2000-597 TOWN OF QUEENSBURY
aw 742 Bay Road, Queensbury, NY 12804-5902 (518) 761 -8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPEIAN+CE
C/ +C Number: C20000597 C/C Date: Tuesday, August 15, 2000
Application Number: A20000597
Permit Number: P20000597
This is to certify that work requested to be done as shown by Permit Number P20000597
has been completed.
This structure may be used as a Septic Alteration Residential
Tax Map Number: 523400-121 -000-0005-001 -000-0000
Location: 83 BURC14 Rd
Owner* W ILSON & JEAN MONROE
By Order of Town Board.
^fp�tp��;.eY��JEENS Y
Director of Building & Code Enforcement
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'I'(]WN OF QUEENSBURY
742 Say Road, Queenshury, NY 12804-5902 (518) 761 -8201
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Community Development - Building & Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20000597 .Application Number: A20000597
Tax Map No: 523400- 121 -000-0005-001 -000-0000
Permission is hereby granted to: WILSON & JEAN MONROE
Owner of property located at: 83 BURCH Rd
in the Town of Queensbury, to construct or place a Septic Alteration Residential
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.
Owner Address: WILSON & JEAN MONROE
" 83 BURCH Rd
QUEENSBURY, NY 12804
Contractor or Builder's Name / Address Electrical Inspection Agency
OUEENSBUR'Y SEWER
JAY SWEET
i
Type of Constructions Septic Alteration Residential Value : $
Plans & Specifications
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
'�
$25600 PERMIT FEE PAID - THIS PERMIT EXPIRES: Sunday, August 11, 2002
(Ifa 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 Town +Que sbu 1yrida A ust 1I, 2000
R SIGNED BY for the Town of CZueetisbury.
Director of Building & Code En 'Is"
Application for Permit - Septic Disposal Systewn
Town of Queensbury 742 Bay Road Queensbury, NY 12804 (518) 761-8256
1. OWNER INFORMATION:
Location of installation: i� �+ Office Use
Tax Map No. l I _ File Permit No. C:� L r
Owner's Name:
A?, Fee Paid
Address: j G.
2. INSTALLER'S NAME . Z- PHONE NO. t r ` L1
3. RESIDENCE INFORMATION: (circleyear 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� ra d 2,000' x 150 gaMdrm =
= 1991 x 130 gal/bdrm =
1991 — present x 110 gal/bdrm =
Garbage Grinder Installed yes _ 4�
Spa or Whirlpool Installed yes / o
4, PARCEL INFORMATION: (circle applicable information & indicate measurements)
T it Nature gr tMd.Wat r Bedrock or Impervious Material Domestic Water SuRRI
al n at what depth at what depth municipal
Ling oam feet feet we
Steep slope clay r 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
S. PROPOSED SYSTEM: For New ostructi n: 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. X�7i--d gallon (min_ size 1, flat) gal.)
Tile Field: each trench ft. Total System Length: Jt
Seepage Pit(s): number of size ofeach: ft. by ft.
Size of Stone to be used: # / depth or thickness feet
Bed System Size: x
Alternative System: length 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.
00' ram+ 4F
lgn r of responsible person Date
TOWN OF QUEERSBIlRY
BUILDING A CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804
(519) 761-8256 \
SEPTIC DISPOSAL SYSTEM INSPECTION
Name
Location _
Date x Permit # AO
At
SOIL TYPE: San oam-Clay-
Results of of tion Test-
( if applic le ) R e- Minute/ Inch
TYPE OF SY
ABSORPTION IELD : otal Length
Length of ea h tren h
Depth of tre ches
Size of stone
SEEPAGE PITS : hTum r-
Size - ft , ft .
Stone size
PIPING: Me Type
Bldg . to Tank 1r &A 5f)k 3S�"
Tank to Dist . Bo If •i
Dist , Box to Fiel it
Openings Sealed ? Yes No 'iceaT
LO ATION/SEPARATI
Foundation to Tan ~ feet
Foundation to AYE rp ' on jRig
feetSeparation of� P ' s eet
Conforms as per P1 ofP n NoLOCATION OF SYSTEM ON P O( circle one )
Front - Rear - Left Sideht Si
Middle front - Middle Rea
COMMENTS: AJ \
SYSTEM USE APPROVED : YES NO
Arrived :
Departed : '
Building Inspector
"I have seen or observed, or believe I saw evidence of,
all objects such as houses, wells, trees, fences, etc.,
shown on this document. I also represent that I have
nally measured the distances set forth on the diagram."
GNATURE DATE
TOWN OF QUEE SBURY
BUILDING & T.
REVIEWED BY
DATE {
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AUG 1 0 2000
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