2001-904 4111libi TOWN OF QUEENSBURY
ET
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20010904 Date Issued: Friday, December 07, 2001
This is to certify that work requested to be done as shown by Permit Number P20010904
has been completed.
Tax Map Number: 523400-302-005-0001-060-000-0000
Location: 17 GREENWAY NORTH
Owner: JOHN LA VALLEY
Applicant: JOHN LA VALLEY
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
Director of Building&C de En rcement
��■r TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
VIEW
Community Development- Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20010904 Application Number: A20010904
Tax Map No: 523400-302-005-0001-060-000-0000
Permission is hereby granted to: JOHN LA'ALLEY
For property located at: 17 GREENWAY 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: JOHN LA CALLEY Septic Alteration Residential
17 GREENWAY NORTH Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name/ Address Electrical Inspection Agency
OUEENSBURY SEWER
JAY SWEET
Plans &Specifications
2001-904
SEPTIC ALTERATION AS PER APPLICATION
$25.00 PERMIT FEE PAID - THIS PERMIT EXPIRES: Saturday,December 07,2002
(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 f Quee 4 bury; F iday,December 07,2001
SIGNED BY for the Town of Queensbury.
Director of Building & - Enforcement
Application for Permit—Septic Disposal System
• Town of Queenshtny 742 Bay Road Queensbury,NY 12804 (518) 761-8256 .
1. OWNER INFORMATION:
Location of installation: / 7 t�r�.,.. I • Office Use
Tax Map No. / / L.,f` u_ I
File Permit No. 9011
I Fee Paid "' Pi/
Owner's Name:(I �i1 . Q . -
Address: rR ✓vt t___,
•
2. INSTALLER'S NAME a e e ,,,<`-B cc v- c - 02, t y r
�v PHONE NO. �'
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate#bedroom(s) and multiply# of
bedrooms with applicable gallons per bedroom to equal total daily flow)
Year of'House: No. of Bedrooms x Computation = Total Daily Flow
1980 or olds x 150 gal/bdrm �.5� .
1991. x 130 gal/bdrm
1991 —present x 110 gal/bdun --=
DF� 0 ti 20
1
Garbage Grinder Installed yes I . 0
T®41/fe'OF C t1 r'�1SButzty
Spa or Whirlpool Installed yes— / n gU��®l��A
---�--_ ND... CODE .
4. PARCEL INFORMATION: (circle applicable information &indicate measurements)
To
pography Soil Nature Ground Water Bedrock or Impervious Material Domestic Water Supply .
artR� at what depth at what depth �mun_ 1_ �
Rolling loam feet feet well
Steep slope clay if well; water supply
_%slope other from any septic-system
•. depth: absorption is ft.
• other^____ __
Percolation Test: (To be completed by licensed professional 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 Grinder, Spa or Whirlpool Tub.
Septic Tank: /o 0-1 gallon (mi . size 1,000 gal)
Tile Field: each trench ,) ft. Total System Length: s;� ft. .
Seepage Pit(s): number of size of each: f. by .ft.
Size of Stone to be used: # / depth or thickness feet
Bed System Size: x
Alternative System 1. L - eJ __eIc; 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 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 Town of Queensbury Sanitary Sewage Disposal Ordinance.
V .
Signatu of esponsible person Date
TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name \,,ps,, pdkrA
Location \ (-,?-EE��. ;
Date \ -7--i Permit #7{7A —90}-
SOIL TYPE .San )Loam-Clay- -_
Results of Percolation Tes
(if applicable) Rate-Minot / nch
TYPE OF SYSTEM:
ABSORPTION FIELD: Total Le gt
Length of each trench
Depth of trenches
Size of stone J
SEEPAGE PITS: Number-
Size - ft. x t.
Stone size
PIPING: c 'ce Type
Bldg. to Tank %%
Tank to Dist. Box ' )' GtC
Dist. Box to Field/P'
Openings Sealed? _Y.es No . :Partial
LOCATION/SEPARATIONS:
Foundation to Tank. to .feet
Foundation to Absorption feet
Separation of Pits feet
Conforms as per Plot Plan I 6-(; ) No
LOCATION OF SYSTEM ON PROPERTY:
(circle one)
Front ear -jft Side - Right Side
Mi ddl hl-r * -- Middle Rea
COMMENTS: .
LffJ . , 0
6 P \)o.u.
SYSTEM.USE APPROVED: (21-2 NO
Arrive, . ";,
Dep. ed: KC`
_ Alf
Building sector
L/
,` TOWN OF QUEENBURY
x BUILDING : ' �� !1 ! PT,
o REVIEWED BY /'i, �%/1 ;U�
DATE IMAIS I.___
1 i
C-4-
"I ha ►e span or observed, or believe I saw evidence of,
all ohjects suirh as houses, wells, trees, fences, etc.,
T , o/ .�,_ shown on this document..I also represent that I have
7� personally measured the distances set forth on the diagram." -
U
SIGNATURE DATE
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