2000-905 TOWN OF QUEENSBURY
742 Bay Road, Queensbury, NY 12804-5902 (518) 76M201
Community Development - Building & Cedes (518) 761=8256
ER' IFIrATE %X7 COMPLIANCE
Permit Number. P20000905 Date Issued: Tuesday, December 12, 2000
This is to certify that work requested to be done as shown by Permit Number P20000905
has been completed. (Z .S 'a q
Tax Map Number: 523400-120-000-000 1-048=000-0000
Location: 481 SHERMAN Ave
Corner: JOHN ADAMS JR
This structure may be used as a;
Septic Alteration Residential
By Order of Town Board
TOWN OF QUEENSBURY
Director of Building & Code Enforcement
TOWN OF QUEENSBURY
(E)w 742 Bay Road, Queensbury, NY 12 8 04-5 9 02 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
BUIEDIN+G PERMIT
Permit Number: P20000905 Application Number. A20000905
Tax Map No. 523400-120-000-0001 -048-000-0000
Permission is hereby granted to: JOHN ADAMS JR
For property located at: 481 SHERMAN Ave
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. Tyne of Construction Value
Owner Address: JOHN ADAMS JR Septic Alteration Residential
481 SHERMAN Ave
QJEENSBURY, NY 12804 Total value
Contractor or Builder's Name / Address Electrical Inspection Agency
JAY SWEET
NY
Plans 8c Specifications
BP
SEPTIC ALTERATION FOR 3 BEDROOM HOUSE
$25.00 PERMIT FEE PAID - THIS PERMIT EXPIRES: Thursday, November 28, 2002
(If a longer period is requited, an application for an extension must be made to the code Enforcement
C7 ffi cer
Dated at the Town Que =19
'Ole;0e
v ber 28, 2000
SIGNED BY �/,'�( for the Town of Queensbury.
Director of Building & Code Enforcement
Application for Permit - Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury, NY 12804 (518) 761-8256
1 . OWNER INFORMATION: 3....................................:...._........._.._.,....,.,,.,:_,,,,,.,,,,,,.,,,,,,.,...,.,._....................._.....r
Office Use
Location of installation:
{� File Permit No
Tax Map No. -l-`''"'—" ! rr 1 'L D,., ko
���] �
Owner's Name: ICJ L�_ r4� , h�S F
Address: _
TV+:rbA �v7 0 OEENSBURY
{ su«::IPlta t.tVD coal
2. INSTALLER'S NAME a c 4
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 f Bedrooms x CoMputation Tgtal Daily Flow
19811 or older 33 x 150 ,gaUbdrm
1980 — 1991 x 130 gal/bdrm =
1991 — present x 110 gal/bdrm =
Garbage Grinder Installed yes 1 no
Spa or Whirlpool Installed yes _ I no
4. PARCEL INFORMATION. (circle applicable information & indicate measurements)
T o ra S re Ground Water Bedrock or Impervious Material Domestic Water Su 1
1411at _ san at what depth at what depth rrnici
Rolling loam feet feet
Steep slope clay ifweli; 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: gallon (min_ size 1, 000 gal.)
Tile Field: each trench fz Total System Length: J`1
Seepage Pit(s): number of size of each: ft. by ft.
Size of Stone to be used: # / depth or thickness feet
Bed System Size: x
Alternative System:i !fj f t f ✓cc { cr t' length and/or size �;2 6-0 �
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: 1 Size of each: gallons ! TOTAL Capacity: gallons
.Nate; 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_
r
Si to of responsible er� Date
9 P P
TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMEN
742 Bay Road
Queensbury NY_12804
cs s 6
SEPTIC DISP$;AL SYSTE INSPECTION
Larne A4J4 '
Locatip �
Hate Permi # ?=L� 5 '�=EL
SOIL Sand- oaT�
Results of, Percolation Test-
( if applicable ) Rate- enute/ Inch
TYPE OF S' M:
ABSORPTION MELD : To a7 Len thx
Length of ea+ h tren �
Depth of tre ches
Size of stone Lti.;y � XLX 1
SEEPAGE PITS : N er-
5ixe - -,_',f ft .
Stone size
PIPING: Size lype
Bldg . to Tank ` } } �
Tank to Dist .
Dist . Box to F el Pi E +
Openings Seal d ? es o ar
LOCATION/SE P TI
Foundation t Tank feet
Foundation Absorp on feet
Separation f Pats Ifeet
Conforms a per Plot P n es No
LOCATION O SYSTEM ON P PE
( circle on )
Front - ear eft Sid ight Side
Middle =
COMMENTS;
SYSTEM USE APPROVED : , YES/ NO
d .Arrive -. • 6 ��`--�`�
Departed:
B d� g . s , ctor
z/ V
���op� � EMS6�R
JI 'D 'COp� Y
TOWN OF +QU N RY
-- BUILDING
t REVIEWED BY PT.
t , DATE
U
a
"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
Personally measured th distances set forth on the diagram . "
l IGNATURE BATE
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