2000-443 BU' ILDIN +G PERMIT
}} +kDc Town of Queensbury, 742 Bay Road, Queensbury, NY 12804
'1 EtiCJ County of Warren (518) 761-8256
r y Building Permit No. "
. :1 . . _
Permission is hereby granted to M ' NAtCa
O%vner of property located at ;L' IPLE+4 P ' .!N�, L-
in the Town of Queensbury, to construct or place a `�"� I � P
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-
Contractor or Builder's Name:
i- , - S G
Contractor or Builder's A
-
Electrical Inspection Argo ncy_
Type of Construction: L 1
and S cificati
JN:oposed Use:
S _ W PERMIT FEE PAID — THIS PERNIIT EXPIRES SAN ack
(If a longer period is rewired, an application for an extension must be made to the Code Enforcement
Ogieer of the Town of Queensbury before the expiration date.)aa
Dated at the To of Queensberry s Day of �
SIGNED BY for the Town of Queensbury
CcOEIEnlorcetnent Officer
Application for Permit — Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury, NY 12804 (518) 761-8256
1 . OWNER INFORMATION:
/ _........_....... _........................................................................................
Location of installation: r` (. c. {)fFice Use
Tax Map No. I I File Permit N `~
Owner's Nacre: ��"���.... I�V p Cf
Fee Paid
.
Address: C c� t ,t-
2. INSTALLER'S NAME
PHONE NO.
3, RESIDENCE INFORMATION: (circle year of dwelling, indicate # bedroom(s) and mult�� f
bedrooms with applicable gallons per bedroom to equal toted daily,, v�)��
' ve
Rear of House: No. of Bedrooms x Computation „ _. Total DailyIf+� - ,
ban
1980 or older 1Wx 150 gal/bdrm = Ci6 D
1980 — 1991 x 130 gaUbdrm =
1991 -- present x 1 10 gal/bdrm =
Garbage Grinder Installed yes / no
Spa or Whirlpool Installed yes � ! no
4. PARCEL INFORMATION: (circle applicable information & indicate measurements)
r rGround. Water 6edro�k or 1tn eryious Maternal QOIRQstic Water Supper
1�7at - n at what depth at what depth municipal
o ling am feet feet well
Steep slope clay if well; water supply
_,_,_Vo slope other from any septic-system
depth: absorption is ft.
other
Percolation Test: Ma 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 sire
of the septic tank and leach field for each Garbage Grinder, Spa or Whirlpool Tub.
Septic Tank: O gallon (min. size 1, 000 gal.)
Tile Field: each trench ft. Total System Length:
Seepage Pit(s); number of size ofeach: fl, by ft.
Size of Stone to be used: # / depth or thickness feet
Bed System Size: x
Akernative System: (1 �'rA,/ l7eng' Th and/or size { r 4
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: 1 Size of each: gallons 1 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 UA 'Town of Queensbury Sanitary Sewage Disposal Ordinance_
Doe � �1�dod2�
'Signature of re pans ble person Date
TOM OF QUEENSBURY
BtjILDIN6 & -. CODE ENFORCEMENT
742 Bay Road
Queensb_ ury _hY_12s04
(51s) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name '� `� F -i " C� �
Location
, ► �+ �
Date ( — 72,.CL,� Penn' t # 2 cx�wLA?_>
SOIL TYPE- and Loam-Cl aY-
Results of Percolation Test-
( if applicable ) Rate-Minute/Inch
TYPE OF SYSTEM: +
ABSORPTION FIELD : Total Length r
Length of each trench 7- cz
Depth of trenches
Size of stone
SEEPAGE PITS : R � f t .
Size - ft . x
Stone size Size Ype
PIPING:
Bldg . to Tank titi
Wank to Dist . Box
Dist . Sox to Field/Pit
Openings Sealed? es V arti a
LOCATION/SEPARATIONS: feet
Foundation to Tank Foundation to Absorption feet
Separation of Pits -- feet
�et
Conforms as per plat Plan
No
LOCATION OF SYSTEM ON PROPERTY :
( circle one )
F - Rear - Left Side - Right Side
ron - Middle Rear
C £NTS :
SYSTEM USE APPROVED : YES NO
Arri v
Dep L
B ding n for
,l
31VO
A9 O3MBlA38
A inBSN3Ano =10 NsMOI
L
r
p
1
?� ±ve Seen or ;,t�served, or believe 1 saw evidence of.
t7S ; {aSOs, v'J>vlls. trees teni ,'.S, etc.,
an this dacurnont. l aiso represent that i have
puj sui,al ensured the distances set forth on the diagram.„
l��
SIGMA R DATE
�� 'id 1i3 dT ?3 7
�rT eL �'1 C7