99-761 BUILDING PERMIT
Town of Queensbury, 742 Bay Road, Queensbury,NY 12804
County of Warren (518) 761-8256
VALUE $ 0 Building Permit No. 9 9 7 61
TAX MAP NO. 125 . -4-5
3C)1 55 VALENT I MARY ANN
Permission is hereby granted to
Owner of property located at 6 6 NORTH CHURCH LANE
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 NYS Uniform Building Codes and the Queensbury Zoning Ordinance.
Owner's Address:
66 NORTH CHURCH LANE
QUEEN S BURY,_ NY 12804
Contractor or Builder's Name:
CONDON SEPTIC & DRAIN SERVICE
Contractor or Builder's Address:
Electrical Inspection Agency:
Type of Construction:
SEPTIC
Plans and Specifications:
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
Proposed Use:
SEPTIC ALTERATION
•
$ 25 PERMIT FEE PAID—THIS PERMIT EXPIRES December 20 2001
(If a 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 To of Queensbury 's 2 0 Day of December 19 9 9
SIGNED BY s for the Town of Queensbury
• Code Enforcement Officer
Application for Permit—Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
Office Use
Location of installation: (d
Tax Map No. ,� / 4- / 5File Permit No. ��(
Owner's Name:
Fee Paid
Address: (3 A H
2. INSTALLER'S NAME C� (�l�(��? ��� `� PHONE NO. rr!—tL Z
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. of Bedrooms x Computation = Total Daily Flow
1980 or older x 150 gal/bdnn = trIteei
1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm =
Garbage Grinder Installed yes / no
Spa or Whirlpool Installed yes— / no
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
Topography Soil Nature Ground Water Bedrock or Impervious Material Domestic Water Supply
F"lac t� san at what depth at what depth rrrtunicipal�
o ing loam feet feet well
Steep slope clay if 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
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: 150b gallon(min. size 1,000 gal)
ft)Fie d each trench37& jO ft. Total System Length: 2....5b ft.
t
Seepage Pit(s): number of — size of each: —ft. by
Size of Stone to be used: # . �( A / depth or thickness feet t rFI LI riEFFOR6
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.
tte cir\ 1 '791 -
-'" Stgnatik of responsible perso� s��Date r
15(:)
9 .
'TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name er C Cc, F
etre%�-
Location ( id �ti�z� /
9 Date , 'Z'_Permit # 97�7/
SOIL TYP Sand- oam-Clay-
Results of Percolation Te.t-
(if applicable) Rat:-Minuae/Inch
TYPE OF SYSTEM: —7
ABSORPTION FIELD: Total Le g0 9-5
76
Length of each tren' -
Depth of trenches)
Size of stone ! f n
SEEPAGE PITS: Numb.
Size - . ( ft.
Stone size .�
PIPING: ,Size Type
Bldg. to Tank ,,Size
Tank to Dist. Box n "7')
Dist. Box to Field/" '
Openings Sealed? Yes No . .Partial
LOCATION/SEPARATION' :
Foundation to Tank. /feet
Foundation to Absor tion — 0-0 feet
Separation of Pits 7 eet
F forms as per Plo Plan es No
. ION OF SYSTEM iN PROPER •
(cir e one)
Front - Rear - Left Side - Right Side
e Front - Midd e Rear
COMMENTS:
•
SYSTEM USE APPROVED: YES NO
Arrived:
Departed:
Building P
t C 1l/�1 f'( 0 V l I tiitl T E /(o(- 6-ZS ( e jc%") t fro t f G v=-vr�r/y r rt.) .: .:.�-c
ce ( t, 0,i T i-i C H u R C f 1- ..&jv E , EF c/ C"/oS cf I a i �I i1I T U� r����� `/ Z
-- TOWN Of QUEENS8l tY EtAili.DNG DEPARTMENT
Based on our irked examination,
9 9 7 61 12 5 . -4-5 vcompliance Wbh our comments shall
not be construed as ind'ating the
VALENTI, MARY ANN �rx plans and specifications a full
66 NORTH CHURCH LANE compliance w+th the code.
SEPTIC ALTERATION.
"I have seen or observed, or believe I saw evidence of,
•
/ all objen ts`such as houses, wells,trees, fences, etc.,�,�,� ` shown on tnis document, i also represent that I have
.-, , / :.. ti �/ 'ersanan, measured the distances set forth on the diagra "
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II SIGNATURE
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TOWNOF LJ E' : URA'
BUILD/ EP-r.
REVIEWED
i�
i�` DATE __._._.. II .
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