2001-458 TOWN OF QUEENSBURY
4111111laki
BayRoad, ueensb NY 12804-5902 (518) 761-8201
742 Q �T',
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20010458 Date Issued: Thursday, June 28, 2001
This is to certify that work requested to be done as shown by Permit Number P20010458
has been completed.
Tax Map Number: 523400-302-017-0001-045-000-0000
Location: 40 WINTERGREEN Rd
Owner: DONALD &DEIDRE OSTROM
Applicant: DONALD &DEIDRE OSTROM
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
(--- J1
Director of Building&Code Enforcement
��� TOWN OF QUEENSBURY
A
742 Bay Road;Queensbury,NY 12804-5902 ,(518)761-8201
Community Development- Building& Codes (518) 761-8256.
BUILDING PERMIT-
Permit Number: P20010458 Application Number: A20010458
Tax Map No: 523400-302-017-0001-045-000-000
Permission is hereby granted to: DONALD &DEIDRE OSTROM
For property located at: 40 WINTERGREEN 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: DONALD &DEIDRE OSTROM Septic Alteration Residential
40 WINTERGREEN Rd. 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
2001-458
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Saturday,June 28,2003
(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 Queensbury; Thursday,June 28,2001
SIGNED BY -- for the Town of Queensbury.
Director of Building 1'�o.4 nforcement
Application for Permit—Septic Disposal System
Town of Queensbury 7.12 Bay flood QueensInoy, NY 1280.1 .518 761-8256
1. OWNER INFORMATION: / A
Location of installation: (/V /ricj ,?f Q Office Usc
Tax Map No. / / Kilo I'otmit No. oi-467
Owner's Name: fl /0 tal✓L Q,S (2 0A-1 lee Paid ��•�a
•
Address: 90 ti ii-i ex_SAP e:v i M
2. INSTALLER'S NAME : .( /c , ,. 7,2,t4-- PHONE NO.
3. RESIDENCE INFORMATION: (circle cac'of I >J dwelling, indicate II bcd►oo»t(ti) and multiply Il of
bedrooms with applicable gallons per bedroom to equal total'daily flow)
Year of blouse: No. of Bedrooms x Coin utation = Total Daily Flow_
1980 or older x 150 gal/hdrm = ,20 0
1980— 1991 x 130 gal/bdrm
• 1991 —present x 110 gal/bdr:n =
Garbage Grinder Installed yes / no p( q D
Spa or Whirlpool Installed yes / no JUN 2
2001
4. PARCEL INFORMATION: (circle applicable information & indicate measurements) TOWN OF QUEENSBURY
BUILDING AND CODE
To rography Soil _ attire Crgiii�d Wald_ Bedrock or Impervious Material Doi i. is Water Supply
A® igigt° at what depth at what depth Oarrfirfr
a ling in feet feet well
Sleep slope clay if well; water supply
slope other from any septic-system
•
• depth: absorption is ft.
other
Percolation Test: (To be Completed by licensed prr fissional 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(kinder, Spa or Whirlpool Tub.
Septic Tank: 1 000 gallon (min. size 1,000 gal.)
'rile Field: each trench 110 fl. Total System Length:` /&D /1.
Seepage Pit(s): number of p /ea size of each: ft. by ft.
• Size of Stone to be used: it f419- / depth or thickness__fret
Bed System Size: .®d IAA}" 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 Town
of Queensbury, any permit or approval granted which is based upon or is granted in
reliance upon any material misrepresentation or tailuro to make a material fact or
circumstance known by or on behalf of an applicant, shall be void.
I have re. regulations with respect to this application and agree to abide by these and all
require tents o he Town of Queensbury Sanitary Sewage Disposal Ordinance.
&2. --d 6 :26/0/-
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Signature of respon able person Date
7tt-A%t--
TOWN OF QUEENSBURY
BUILDING !' CODE ENFORCEMENT)1l A
742 Bay Road
Queensbury NY 12804
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name Q6Y0Y \
Location /Q i n _
Date 22O/Fermit GOY)/— L/'5
SOIL TYPE: Sand-Loam-Clay-
Results of Percolat' . Test-
(if applicable) Ra e- 'nute/Inch
TYPE OF SYSTEM: //
ABSORPTION FIELD: Total en•th /
Length of each t ench b
Depth of trenches ®'^'
Size of stone MU -
SEEPAGE PITS: Nu ber-
Size - ft. x ft.
Stone size .�
PIPING: We Type
Bldg. to Tank
Tank to Dist. Box �L
Dist. Box to Field/P '/
Openings Sealed? 'es No ,Partial
LOCATION/SEPARATION :
Foundation to Tank feet
Foundation to Absorption . _3S feet . .
Separation of Pits feet
_ Conforms as per Plot 'lan 40 No
LOCATION OF SYSTEM ON PROPER .
(circle o...
Front - 'ea. - Left Side - Right Side
Middle E- t - Middle Rear
COMMENTS:
•
SYSTEM.USE APPROVED: YES NO
Arrived: 0
Departed:
DIQI o Building nspecr
if..., i-- )
•
/00 Sg'L
'D. B Q �Nr�
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4 \ 0)y, m
RECEIlit6
�{ CD; �f°' JUN 252001
� � Esn'SeUR,,
INo Cope
•
•
"I have seen or observed, or believe I saw evidence of,
all objects such as houses,.wells, trees, fences, etc.,
sho',A on this ,cocurn!,,,, ;tsu that
represent I have
per or.i y mea.surec' ; bJ t i. "nce„c ►,/ �., . ih on the diagram. '
/..
s— d
SIGNAT '''E DA