97-134 1
CERTIFICATE OF COMPLIANCE
TOWN OF QUEENSBURY
WARREN COUNTY, NEW YORK
' Date 19
A!',-i1 16 97
36) / " a•
This is to 'certify ..that work requested to be done as shown by Permit No. �713'
has been completed.
' This structure may be used as a SEPTIC ALTERATION
Location 17 LADY SLIPPER DR.
Owner ' HUMM L, ROBERT & SUSAN ,
By Order of Town Board
TAX MAP NO. 90. -7--36 TOWN OF QUEENSBURY
. Director of Building & Code Enforcement
BUILDING PERMIT
VALUE $ 0 TOWN OF QUEENSBURY No 97134
TAX MAP NO. 90. —7-36 WARREN COUNTY, NEW YORK
PERMISSION is hereby granted to HUMMEL, ROBERT & SUSAN
OWNER of property located at 17 LADY SLIPPER DR. Street,Road or Ave.
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 Town of Queensbury Building and Zoning Ordinance.
1. OWNER'S Address is
R. D #2 LADY SLIPPER DR.
QUEENSBURY, NY 12804
2. CONTRACTOR or BUILDER'S Name
SANITARY SEWER
3. CONTRACTOR or BUILDER'S Address
DAN DRELLOS PO BOX 224
GLENS FALLS NY 12801
4. ARCHITECTS Name
5. ARCHITECT'S Address
6. TYPE of Construction—(Please indicate by X)
SEPTIC
( 1 Wood Frame ( ) Masonry ( I Steel ( )
7. PLANS and Specifications
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
8. Proposed Use
SEPTIC ALTERATION
$ 25 PERMIT FEE PAID —THIS PERMIT EXPIRES
April 14 19 99
(If a longer period is required an application for an extension must be made to the Building and Zoning inspector of the
town of Queensbury before the expiration date.)
Dated at the Town of Queensbury this 14 Day of April 19 97
SIGNED BY __ for the Town of Queensbury
Building and Zoning Inspector
' Application for SEPTIC DISPOSAL PERMIT
(
Town of Queensbury Permit No. Q 7
t.-
Dept. of Community Development !
Building &Codes CI
D
Bay Road Fee Paid
Queensbury, NY 12804
Location of property for installation: I -7 LA—6{,e)
s L
Property Owner's Name: (R,�—,---- 1-1---u i-„i,t,e--(._
Property Owne ' Mailing Address: 1 -7 LAD Li U t t F )A-
) l i
Installer's Name: A) 5 . ,f ./f Phone # '7 ��.47
Number of bedrooms (if residential): Total daily flow: / �1-)
(residential - compute @ 150 gal./bdrm.)
Topography: !J flat, rolling, steep slope % of s"I.e ,
Soil Nature: L. sand, loam, clay, other /depth:
—APR 141997
Ground water: at what depth? feet / Bedrock or Impervious Material- at.what d t?: . feet
TOWNu �1v�rd Percolation test: not required, _ required [rate .p r iirfch INC AND CODE
Domestic water supply: municipal, well, other
If domestic water supply is a WELL, water supply from any septic absorption is feet. .
PROPOSED SYSTEM
Septic tank: gallon (minimum size: 1,000 gal.)
Tile field: each trench feet / Total system length: feet
Seepage pit(s): number of 2 / size each: d" ft. by ft.
Size of stone to be used: # 2 / depth or thickness Z�feet
HOLDING TANK SYSTEM: (if required)
Number of tanks: Size of each: gallons
\`Alarm system and associated electrical work to be inspected by a certified agency.
For your protection, please note that pursuant to Section 136-29 of the CI-AP 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 . di:ap ication and agree to abide by these and all requirements of the Town of
Queensbury Ssnitaty Sewage Disposal • .h,: .
0
Signature of responsible person: ( PvLe-At t<l�
Date: , 977
Ilk . we d 01-61L)1-1/11/1
TOMN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
531 Bay Road
Queensbury NY 12804
518-745-4447
SEPTIC DISPOSAL SYSTEM INSPECTION
Name Au'r\-\ m.-a ::-2\(42A—N
Location �� (f c) t �,N a
Date l ✓/� 7 Permii# 4 7- /
-51--(
SOIL TYP San am-Clay-
Results of Percolation Test-
(if applicable) Rate-Minute/Inch
TYPE OF SYSTEM:
ABSORPTION FIELD: Total Length
• Length of each trench
Depth .f trenches
Size of ,ton-' -
SEEPAGE PH .. Number- -7
Size - Ai, ft. x to ft.
Stone siz " ,
PIPING: Size Type
Bldg. to Tank
Tank to Dist. Box p'6f�� '�
Dist. Box to Field/Pit " 6pe'3 -)
Openings Sealed? ,Yeses No Partial
LOCATION/SEPARATIONS:
Foundation to Tank - jL feet
Foundation to Absorption 7?7 feet
Separation of Pits -et
Conforms as per Plot Plan ►!.o
LOCATIv,, OF SYSTEM ON PROPER ":
(circle one)
Fro �- Left Side - Right Side
i ddl e Rear
COMMENTS:
SYSTEM USE APPROVED:
Arrive.: (ZY
Dep. . , ed• `
— / /;uildi' pector
"1 have seen or observed,or believe I saw evidence of, •-
all objects such as houses, wells,trees,fences,etc., - s _ �'
shown on this document I also represent that I have
personally measured the distances et forth on the diagram." PR4 �997
SIGNATU E DATE
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i. BUyjiLDING
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