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2004-227m C bV CA Q o �l �lOd "d o o ~ ' J y 0 n b o" rD ieD rr A p O M. C7 IQ 0 4 eei R n OCD 0 td O O O 1 r O O G "' . 4 CD O C N O 00 N C7 cnp p CL o G Oso Pt v' ti p G h CDp° C p 6co � 'C ci ti cncr C A C CJ N o f D o rro WUl p Cif 00 z I ON b rD 00 CA N FI r Ul 8 O H .' bd O o G �t 0 o oNo M O to ^ J �n 4 COII 0 n P n Permit Number: TOWN OF QUEENSBURY 742 Bay Road, Queensbury, NY 12804-5902 (518) 761-8201 Community Development - Building & Codes (518) 761-8256 BUILDING PERMIT P20040227 Application Number: A20040227 Tax Map No: 523400-290-005-0001-050-000-0000 Permission is hereby granted to: PAR 3 CTOJ,F COJTRSE For property located at: 168 SUNNYSIDE Rd 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: BRIAN P JACOBS TRUST 13 OWEN Ave QUEENSBURY, NY 12804 Contractor or Builder's Name / Address OJJEENSBJTRY SEWER JAY SWEET Plans & Specifications I:\IIIYtI[7:W630 Septic Alteration Commercial Total Value Electrical Inspection Agency $35.00 PERMIT FEE PAID -THIS PERMIT EXPIRES: Wednesday, April 27, 2005 (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 Tp rr O ueen � �pri127, 2004 SIGNED BY l (tiL//l /T/'tfor 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: ............I......................................................................... Office Use Location of installation: 16, File Permit No. 0 c/ "c)=� _ Tax Map No. Owner's Name: Fee Paid �, S © v -'-i�7 j ���� u ........................................................................................................................... Address: 2. INSTALLER'S NAME PHONE NO. l Z7S % 3. RESIDENCE INFORMATION: (circle year o 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/bdrm = _L 1980 - 1991 x 130 gal/bdrm = 1991-present x 110 gaUbdrm = Garbage Grinder Installed yes _ /(r Spa or Hot Tub Installed yes_ / Gl_ 4. PARCEL INFORMATION: (circle applicable information & indicate measurements) NO TovoArapliv Soil Nature Grolind Water RPArnrlr 117. Va� 7Folling o s loam at what depth feet at what depth feet a+vaaaw u.. yr awa uu 1 municipal we Steep slope clay if well; water supply slope other from any septic -system depth: ab t' /2c s rp ton is — ft. other Percolation Test: (To be c1pipleted by licensed professional engineer or architect) Rate: /-•0 8'yRth�t a per inch 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: ,-&V� gallon (min. size 1, 000 gal) Tile Field: each trench ft. Seepage Pit(s): number of, Size of Stone to be used: # i Bed System Size: Alternative System: Total System Length: 5 .SZ, fi. x size of each: ft. by ft, depth or thickness feet length and/or size 6. HOLDING TANK SYSTEM: (if required) Number of tanks: / Size of each: %O gallons / TOTAL Capacity: _gallons Note: Alarm System and associated electrical work must be inspected by a Town approved electrical inspection agency. 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, C Si nat re f responsible person Date ' '1'invn cif <Zutanlsstsui•y Sewers and SewiV;q I>iagostl tausplcr Apptnntlix (: ' A11.�+UIi1�'•I'it)N I' I1;1,I1 SIB:i'A KA'1'i(JN tZ:I:(21.111t1:t41 h:�l'I`:1 WLLL IN IlATPA, ."%tt tY Intl; 7. SIGNA.TURE & INFORMATION FOR MpUNbW& Jr rzgw'Jw , v..o,......"..;:r Septic Inspection Report Office No. (518) 761-8256 Date Inspection rec, Queensbury Building & Code Enforcement Arrive: a: 742 Bay Rd., Queensbury, NY 12804 Inspector's Initials: NAME: , AR C u F � �E 1P/E LOCATION: RECHECK: Soil T e: and Loam / Clay Type of Water: Municipal / el Water Waterline separation distance ft. Well separation distance Other wells: eQ ft. ft. Abso tion Field: Total length } ft. Len h of each trench ft. Depth of trenches ft. Size of Stone e Seepage Pits: Number Size: x Stone Size: Piping Size Type Building to tank tt Q to Distribution Box -Zt t L LAb Distribution Box to Field / Pit LA t i ening Sealed: CD N/ Partial Location / Separations Foundation to tank Z ft. Foundation to abso lion ft. Separation of Pits fr. Conforms as per Plot Plan VY N Location of System on Property: Fro Rear eft Side Right Side Middle Front Middle Rear Svstem Use Status: \o_--2,u�m NO.: 7 Cat I — 2-7 'ON: L1 —Zn—D, A Comments and/or diaeram REARM POtAv UN` \. Approved artial Approved and needs to be re -inspected, please call the Building & Codes Office Disapproved 7 L:1.SueHemingwayU3uilding.Codes.Inspection.FORMS\Septic Inspection ReporLortdoc January 28, 2003 COMMONWEALTH ELECTRICAL INSPECTION SERVICE, INCO,/, Main Office 176 Doe Run Road - Manheim, PA 17545 Y MUNICIPAL CERTIFICATE - ELECTRICAL APPROVAL, Permit No........................................Cert. N 0 90066 Cut -in Card No................................ / Location ................G%ii..e Installation Consisting of installed By...... ".(IQ2. ....6..................... ................ Lic. No. ............ The conditions following governed the issuance of this certificate, and any certificate previously issued is ancelled: - This certificate only covers the electrical equipment and installation conditions as of date. Upon the ntroduction of additional equipment or alterations, application shall be promptly made for inspection. Inspectors of this Company shall have the privilege of makin inspections at any time, and if its 'ides are lv.iiolatted,ttthe /C�om/p�any shall have the right to r vokeT,_ce ;cate.Date........(..:..L...L :..V....7.k......... INSPECTOR..�................ .........................N CDA rAL'r