2001-555 TOWN OF QUEENSBURY
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742 Ba Road ueensbu NY 12804-5902 518 761-8201
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Community Development - Building.& Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20010555 Date Issued: Friday, August 03, 2001
This is to certify that work requested to be done as shown by Permit Number P20010555
has been completed.
Tax Map.Number: 523400-279-017-0002-009-000-0000
Location: 122 SUNNYSIDE RD.NORTH
Owner: JON & SUSAN DOUGHER
Applicant: JON& SUSAN DOUGHER
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
tpi 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20010555 Application Number: A20010555
Tax Map No: 523400-279-017-0002-009-000-0000
Permission is hereby granted to: JON& SUSAN DOUGHER
For property located at: 122 SUNNYSIDE RD. NORTH
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: JON& SUSAN DOUGHER Septic Alteration Residential
122 SUNNYSIDE NORTH Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name/ Address Electrical Inspection Agency
OUEENSBURY SEWER
JAY SWEET
Plans &Specifications
2001-555
SEPTIC ALTERATION PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID - THIS PERMIT EXPIRES: Tuesday,July 23,2002
(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 of Q ns ury• hnda ,July 23,2001
`4
SIGNED BY c_P
for the Town of Queensbury.
Director of Building&Code Enforcement
• ' Application for Permit — Septic Disposal System
Towl1 of Queens.buly 742 Bay Ruud Queeusbtu;y, NY 12804 (518) 761-8256
1, OWNER INFORMATION:
Office Use
Location of installation: / v at.h h l .Si .,2 /v '
Filo i'onnit No. I)—5 5
Tax Mnp No. / /
Ln
Foe Paid act
Owner's Name: �) 0 /U • 3—t,�S a ti "'Doug
. Address: / -6 i.,u,1*.tn.<f `c; , /tJ
2. INSTALLER'S NAME : ("fk ),(2O 1 kitf\� PHONE NO.
3, RESIDENCE INFORMATION: (circle year of ng, Irdicale #bedroom(s) and multiply ii q CEI
VEE
bedrooms with applicab a gallons her hedruoltr to equal Io(u1 daily flow)
JUL 1 S 2001
Yoar of House: No. of I3odrwotLs x Compujatiou = Total Daily Flow TOWN OF QUEEN
BUILDING AND CODE
x 150 gal/burin = 3 ---6
1980— 1991 x 130 gal/bdrnl =
1991 —present x 110 gal/bdrin =
Garbage Grinder Installed yes k:Ig)
Spa or Whirlpool Installed yes / 0 ;
s
4. PARCEL INFORMATION: (circle applicable information & indicate measurements) •
IO1.1941Uu ply .S •1.Nattr.tc_ . . .Cl.rvonct.Wntot_. _u.oskock..or..ilnporyjvu5_M.a.tor.iAil_ _Donteslic_Watvr.Supply
/`T� rrl who/depth rrl who/ depth /mmialprrlf
ak,
Rolling loan: feel _feel
Steep slope _clay — — if well; water supply
,__%slope other from any septic-system
depth: absorption is fl,
other
' Percolation Test; (To be completed by licensed professional engineer or architect)
Rate: A• minute per Inch
5, PROPOSED SYSTEM: For New Construction: All Individual sewage disposal systems must be designed by it licensed
professional engineer or architect (unless Installed in a Planning ilontd approved sutxlivision), Add 25(1 gallons to the site
of the septic tank and leach field for each Garbage (hinder, Spa or Whitlix)ol Tub. .
Septic Tank:f<frerp gallon (min. size 1,000 gal.)
Tile Field: each trench fl, Total System Length: ft•
Seepage Pit(s): number of size vf•each: ft. by fl, .
Size of Stone to be used: ll ,____ ,__r, / depth m'thickness „__..._,_._...._..pet
Bed System Size: x
Alternative System: � nth and/or size l b — 2 Z
6, HOLDING TANK SYSTEM: (if required)
Number of tanks: / Sizo of each: gallons /TOTAL Capacity: gallons
Note: Alarm System and associatod•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 Quoonsbury, 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 or an applicant, shall be void. .
I have rend the regulations with respect to this application Hitt agree to abide by those and all
requirements of the Town of Qucensbury Sanitary Sewage Disposal Ordinance.
, 0 '1/4 --L.A /S 7- /- - / .
Sig -atu a !responsible person Date
TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name C-1V- F0-:
l
Location S1��-A(\_..tom\�`61n __
Date ` -j-OI Permit # Zz ) 15-C
SOIL TYP Sand- am-Clay-
Results of Percolat'on T.st-
(if applicable) Rat -Minu ,e/Inch
TYPE OF SYSTEM:
ABSORPTION FIELD: Total Le' gth 4r)
Length of each tren4 h . -7;_e?� 77/7)1
Depth of trenches I -
Size of stone `s., ! �
SEEPAGE PITS: N mbeW'
Size - ft. ft.
Stone size
PIPING: Size Type
Bldg. to Tank U
Tank to -Dist. Box s<<
Dist. Box to Field/Pi '
Openings Sealed? AP No . .Part a.l
LOCATIOd/SEPARATION : • El�
Foundation to Tank t 0 , feet
Foundation to Absorption feet
- Separation of Pits _ feet
Conforms as per Plot P1 a Ye No
LOCATION OF SYSTEM ON PR PER .
(circle one)
Front - Rear - Le Si : Right Side
Middle Front - iddle Rear
COMMENTS:
ULC
SYSTEM.USE APPROVED: YE NO
Arrive :1
Depa ed '
Bu ding In "car
groo
TOWN OF QUEENSBURY M
BUILDING &_CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804 �
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name C6 t\i--)PlIC. D C =JR
Location _ \\5
Date (a— I —01 Permit # ___ KKE_
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 Side
Middle Front - Middle Rear
COMMENTS:
.� \16 i���\ FFR �t����
1k ARAy0
BR (Wi ED0' � '1+i
SYSTEM USE AP Oil D: YE
Arrived: (1'..cx:)
Departed:
ui ing Inspe r