1989-131 �-3
BUILDING PERMIT
TOWN OF QUEENSBURY No $ _ 1 1
WARREN COUNTY, NEW YOR K �
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PERMISSION is hereby granted to Ken & liolly Wheeler t
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Street, Road or Ave.
OWNER of property located at 16 Richardson Street C'
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in the Town of Queensbury, To Construct or place a Sewa e 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.
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:OWNE R"S Address is
ame
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CONTRACTOR or BUI LDER"S Name
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Sanitary Sewer
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3. CONTRACTOR or BUILDERS Address
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PeO . Box 224 rr
Glens Fallsr NT Ye 12801
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4_ ARCHITECT'S Name
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5. ARCHITECT'S Address
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6. TYPE of Construction — (Please indicate by X) 0
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i ) wood Frame i ) Masonry ( 1 Steel ( )
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7_ PLANS and Specifications O
No. 1000 gal , tankr 2 -6 ' x 8 ' seepages pits as per plot plan , �
specifications , and application .
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8. Proposed Use
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Sewage Alteration
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$ 25 0 PERMIT FEE PAID - THIS PERMIT EXPIRES April 4 19 91
(if a longer period is required an application for an extension must be made to the Building and Zoning inspector of the (y
town of Queensbury before the expiration date.)
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Dated at the Town of Queensbury this 4th Day of A ?r 1 - -19 S fD
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SIGNED BY for the Town of Queensbury i
Building&Dning;19Ctor
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TOWN Ors QUKENSBURY
,?G? APPLICATION FOR SEPTIC DISPOSAL RECEIVEO
MAR 3 11989
DATE "" f p q BLDG* & CODE DEPT.
LOCATION OF PROPERTY FOR. INSTALLATION / � f ► l C !l�/4C� P-Q "-'�/0 /
Owner's NaName** rl� lC W ��- Telephone: �+� v C�
Address: Ke Etc & cgh)
Installer's Name: } AAJ t7A:Akj 4G' - Telephone: g- ?
Number of bedrooms (residential only)
Total daily flow (compute @ 150 gal per bedroom)
Topography: circle one: Fla Rolling Steep Slope i of slope _
Soil Nature: circle one: Loam Clay Other / Depth: _ feet
Groused Water: At what depth? tv ............._ feet
Bedrock or Impervious Material: At what depth? _ /� feet
Percolation tests circle one: not require required / rate min. inch.
Domestic water supply: circle one: 46unici al Well Other
IF domestic water supply is a Well!
Separation: Watersupply from Septic absorption — feet
PROPOSED SYSTEM: Septic Tank. gal. (minimum size: 1 ,000 gal.)
TILE FIELD: Each Trench feet / Total system length feet
SEEPAGE PIT(S) : Number of � I Size each _ feet by r3 feet
Size of stone to be used # / Depth or Thickness ,. feet
IMPORTANT
...Please...LIST NEW EQUIPMENT TO BE INSTALLED
(over)
. M
Section II Septic System Inspections:
A. All applications for septic system installation, alteration or repair, as
required by the 'Town of Queensbury Sanitary Sewage Ordinance, shall
be submitted to the Building Department at least 24 hours before start
of construction and shall include a plot plan showing:
10) the proposed location of the system
2.) location and distance to lot lines
3.) location and distance to structures
4.) location and distance to any water supply
5.) size and dimensions of all tanks, distribution
boxes, tile fields anti/or drywelis
B. No System shall be covered before inspection and approval by the building
Inspector. Failure to comply with this requirement may result in the
uncovering of the system by the installer and a fine of up to $250.00.
Co An approved copy of the plot plan shall be available on the construction
site. Failure to produce said plot plan at time of inspection may result
in an immediate work stoppage.
D. Should unforeseen problems during construction prevent proper installation,
alteration or repair of an approved system, a new proposal must be submitted
to the Queensbury Building Department before further construction.
I have read the regulations above and agree to abide by t and all requirements
of the Town of Queensbury Sanitary Sewage Mpposal ina n e.
Signature of responsible person:
Date:
Town of Queensbury
Building and Code Department
Bay at Haviland Road
Queensbury, New York 12801
(518) 792-5832
5ETTLED 1763 . . HOME OF NATURAL BEAUTY . . . A GOOD PLACE TO LIVE
—.._�. . __—�.....__..- .._ ...... ... .. . ... . .... . _ _. . ... _ - . ._.___..__..�_-_. . .. . .`. .. _ _.ISSUE DATE IMMIDDIYY)
•�•+1`.Ifl:lt, CERTIFICATE OF INSURANCE 11 r / $
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS i
NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND. '.
j ack Robinson Assoc . , Inc . EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW I
P . O . Box 1364
71 Saratoga Ave . COMPANIES AFFORDING COVERAGE
So . Glens Falls , IVY 12803
COMPANY A
LETTER Firemens Ins - Co .
CODE sue-CODE
31784051 COMPANY LETTER LETTER
INSURED
Sanitary Sewer Service Division COMPANY
of C . P . Drellos , Tnc - LETTER C
P . O . Box 224 COMPANY
Glens Falls , NY 12801 LETTER
COMPANY E
LETTER
COVERAGES
THIS iS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION ALL LIMITS IN THOUSANDS
LTR DATE IMMIDDIYY) DATE (MM)DD1YY)
GENERAL LIABILITY GENERAL AGGREGATE E 1 y 0 0 (�
A X COMMERCIAL GENERAL LIABILITY C13P 6034837 6 / 1 5 / '8 8 6 / 1 5 / 8 9 PRODUCTS-COMP?OPS AGGREGATE S 1 0 0 0 0
CLAIMS MADE X OCCUR. PERSONAL & ADVERTISING INJURY $ 500
il:"JNER S & CONTRACTOR S PROT EACH OCCURRENCE $ 500
FIRE DAMAGE {Any one fire) $ 5 0
MEDICAL EXPENSE (Any one person) S 5
COMBINED
A AUTOMOBILE LIABILITY SINGLE ,$ 350
A'YY AJTO LIMIT I
BODILY
ALL O'wNED AUTOS yRY $
X SCHEOULEO AUTOS CBP 6034837 6 / 1 5 / 8 8 6 / 15 / 8 9 {Per persorll
HIDED AUTOS 4NJURY I
INJURY $
NON-O'WNEO AUTOS (Per accident)
GARACE LABILITY PROPERTY 5
DAMAGE
EACH AGGREGATE
EXCESS LIABILITY OCCURRENCE
OTHER THAN UMBRELLA FORM
STATUTORY
WORKER'S COMPENSATION
S 100 (EACH ACCIDENT)
I A AND 1 1W 81 2 3 7 7 6 8 8 D 4 / 14 / 8 8 4 / 1 4 / 8 9 5 V o (DISEASE—POLICY LIMIT)
EMPLOYERS LIABILITY $ 100 (DISEASE—EACH EMPLOYEE'
1 k
OTHER 331
4 I I
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS
I
G E���RTIFICATE HOLDER CANCELLATION
Town of Queensbury SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
cl. at Hav1laTLd Rcl . EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
Bay MAIL 15 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
Queensbury , NY 12801 - 9725 LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE COMPANY. ITS AGENTS OR REPRESENTATIVES.
Attn : David Hatin , AUTHORIZED REPRESENT IV
Dir . of Bldg . & Code Enforcement
�A RPORATION 1988
ACORD 25-S (3l88) - - -
awn a/ �etee►zsbur�
BLJILI]ING and ZONING DEPARTMENT
Bay and Haviland Road, R.D. 1 Box 98
4ueensbury, New York 12801
SEPTIC DISPOSAL_ SYSTEM INSPECTION
NAME ;e'i Z"ell I .
LOCATION Ric
DATE _ / /� PERMIT NO . -I
SOIL TYPE Sand. - Loam - Cla
percolation Teat Required? S = NO
Percolation rate - Min/Inch
TYPE of SYSTEM: i
Absorption field , total length
Length of each trench
Depth of trenches � .
Size of gravel ----�7
SEEPAGE PITS-(Number of) _
Size X ft.
Gravel size
PIPING : Siz IT
Bldg . to tank
Tank to rust. box
Dist. box to f ield/ _
Openings sealed? YES NO artial
i
LOCALTION/SE't>ARATIONS
Foundation to tapk �ft�
Foundation to a}'isorpti.on
Absorption to dot line t. .
Separation of,: pits ft.
LOCATION CF SYSTEM ON ' PROPERTY (c a one)
Front - Real - Left side - ight side
CCMMEN"TS : .
SYSTEM 'ISE APPROVED OY'ES NO
Building nspector
01/86 and vl
SANITARY SEWER SERVICE
Division of G. P. Drellos,, Inc.
53 FOURTH STREET GLENS FALLS, N . Y. 12801
TELEPHONE 792-7257
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