2000-844 TOWN OF OUEENSBURY
742 BaV Road, Queensbury, NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761=8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20000844 Date Issued: Thursday, November 02, 2000
This is to certify that work requested to be done as shown by Permit Number P20000844
has been. completed.
Tax Map Number: 523400-048-000-0003-046-002-0000
Location: I SUSAN PI
Owner# DAVID & COLEEN JARVIS
This structure may be used as a:
Septic Alteration Residential
By Order of Town Board
TOWN OF QUEENSBURY
Director of Building & Code nfotcPment
T(J\ N of QUEENSBURY
Y 742 Bav Road, Queetisbury, NY t2804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761�8256
BUILDING PERMIT
Permit Number: P20000844 Application Number: A20000844
Y.
Tax Nlap No: 523400-048-0o0-0003- 046-002-0000
Permission is hereby ,granted to: DAVID & COLEEN JARVIS
For property located at: I SUSAN PI
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 a e
Ordinance. 'Tine of Construction
Owner Address; DAVID & COLEEN JARVIS Septic Alteration Residential
1 SUSAN PI Total value
QUEENSBURY, NY 12804
Contractor or Builder's Name / Address Electrical Inspection Agency
FLOWER
IC
WARREN STREET
URY, NY
Plans & Specifications Jill Jill
2000-844
SEPTIC ALTERATION AS PER APPLICATION
Jill Jill
$25600 PERMIT IIIII FEE P 11 AI 11 D 11-Jill THIS IIIIII PERMIT EXPIRES: Saturday, November 02, 2002
(ifa longer period is required, an application for an extension must he made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the To of u ; b h ember, 02, 2000
SIGNED BY ` 4 for the Town of Queensbury.
*' Director of Building +Code nforcement
Application for Permit — Septic Disposal System
Town of Queettshury 742 Boy Road Queensbury, NY 12804 (518) 761-8256
1 . OWNER. INFORMATION: _.......__....,.......__.................................._.................,_„,,,.................. ...._....
] Office Use
Location of installation. c'k (� C - ��
File Permit No. ( ' c�
Tax Map No. ! I r7 �-+ dO
\ / �' / + j Fee Paid Cx r3.
Owner's Name: l CX- -4 Q6 ( `; �'
.... ........... ...._ . . ............ . .............. ......
Address
2. INSTALLER S NAME ,1 - l� � .�`�-�_
PHONE NO.
3 . RESIDENCE INFORMATION: (circle year of dwelling, indicate ff bedroom(s) and multiply # of
bedrooms with applicable gallons per bedroom to equal total daily flow)
Year of Hoes • No. of B
edrooms x Complstation = TgtAl Daily Flow
1990 or older T x 150 gallbdnn
1980 — 1991 x 130 gallbdrm = ,-� + � � ' '•
1991 w present x l 10 gaUbdrm
Garbage Grinder Installed yes ! no ZOhL;
Spa or Whirlpool Installed yes ! no T ,�n;n, 3UEENSb.
Nam,...
4. PARCEL INFORMATION: (circle applicable information & indicate measurements)
- 1 Qrsu d�atD� BgslroGk__or crape �u ._1� f ri l ,DgniQslic 'Watcr_$suPpply
Laphy17n � }� tort what ele•1rr1+ err wlrnt cle�litlr "M )rrl
olling loom fear --feet well
Steep slope clay tf well; water stclxply
slope other from any septic-system
depth: absorption Is O c JI.
other
Percolation Test: (robe completed by llrensed professlonal engineer or architect)
Rate: minule per Inch
5. PROPOSED SYSTEM: For New Cvnetruction: All individual sewage dispersal systems musk be designed by it licensed
professional engineer or architect (unless installed in a Planning Board anxoved subdivision). Add 250 gallons to [lie sire
of the septic tank and leach field for cacti Garbage Grinder, Spa or Whirlpool 1'ub.
Septic Tank: + gallon (min, size 1. 000 gal j
Tile Field: each trench 3 ft. Total System Length: 4 1Z
seepage Pit(s): number of size of each: fl. by 1?
Site of Stone to be used: H -- / delrflr or thickness
Bed System Sire: x
Altemauve System: length and/or size
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: / Size of each: gallons ! TOTAL Capacity: gallons
Now 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
ofQueensbury, 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
circurnstance known by or on belialf 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
iTown of Queensbury Sanitary Sewage Disposal Ordinance.
000,
gnat+ure of responsible person Date
N.
TowNE OF QUEENSBURY
BUILDING A CODE ENFORCEMENT
742 Bay Road
Qoeensbury NY--12804
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name f.�5r r
Location (`
DaterPITS ,, Numbe
it
SOIL nd- 'Loan Tay
Resulrcolation Te t-
( if ae ) Rate- Mina a/ Inch
TYPE M:
ABSaRIELD : Total n_aCJfV
Lengtch trench I
Depthchest
Size
SEEPA , Num er-
Size - 'i ft . x ft .
stone size
PIPING: - ize� e
Bldg . to Tank 6v rT/AV
Tanis to !list . B x
Dist . Box to FidVdJ i it tr
Openings Seal ed7'k3 Ves a anal
LOCATION/SEPARAT
Foundation to Tan / feet
Foundation to Ab rpti on feet
Separation of Pi s et
Conforms as per l of , Plan es o
LOCATION aF aY M PROPER
( circle one )
Front - Ream Left Sine Right Side
Middle Front, Middle Rya
COMMENTS : /
SYSTEM USE APPROVED : OESNO
Arrived:
Departed :
l[�- �-
Building Inspector
TOWN OF +QUEENSBURY
BUILDING
REVIEWED BY
DATE
FILE COPY `7 NOV V 2 zooa �
`J TO OF QUEENSBUR� �
°✓ `. B iLDING AND CODE
i 'y1
I
"I ha a seen or observed, or beiHM i evidence of,
all a jests such as hoes. W8114 C• etc.,
show on this docrsr f*L 1 810 rep
that 1 have ,..3
per n easolned SO on the diagram:C aj.I '
cue
SIGNATURE DATA
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