2001-574 7 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: P20010574 Date Issued: Tuesday, July 31, 2001
This is to certify that work requested-to be done as shown by Permit Number P20010574
has been completed.
Tax Map Number: 523400-295-019-0002-014-000-0000
Location: 243 AVIATION Rd
Owner: EDWARD & JILL CLARK
Applicant: EDWARD & JILL CLARK
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
4 *.a./
Director of Building&Code Enforcement
1
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development- Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20010574 Application Number: A20010574
Tax Map No: 523400-295-019-0002-014-000-0000
Permission is hereby granted to: EDWARD &JILL CLARK
For property located at: 243 AVIATION 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: EDWARD & JILL CLARK Septic Alteration Residential
243 AVIATION Rd Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name/ Address Electrical Inspection Agency
I.B.S. SEPTIC
2 LOWER WARREN STREET
OUEENSBURY,NY
Plans &Specifications
2001-574
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
ti
$25.00 PERMIT FEE PAID - THIS PERMIT EXPIRES: Saturday,July 27,2002
(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 T of Que sb ; F is y,July 27,2001
SIGNED BY `�' for the Town of Queensbury.
Director of Building&Code Enforcement
Application for Permit—Septic Disposal System
limn of Qiteenshiny 742 Day Road Queensbury, NY 12804 (518) 761-8256
1. OWNER INFORMATION:
•
•Location of installation: o2 V3 Office Use
Tax Map No. / / Filo Permit No. ) /'S�
Owner's Name: j ', ( ( C ( u r Fee Paid 5 1
Address: ,�,(, CO (,/ �./ /()/tT /10/ ( (Cie
`7
2. INSTALLER'S NAME : I e ` /C fo,'PHONE NO.�pjP t( `V
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate II bedroom(s) and mu t:i,ly II of
bedrooms with applicable gallons per bedroom to equal totct ow)
Year of House: No. of Bedrooms x Computation = Total Daily (+,lbwOto,
1980 or older S x 150 gal/bdrin = it0 '.'eel
1$4.0
1980— 1991 x 130 gal/bdrm = `" N., O 0/
1991 —present x 110 gal/bdrm = , 4454/Se,_
OO�c'1),
Garbage Grinder Installed yes / no
Spa or Whirlpool Installed yes / no '
4. PARCEL INFORMATION: (circle applicable information &indicate measurements)
.'•fi. ra by turo Ground Wales_ Bedrock or Impervious Material . :'csi ater Stpply
Matz arnd ' at hu .lepth at►nh t pill municipal
ing vain 'el —7� eat
Steep slope clay if well; water supply
__%slope oilier from any septic-system
' depth: absorption is ft.
other - '
Percolation es (7o be Completed by licensed professional engineer or architect)
•
Rale: M_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 13oard approved subdivision). Add 250 gallons to the size
of the septic tank and leach field for each Garbage Grinder, Spa or Whirlpool Tub.
Septic Tank: /0(90 gallon (min, size 1,000 gal)
/r
Tile Field: each bench!�,. Q ft. Total System Lcugt!' � fl.
Seepage Pit(s): number of size of each: fl. by fl.
Size of Stone to be used: It / depth or thickness I fret
Bed System Size: • x
Alternative System: length and/or size
•
6. HOLDING TANK SYSTEM: (if required)
1 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 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 these and all
requirements of the Tow' f Queensbury Sanitary Sewage Disposal Ordinance.
0, 2....._•cv-d.,i .
nature of
rasp le person Date
3. i,
TOWN OF QUEENSBURY 1S- 0
BUILDING & CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name bp J
CIDGO))1/(-
Location1-13 C\-1 (\
)
Date— Q— Permit M/— -/tf
SOIL TYPE: (Sa ).oam_ClaY_
Results of e colation Test-
(if appli ableNRate-Minute/Inch
TYPE OF S STEM: \\ �-
ABSORPTION FIELD: 'Total L�e gifh dew
Length of e ch tren h \ ll0
Depth of tre ches
Size of stone4-.'A
SEEPAGE PITS: Numbe
Size - ft. x ft.
Stone size
PIPING: Si4e Type
Bldg. to a • I 2
Tank to Dist. B.): nu.
Dist. Box to Fie' d/Pit 1.A . 64:A0a-()
Openings Sealed? Yes No , ,Partial
LOCATION/SEPARATIoNS:
Foundation to Tank lLfeet •
Foundation toAbso ,tion �feet
Separation of Pits N eet
Conforms as per Plot Plan Yes No
LOCATION OF SYSTEM 0 PROPER :
(circle-1 e
Front - Rea - Left Side - Right- ide
Middle Front - Middle Rear
COMMENTS:
SYSTEM.USE APPROVED: OYES NO
Arrived: '4
Departed: ' t C \
•
. Building Inspector
CC20
/ SI"I have,seen or observed,or believe I saw evidence of, 1
all_objects suchSIG.asNATURE-houses, wells,trees; fences, etc.;
i r►,'nP
shown on this documentI also represent-that I have � 1 G �� �
personal) asured the dis noes set forth on the diagram:' Q /
-)2. ),96f
DATE
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