DEMOLITION PERMIT, STATE SIZB'AND " whether interior or corner lot. Show location
'CATION OF STRUCTURES AFFECTED. " of water supply and location and configuration
" of septic disposal area.
r
" COMPLETE INFORMATION REQUIRED BELOW.
" Size of property, ))3 ft X ft.
" Existing.building(s) Size ft X ft.
'ROPOSED BUILDING AND USE:
[ize of new structure -X—ft X tuft
'oundation-pier/slab/crawl/partial ull
(circle one)
lo. of stories (habitable space) 2
[eight (grade to ridge)23' ft.
:f residential, no. of families ..'1
10. of rooms(excluding baths)' g
'o. of bedrooms 3
O. of bathrooms li
rimary heating system,.,
ype of fuel ElevYr;o
o. of fireplaces to be installed t
ill a wood stove be installed?
antral Air conditioning? Yes
UILDING STYLE, PRIMARY STRUCTURE
anch Contemporary Log cabin
wised ranch Mansion Duplex
Alit level Old style Bungalow
a e Cod Cottage Other
olonia Rbw Town House
( CIRCLE ONE PLEASE )
:STIMATED MARKET VALUE OF
:ONSTRUCTION $
" Existing building(s) Use
•
"Proposed buillddinng, distance from property line
Attached
" Front yard_ ply ft Rear yard ft
" Side yards ft and ft
" If on corner, setback from side street ft
" OCCUPANCY INFORMATION
"
" PRIMARY BUILDING -
" One family dwelling
" _Two family dwelling
" Multiple dwelling / Number of units
" Permanent occupancy
" Transient occupancy
" Business
" _Industrial
Other'
" If addition, what will use be?
r _
" ACCESSORY BUILDING-
" _Detached garage/one car/ two car/ car
X Attached garage/one car/ two car/_x car
" Private storage building
" Other
NFORMATION ON BUILDING SPECIFICATIONS, ON REVERSE SIDE OF THIS SHEET, TO BE COMPLETED!
'Oru nPA I /OG -4 ...
BUILDING SPECIFICATIONS:
Type of construction, wood frame, fire safe,etc. Wood Frame
will any second-hand ;or ungraded lumber be used? If so, for what? .No
Foundation wall materiah+� rSti,rrnro "" ^"`-- - - --
Depth of foundation below grade (to bottom of footing) M
Will there be a cellar? USHeated or unheated? Floor sq. footage 1.755 sq ft
14UI,there be a basement? Will any portion be. used as living space?
(If so, what portion? sq.ft. - - Type of use?
Type of . root - sloped/flat/shed/other Material. of roof Asphalt Shingles
Size, wood studs 2. "X 6 " spacing24 "o.c. length __I_ft.
Joi`ats(floor beams) 'lot. floor 2_"X--,juL" spacing^16_ "o.c. span 14 ft.
Joisfs(floor beams) 2nd. floor 2 "X 10 " spacing_j¢-"o.c. spanjj_ft.
Overlays(ceiling beams) "X spacing "o.c. span ft.
goof rafters "X " spacing o.c. span ft.
Rvof trusses (pre-engineered) spacing_A_"o.c: epan ft.
Exterior wall finish Alumina Of what material?
Interior wall finish " aheetiodc-pninrgl
If•a garage is to be attached, describe materials to be used for FIRE SEPARATION.
Is there to be an opening between garage and dwelling7�Ye _ If so will a Fire-rateo
door, enclosure, and self -closing device be provided? Yes ft.
Will a flue -lined chimney'be installed? yes Height above roof 9 —
Depth of chimney foundation below grade 8_ft.
Depth of fireplace hearth' ft. 8 in. .
Water supply -'Municipal or private well_jipjpl,rt
SEPTIC SYSTEM Distance from ANY private well(ineluding adjoining properties ft.
(A separate.applieation is nec see ary for any, repair or new installation of septic system)
Town' of Queensbury A F F i D A V I T STATE OF NEW YORY.
County of Warren
I swear that tq, the best of my knowledge and belief the statements contained
In this application, together with the plans and specifications submitted, are a true and
complete statement of ail proposed work to be doneon the described premises and that all
provtsions•of the BUILDING CODE, THE ZONING ORDINANCE, and all other laws pertaining to
tho proposed work shall be complied withr whether specified or not, and that such. work is
authorized -by the owner. ;
SWORN:TO BEFORE HE THIS •.'Signature_-� - -----------------
Owner, owner's agent,arcnytect,contractor
day of - 19_
Notsry Public, Warren County, N.Y.
SPECIAL CONDITIONS OF THE PERMITS
y . By.
cv.r.. yr VUZnL40bvxs
WARREN COUNTY, NEW YORK
Application for: BUILDING PERMIT IN COMPLIANCE WITH THE NEW YORK
STATE ENERGY CONSERVATION CODE
A permit must be obtained before beginning work.
ANSWER ALL of the following:
1. Gross floor area //6a Sn. Ft.
2. Type of heat Electric Beat Pump
3. Is the building mechanically cooled? YES
4. Percentage of area of windows and doors 1470
A. Over 16% Only
1. Uo value of gross area of walls, roof/ceiling and floors
exposed to ambient conditions See Arrarhvd
2.
Floor over heated spaces YES NO
a. Are foundation walls insulated? YES NO
1. If YES, what is the R value? R-13
3.
Slab on grade YES 40
a. If YES, what is the R value of insulation around
perimeter of floor?
4.
Is basement heated? YES NO
a. R value of insulation
S.
Type of insulation Fiberglass
B.
Under 16% Only
1.
R value of roof and floors exposed to ambient conditions
2.
R value of exterior walls
3.
R value of glazed area
4.
_R value of doors
5.
R value of floors���jj
$e unheated spaces
6.
R value of slab edge insulation - unheated slab
7.
R value of slab insulation - heated slab
B.
R value of heated basement/cellar walls (above grade)
9.
R value of heated basement/cellar walls (below grade)
10.
Type of insulation
C.
Controls
1.
Thermostat maximum heat setting 900
D.
Duct Systems '
1.
Is duct system installed in unheated spaces? YES NO
a. If YES, R value of duct installation
b. R value of duct in other areas
E.
Piping
Insulation
1.
Size of hot water or cooling carrying agent pipe" 6 3/4 Copper
2.
R value of pipe insulatiod
F.
Service Water Heating
1.
Performance efficiency
2.
Temperature control setting maximum
G.
Fpr
Swimming Pool Only
I.
Maximum heating
Telephone No. 370-1058 /JLM R
(applicant's signature)
i��EW YORE: STATE /NE �vlr'alIU6
E `FRCRY ;ONSERVATION CONSTRUCTION CODE
PART 6 WORKSHEET
THERMAL RAT114G METHOD
ONE- AND TWO-FAMILY BUILDINGS
BUILDING
ADDRESS
GROSS FLOOR AREA 123D
NUMBER OF STORIES 2
DEGREE DAYS 7000
CO:ITRA.CTO?, ARCHITECT OR ENGI14EER .— bktllLn 6RO&BOILVIR3 INC.
3p4q 81?OAL)VAY
_Y,6Lt EC7�.4 y. Iur-W Y,0h
TELEPHONE 320- 162
If ths buildirc dces not meet the follcv:i-a•pre-qualifying
conditions, Part 6 of the Energy Code may not be used.
YES NO
Building is one- or tv:•q-family residential.
_ Building is detached.
Building is less than 5,000 gross square feet.
Building is three stories or less in height.
_ Entrance doors have a storm door
or certified U value of .40 or less.
Glazing area/gross wall area is equal to or
less than:
24% if 5,000 degree days
232 if 6,000 degree days
20% if 7,000 degree days
182 if 8,000 degree days
16% if 9,000 degree days
If all of the above conditions are not met, either PART 3,
PART 4 or PART 5 of the Energy Code must be used.
DIRECTIONS: For each component of the proposed building design enter the
design information requested such as Areas, "U" or "R" Values.
Additional lines are provided for designs with more than one component
construction type. Obtain thermal ratings for each item by consulting
the appropriate Tables.
A. ROOF/CEILING Obtain Thermal Ratings from Table 6-1,
6-2, 6-1E or 6-2E depending upon degree
days and heating type.
Area:
qU-
Square Ft.
Area:
Square Ft.
U-Value: .63
U-Value:
14
h—e—r m- TF Rating
Thermal Rating
B. NET WALLS Obtain Thermal Ratings from Table 6-1 or
6-lE depending upon heating type.
Area: 2�064 U-Value:
Square_ Ft. Thermal Rating
Area: U-Value:
Square Ft.
Thermal Rating
Note: Net Wall Area = Gross Wall Area minus Basement/Cellar
l:'alls, Glazing Areas and Door Areas.
C. GLAZING Obtain Thermal Ratings from Table 6-3 or
6-3E depending upon heating type.
WINDOWS
Area of Glazing: Is� U-Value: #44
Square Ft. Thermal Rating
Area of Glazing: U-Value:
Square Ft. Thermal Rating
SKYLIGHTS
Area of Glazing: U-Value:
qua are�t, Thermal Rating
D1. FLOORS Obtain Thermal Ratings from Table 6-1.
6-lE or 64E depending upon degree days
and heating type.
Floor Area: U-Valuer
Sq. Ft. Thermal Rating
D2. BASEMENT/CELLAR WALLS Obtain Thermal Ratings from
Table 6-4. 6-5. 6-6 or 6-5E
depending upon degree days
and heating type.
V.1all Perimeter: 13
Linear Feet
Exposure Above Grade: 2-
feet
U-Value of V.'all: ,0�
Depth of V'all U-Value ^ O
Below Grade: `t
Inches Thermal Rating
(dote: Use the above grade U-Value of the wall. The Thermal
Rating Tables have been designed to take into account the
insulating effect of the earth.
D3. SLAB INSULATION Obtain Thermal Ratings from Table 6-7
or 6-6E depending upon heating type.
Slab Perimeter:
Linear feet
Insulation R-Value: NA
Thermal Rating
E. INFILTRATION CONTROL Obtain Thermal Ratings from Table 6-8
or 6-7E depending upon heating type.
If the building does not meet the following conditions,
enter NA (Nct Applicable) for Thermal Rating.
YES NO
All windows have an air leakage rate of 0.35 cfm
or less per linear foot of operable sash crack;
All net wall areas have an infiltration barrier;
and
A heat recovery ventilator, which transfers heat
between the outgoing airstream and the airstream
entering from the outside, is installed.
Conditioned Floor Area: NA
(Shall not include qua —re Ft—. hermaT 1 Rating
basement/cellar floor area)
F. SOUTH FACING GLAZING Obtain Thermal Ratings from Table 6-9
or 6-8E depending upon heating type.
If .-.e building Bees net meet the following conditions,
enter 14A (Not Applicable) for Thermal Rating.
YES 140
_ The building is no less than 1.250 square feet in
conditioned floor area;
At least 45 percent of all glazing faces within
30 degrees of true south;
All glazed areas in buildings are no more than
U(glazing) 0.58;
South facing glazed areas are free of any site.
obstructions during the heating season; and
An area of four -inch thick concrete or masonry
is exposed to direct sunlight from south facing
glazing. The area of this concrete or masonry
shall be no less than three times the area of
south facing glazing.
Conditioned
South Glass/Total Glass: Z Floor Area: Square Ft.
(See Above)
Glass Area/Gross Wall Area: Z
Therma Rating
SUM✓IJ,ARY OF TOTAL THERMAL RATING
If the Total Thermal Rating is'zero (0) or greater;".the proposed
design for the building envelope complies with the Energy Code.
AREA
U—VALUE
A. ROOF/CEILING
Type 1
q J 6
f 033
Type 2
B. 14ET WALLS
Type 1
Z 0(4
Type 2
C. GLAZING
Window
type 1
-44
Window
Type 2
Skylights
D1.
FLOORS
D2.
BASEI4ENT/CELLAR WALLS ,�yy
13`I
Wall Perimeter
Feet
Exvosure Above Grade =t
Fee
Wail U—Value
Depth of Wall U—Value
Below Grade
Inches
D3.
SLAB INSULATION
Slab Perimeter
Feet'
Insulation R—Value
E.
INFILTRATION CONTROL
Conditioned Floor Area
Sq. Ft.
'F.
SOUTH FACING GLAZING
South Glass/Total Glass
Percent
G1. Area/Gross Wall Area
Percent
Conditioned Floor Area
Sq. Ft.
TOTAL THERMAL RATING
THERMML
RATING
4
-F�
TABLE
USED
62
.6-
- o - 6-6
Ulm
Z;Utft of Qu aw,
APPLICATION FOR SEPTIC DISPOSAL PERMIT
DATE /9Akulk X / CIO
LOCATION OF PROPERTY FOR INSTALLATION y S CT
Owner's Name: IhASOUO BI?Z. W12W.i//7/CTelephone: 3�O
Address: 30'0' /1349 R6 WAY . SCIIE/U� cTi40Y A/L'l✓%/�� 12,306
/ Installer's Name: AN /1)zz o 840S. WIWTelephone: 710—/0SS
Number of bedrooms (residential only) _ 3
Total daily flow (compute @ 150 gal per bedroom)
Topography: circle one: lit Rolling Steep Slope % of slope
Soil Nature: circle one: and Loam
pp Clay . Other / Depth: feet
Ground Water: At what depth? /b� feet
Bedrock or Impervious Material: At what depth? _ /� /d feet
Percolation test: circle one: of required required / rate min. inch.
Domestic water supply: circle one: Municipal Well Other
IF domestic water supply is a Well:
Separation: Watersupply from Septic absorption _ feet
PROPOSED SYSTEM: Septic Tank I&VO gal. (minimum size: 1,000 gal.)
TILE FIELD: Each Trench j feet / Total system length 2X feet
SEEPAGE PIT(S): Number of / Size each feet by feet
Size of stone to be used # 2 / Depth or Thickness feet
IMPORTANT
... Please ... LIST NEW EQUIPMENT TO BE INSTALLED
ssssssssssssssssssssssss!!!s!slssss#s##s#
(over)
Section II Septic System Inspections:
A. All applications for septic system installation, alteration or repair, as
required by the Town of Queensbury Sanitary Sewage Ordinance, shall
be submitted to the Building Department at least 24 hours before start
of construction and shall include a plot plan showing:
1.) the proposed location of the system
2.) location and distance to lot lines
3.) location and distance to structures
4.) location and distance to any water supply
5.) size and dimensions of all tanks, distribution
boxes, tile fields and/or drywells
B. No system shall be covered before inspection and approval by the building
Inspector. Failure to comply with this requirement may result in the
uncovering of the system by the installer and a fine of up to 5250.00.
C. An approved copy of the plot plan shall be available on the construction
site. Failure to produce said plot plan at time of inspection may result
in an immediate work stoppage.
D. Should unforeseen problems during construction prevent proper installation,
alteration or repair of an approved system, a new proposal must be submitted
to the Queensbury Building Department before further construction.
I have read the regulations above and agree to abide by these and all requirements
of the Town of Queensbury Sanitary Sewage Disposal Ordinance.
Signature of responsible person:
Date:
Town of Queensbury
Building and Code Department
Bay at Haviland Road
Queensbury, New York 12801
(518) 792-5832
- oain of QueenjLry
��Q
���0 " BUILDING and ZONING DEPARTMENT
ay and Haviland Road, R.D. 1 Box 98
Queensbury, New York 12801
ING INSPECTOR'S REPORT
AME
/ 0 _ . M ��
LOCATION
Date Permit No.
�_Footic
Found:
Waterl
Backf:
Framii
Roo f it
Sidinc
Mason]
Rough
Reliel
Ext. I
Finisl
Inter:
Stair:
Cellar
Concre
Plbg.
Gar. I
Door
Smoke
Chimnc
INSULF
Foundz
Floor:
Walls
Ceilir
FINAL
URIVEW
Final
ig/Pier Forms• •.��.,.,. �., -
ktion
//
....
goofing
11
kg
Lg
I
'y Veneer
Plumbing
Valves
'orches
ied Floors
or Trim
& Railings_
Drain Tile
.te Floors
Fixtures
'ireproofing
'losers
Detectors
y
TION:
tion
9
ELECTRICAL INSPECTION
ky APPROVAL
Building Survey
Next scheduled inspection (call when ready)
Remarks-
T i N bYZ M �- r) l-Dc? iW 6_S 1�
rooI IN6 s
rl / I r�, 1 -4, L - -
Bui ding Insp ctor
6/86 and-vl
Jown o/ Queensbury
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road, R.D. 1 Box 98
Queensbury, New York 12801
BUILDING INSPECTOR'S REPORT
LOCATION
v/
Date y / Permit No.�
✓ — nvnarnrvn _ vcc / nin
Footii
Found+
rF]ater]
]°$ackf:
Framii
Roofii
Sidinc
Mason:
Rough
Relie:
Ext. ]
Finis]
Inter:
Stair<
Cellar
Concre
Plbg.
Gar. I
Door
Smoke
Chimnc
INSULT
Founde
Floor:
Walls
Ceilir
FINAL
DRIVEW
Final
ig/Pier Forms --
ition
--
-
)roofing
.11
Lg
ig
I
y Venee
Plumbing
Valves
'orches
Led Floors
.or Trim
& Railings
Drain Til
:te Floors
Fixtures
'ireproo ing
'losers
Detec ors
Y
.TIO
tion
9
ELECTRICAL INSPECTION
kY APPROVAL
Building Survey
Next scheduled inspection (call when ready)
Remarks-
TOWN OF QUEENSBURY /I
BUILDING AND CODES DEPARTMENT Iul
BAY & HAVILAND ROADS
QUEENSBURY, NEW YORK 12809-
TELEPHONE (518) 792-5832
BUILDING INSPECTOR'S REPORT
REQUEST 0 INS CTION RECEIVED
NAME L/�%,
LOCATI N v// S
DATE - W PERMIT N
APPROVED
I YES I NO
FOOTING/PIERS
MONOLITHIC POUR FORMS_
FOUNDATION/DAMP\-PROOFING_
BACKFILL APPROVAL
L,R'OUGH PLUMBING
L IWMMING
ELECTRICAL ROUGH -IN
INSULATION:
FLOORS
WALLS
CEILING
FINAL INSPECTION:
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PORCHES/STEPS
STAIRS -CLEARANCE & RAILS_
PLUMBING FIXTURES/RELIEF VA
INTERIOR TRIM/PRIVACY DOORS
FINISHED FLOORS
GARAGE FIREPROOFING
DOOR CLOSER(S)
SMOKE DETECTORS
FINAL ELECTRICAL INSPECTION_
FINAL APPROVAL OF CONSTRUCTIO.
A SIGNED CERTIFICATE OF OCCUPANCY MUST BE
OBTAINED FROM THE BUILDING DEPARTMENT BEFORE
THESE PREMISES ARE OCCUPIED!
REMARKS:
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT
BAY & HAVILAND ROADS
QUEENSBURY, NEW YORK 12801-
TELEPHONE (518) 792-5832
BUILDING INSPECTOR'S REPORT
REQUEST FOR INSPECTION RECEIVED
NAME
LOCATION��
DATE -=�-9 �r� PERMIT #'d
APPROVED
FOOTING/PIERS
MONOLITHIC POUR ,ORMS
BACKFILL APPROVAL
ROUGH PLUMBING
FRAMING
au[ ULATIVN: %
FOUNDATION
FLOORS
WALLS !�-19
CEILING
FINAL INSPECTION:
CHIMNEY HEIGHT
EXTERNAL PORCHES/STEPS \
,S1A1XS-CLEARANC & RAILS
PLUMBING FIXTU ES/RELIEF VALVE
INTERIOR TRIM/ RIVACY DOO
FINISHED F S
GARAGE FIREP OOFING
DOOR CLOSER S)
SMOKE DETE ORS
FINAL ELECT CAL INSPECTION
FINAL APPRO AL OF CONSTRUCTION
A SIGNED CERTIFICATE OF OCCUPANCY MUST BE
OBTAINED FROM THE BUILDING DEPARTMENT BEFORE
THESE PREMISES ARE OCCUPIED!
REMARKS:
_loom o/ QueenjLrY
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road, R.D. 1 Box 98
Oueensbury, New York 12801
SEPTIC DISPOSAL SYSTEM INSPECTION
NAME ` % c?,,,_)
LOCAT ION
)ATE PERMIT NO.
SOIL TYPE - Sand - Loam - Clay -
Percolation Test Required? YES - NO
Percolation rate - Min/Inch
TYPE of SYSTEM:
kbsorption field, total length 2;
Length of each trench
depth of trenches %Z
Size of gravel_
SEEPAGE PITS{Number of)
Size- ft. X ft.
ravel size
?IPING: AND
'Type
3ldg
)ist. to tank
Cank to (list. box
)ist. boy: to field/
)penings sealed? yPartial
,OCATION/SEPARATIONS:
'oundation to,'tankft.
'oundaticn to abscrption ft.
Lbsorption to lot line ft.
separation of pits ft.
,OCATIONle TEM ON PROPE TY(circle one)
'ront - ear - Left side - Right side -
'CIRMENTS .
YSTEM USE APPROVED (J�ES / NO
M
1/86 and vl
I It3 1 113