2000-398 M 1C'*'ate of Comp I lanceAMNLA
()' ert' i
'down of Quoensbury
Warren County,Now York
Date June 7, 2000 e
2@e0S9S
This is to certify that work requested to be clone as shown by Permit No, —
has been completed.
This stiicture may be used as a......._. . EPIC ALTERATION.� �..�..
17 HUCHES COURT
Location
Owner DEMBOSK I LLOYD &
By Dt'dez Town Bo ,rd . ,.
0 OF Y
4
Birec—t—orof uilding&Code Edorcement
�.
BUILDING PERMIT
Town of Queensbury, 742 Bay Road, Queensbury,NY 12804
County of Warren (518)761-8256
VALUE $ 0 Building Permit No. 2000398
TAX MAP NO. 114 . -1-10
Permission is hereby granted to DEMBOSKI , LLOYD &
Owner of property located at 17 HUGHES COURT
in the Town of Queensbury,to construct or place a SEPTIC ALTERATION
at the above location in accordance to 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.
Owner's Address:
MARGUERITE 17 HUGHES COURT
QUEENSBURY, NY 12804
Contractor or Builder's Name:
QUEENSBURY SEWER
Contractor or Builder's Address:
JAY SWEET
Electrical Inspection Agency:
Type of Construction:
SEPTIC
Plans and Specifications:
Proposed Use:
SEPTIC ALTERATION
0 - June 7 200.2
$ PERMIT FEE PAID—TIES PERMIT EXPIRES
(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.)
7 June 2000
Dated at the To . off�Queensbrury this—Day of-
SIfjNED BY �_P_ kK�� for the Town of Queensbury
CoN nforcement Officer
Application for Permit—Septic Disposal System
Town of Queensbuty 742 Bay Road Queezzsbwy,'ArY 12804 (518) 761.8256
L OWNER INFORMATION:
........................................................................................................... .................k .
Location of installation: Offiyce�Use
Tax Map No. / j t f File Permit N9�i-z /�� "9 1
Owner's Name: f1 / 1� t a> f
I Fee Paid
Address: f�7 _/2 z , t
2. INSTALLER'S NAME �- J tea,/ PHONE NO. t� �
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 is Computation = Total Daily Flow
1980 or older x 150 gal/bdrin =
1980 x 130 gal/bdrm =
1991 —present x 110 gal/bdrin = f -
Garbage Grinder Installed yes / no JUN 0 6 2000
Spa or Whirlpool Installed yes t no 1 fl N OF- z,-..1= Si3vF1Y
BUILDi\iG'AND CODE
4. PARCEL INFORMATION: (circle applicable information 8c indicate measurements)
Topography Soil Nature Grouiid Water Bedrock or Impervious Material Domestic Water Supply
e�M sa at what depth at what depth zzrtzrcr a
o rng loam _ j feet feet we TF
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 pre fessional 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: l d-z gallon (min. size 1,000 gal.)
Tile Field: each trench , 6 ft. Total System Length:, -� ft.
Seepage Pit(s): number of size of'each: ft. by f[.
Size of Stone to be used: it / depth or thickness feet
Bed System Size:
Alternative System: �j length and/or size
6. HOLDING TANK SYSTEM: (if required)
Number oftanks: 1 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 noto.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.
Signat re f responsible person Date
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have seen or observed,or believe I saw evidence of,
r all objects such as houses,wells,trees,fenced etc,
shown as this document)also,represent that I have
sonally measured he distan es set fort on the diagram;'
SIGNATURE DATE
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