1990-642 _
•
•
.
CERTIFICATE OF OCCUPANCY
(
TOWN OF QUEENSBURY
WARREN COUNTY, NEW YORK
Date November 20 iq 90
This
-
This is to certify that work requested to be done as shown by Permit No. qn-6/12
has been completed.
This structure may be occupied as a single family diaPllino
Location Lot 37 Queens Lane
FOREST WOOD HOMES
Owner
By Order Town Board
TOWN OF QUEENSBURY
40.6ced, WOJ-14'
Director of Bldg. & Code Enforcement
BUILDING PERMIT
TOWN OF QUEENSBURY No 90-642 x
WARREN COUNTY, NEW YORK
PERMISSION is hereby granted to FOREST WOOD HOMES
OWNER of property located at Lot 37 Queens Lane Street, Road or Ave. Lc,
in the Town of Queensbury,To Construct or place a Single family dwelling
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
HCO2 Box 286P c
Warrensburg NY 12885
2. CONTRACTOR or BUILDER'S Name c
G
2
O
3. CONTRACTOR or BUILDER'S Address rn
cn
4. ARCHITECT'S Name
5. ARCHITECT'S Address
O
c r
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V
6. TYPE of Construction—(Please indicate by X)
CD
rD
AA Wood Frame ( ) Masonry ( I Steel ( ) to
r
a)
7. PLANS and Specifications
rD
No. 26'x46' Single family dwelling as per plot plan, specifications
and application including attached two car garage and septic system.
8. Proposed Use
Single family dwelling
cn
$ 233.00 PERMIT FEE PAID —THIS PERMIT EXPIRES September 24 19 91
co
(If a longer period is required an application for an extension must be made to the Building and Zoning inspector of the -fi
town of Queensbury before the expiration date.) 0)
Dated at the Town of Queensbury this 24th Day of September 19 90
rp
SIGNED BY q0iii-Ce1)4/aDziin-emso/ for the Town of Queensbury
Building andr
to
TOWN OF QUEENSBURY
--7111.111— REVIEWED
FEE PAID $. (3,,3
IFIFF0 PERMIT NO. Qd-(A 2.,
BUILDING PERMIT APPLICATION a, l� 1eJ r '+ b
SEP 2r) 1990
A PERMIT MUST BE OBTAINED BEFORE BEGINNING CONSTRUCTION. NO INSPECTIONS
WILL BE MADE UNTIL APPLICANT HAS RECEIVED A VALID BUILDING PERMIT.
All applicants spaces on this application MUST, be completed and the signature of the
applicant MUST appear on the reverse side of this application.
* * *. * * * * « * * * * * * « .a * « * * * * * * * * * * * * * * * * « * « « * * *
The owner of this property is: Fnrefl wood - yne.s
P.O. Address lie-N Ioax QV, P Wavvevls ktr1 ,. Tel. 6d3`.3”�
s -
Property Location I Pi- 37 attPJ'ris. I i"� Tax Map No. 70 /
Has there been any split of this property since October 1, 1988? / )�
If yes Planning Board Review is necessary. yes no
SUBDIVISION NAME, IF APPLICABLE Vali) Polive e5Ta&c LOT NO.
THE PERSON RESPONSIBLE FOR SUPERVISION OF WORK AS REGARDS TO BUILDING CODES IS:
*
NATURE OF PROPOSED WORK: ESIIMATED MARKET VALUE OF•
Construction of a new building * CONSTRUCTION: $ 9�l R
Addition to a building • COMPLETE INFORMATION REQUIRED BELOW:
* Size of property f - c ft x
Alteration to a building * Existing Buildings(3) Size ft. x ft.
(no change to exterior dimensions) •
Proposed building - distance from property line:
Other work (Describe) • Front yard 4-1—, ft. Rear yard ft.
•
Side yards &.1 ft. and a 7 ft.
•
GROSS AREA OF PROPOSED STRUCTURE • If on corner, setback from side street ft.
1st Floor C qg sq. ft. eiP ( � D g•
• OCCUPANCY INFORMATION
2nd Floor sq. ft.ate_ D „ Primary Building -
qr. t,,-'''One Family Dwelling
Other Floors sq. ft.
(not cellar or basement 3 S' Two Family Dwelling
TOTAL FLOOR AREA Ir731P sq. ft.
Multiple Dwelling/Number of units
35
Size of new structure_ft x UG,' ft. • Business
Foundation-pier/slab/crawl/partial ull Industrial
(circle one) • Other
a
llo. of stories (habitable space) •
Height (grade to ridge) S ft. • If addition, what will use be?
If residential, no. of families •
No. of rooms(excluding baths) •
Accessory Building
No. of bedrooms " __Detached Garage ONE/TWO Car
No. of bathrooms_ •
Primary heating system r • tf Attached Garage ONEGI'WO C�
Type of fuel 5 " _Private storage building
No. of fireplaces to be installed c •
• Other
Will a wood stove be installed h •
`
Central Air conditioning v
OV' ER
BUILDING PERMIT APPLICATION CONTINUED -
BUILDING SPECIFICATIONS:
Type of construction, wood frame, fire safe, etc. S � 1 ( ,� tjui L c;,,f rp , Q
Will any second-hand or upgraded lumber be used? If so, for what? In
Foundation wall material C_c�&o vp - , Thickness
Depth of foundation below grade (to bottom of footing) '
Will there be a cellar? lit- Heated or unheated? Floor sq. footage sq ft.
Will there be a basement? y• Will any portion be used as living space? h 0
(If so, what portion? • sq ft. Type of use?
Type of roofloped/�flat/shed/other Material of roof -r,` u
Size,. wood studs "x " spacing k. " o.c. length S' ft. C
Joists (floor beams) 1st floor �_ "x (c) " spacing (,G., "o.c. span 'i at ft.
Joist (floor beams) 2nd floor -."x l cp " spacing I(4 "o.c. span ;v ft.
Overlays (ceiling beams) "x " spacing " o.c. span ft.
Roof rafters "x " spacing o.c.. span ft.
Roof trusses (pre-engineered) spacing ,�y " o.c. span ft.
Exterior wall finish 1r v 5 of what material?
Interior wall finish �'��,� �_ �t= >� ct,-,1 edi
If a garage is to be attached, describe materials to be used for FIRE SEPARATION: s1.az•�®-�,�� �g
n„ _ Mucv.� h `� w�M ��C� '�,r;5�.I - 'z��
Q � 01 - On ig
s"-1'\O.6 4u ; -S
Is ..there to be an opening between garage and dwelling? yy If so will a Fire-rated door, enclosure,
self-closing device be provided? v c S
Will a flue-lined chimney be installed? Height above roof ft.
Depth of chimney foundation below grade ft.
Depth of fireplace hearth ft. in.
Water supply - Municipal or private well 4,,1 , v.,,' r.;j9 cn 1
SEPTIC SYSTEM Distance from ANY private well (including adjoining properties ton ft.
(A separate . application is necessary for any repair or new installation of septic system)
NAME OF BUILDER ;rev- i sbtkv) ADDRESS {Q; „ja aa6p,Alcvn,c,,,,,o:EL. NO. 6�
NAME OF PLUMBER (a, ADDRESS �c:>_`,AQt11 Mc,,,-,,, TEL. NO. \ c t4rs
NAME OF MASON 1 t�.) ii W /
�,�-rsa-�'�= �_� >��,�`;s; ADDRESS d � �ti c TEL. NO. 77-1/7- Q d,ICI -•
i
NAME OF ELECTRICIAN. ��; ' e.(Q*:r ADDRESS � 'A-°uny TEL. NO. 71
DECLARATION
To the best of my knowledge and belief the statements contained in this application, together with the
plans and specifications submitted, are a true and complete statement of all proposed work to be done on
the described premises and that all provisions of the BUILDING CODE, THE ZONING ORDINANCE, and
all other laws pertaining to the proposed work shall be complied with, whether specified or not, and that
such work is authorized by the owner. 4-1/
Signature I.{� 4-7
Oviner, owner's agent, architect, contractor
SPECIAL CONDITIONS OF THE PERMIT: .
BY
WARREN COUNTY , NEW YCEtK .
•
Application for : BUILDING PERMIT IN COMPLIANCE WITH THE •NEW YORK
. STATE ENERGY CONSERVATION CODE -
- A 'permit must be obtained . before beginning work .
ANSWER ALL of the following: .
1 . Gross floor area 1-70.6 „ 6 ir=' Fri H ` ii !.,
2 . Type of heat aa_S in n..I of ( : • .
3 : " Is the building mechanically cooled? GAO _
:4 . - percentage of area of windows and doors /d,-' / C)
A. Over 16% Only
. '1... Uo value of gross area of walls , roof/ceiling and ' floors.
- exposed to ambient conditions •
. 2 . Floor over heated spaces YES NO
a: Are -foundat on walls insulated? - YES - NO
•
1 . If YES . what is the R value?
3 . _ Slab oh grade YES NO a
a. If YES , wh .t is the R value of insulation around
• perimeter of floor?
4. Is basement, heated? YES NO .
a. R value of insulation
. 5. Type of insulation
•
. 8. Under 16% Only -
1. R value of roof and floors exposed to ambient conditions_
2. R value of exterior walls • K- l9 .
3 . R value of glazed area le-
4. R value of doors . - 1 i0
5. R value of floors over unheated spaces
6. R value of slab edge insulation - unheated slab N
7. R value of slab insulation - heated slab ll
•
8. R value of heated basement/cellar walls (above grade) \
. \ 1
9. R value of heated basement/cellar walls (below grade)
•
10. Type of insulation -�-)- 1,o.,r- a1 S-S . •
C. Controls v `t� 0
1. Thermostat maximum heat setting
D. Duct Systems •
' 1. Is duct system installed in unheated spaces? dim NO
a. If YES, R value of duct installation -r—t -
b. R value of duct in other areas
E. Pizina Insulation
1. Size of hot water, or cooling carrying agent pipe , .
2. R value of pipe insulpt{^"
• .P. Service Water Heating
1. Performance .efficiency h
. • 2. Temperature control setting maximum J-w-
G. For -Swimming Pool Only .
1. Maximum heating •
29 .
"Telephone No. 3 r/.
(applicant' s signature). .
7 OWN OF QUEENSELIRY
APPLICATION FOR
> SEPTIC DISPOSAL PERMIT >> I r.' \JJ
1 � l`r7 `� IJ JI L u
EP2n 1990
DATE &rf, !g, 1110
LOCATION OF PROPERTY FOR INSTALLATION 10 f 57 iA. .P,f1 c I a 1,1e.
Owner's Name: Pn ie,S-'4- Mood 1 f(-)fftz a Telephone:
Address:
d
Installer's Name: -61/42-s excourbk,o, Telephone: 7/W7-011(1
v —
Number of bedrooms (residential only)
Total daily flow (compute (a 150 gal per bedroom) 4 CEO
Topography: Circle one: lolling Steep Slope % of Slope
Soil Nature: Circle one Sand oam clay Other /Depth: Feet
Ground Water: At what depth? 2 Feet
Bedrock or Impervious Material: At what depth? ° % Feet
Percolation test: Circle one:cot required)required rate min. inch.
Domestic water supply: circle one: blunicipal� Well Other
If domestic water supply is a well:
Separation: Water supply from septic absorption feet
PROPOSED SYSTEM: Septic Tank 0000 gal. (minimum size: 1.000 gal.)
TILE FIELD: Each Trench SD feet/Total system length •as•'Q feet
SEEPAGE PIT(S): Number of • / Size each feet by feet
Size of stone to be used # /Depth or Thickness feet
*************************
I have read the regulation on the reverse side of this sheet and agree to abide by these
and all requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance.
SIGNATURE OF RESPONSIBLE PERSON: .14..\--e '
DATE: ?YA//% /9/ i
OVER
•
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT //72
BAY & HAVILAND ROADS
QUEENSBURY, NEW YORK 180-
TELEPHONE (518) 7192-5832
BUILDING INSPECTOR'S REPORT /
REQUEST FOR INSPECTION RECEIVED ////J4'/)
NAME 1 9g-/�E'./1I ?��G'.V7i, i`7�'�C�///
LOCATION (94\3/ 42//),4(_; 4A-z_Q_�
DATE /// G/W PERMIT #- 9 -41o?
APPROVED
YES NO
FOOTING/PIERS \ I
MONOLITHIC POUR FORMS d
FOUNDATION/DAMP—PROOFING ;'
BACKFILL APPROVAL "„ ;I
ROUGH PLUMBING ".
FRAMING 16 'I .
ELECTRICAL ROUGH—IN \ 1
x INSULATION:
,A, FOUNDATION
FLOORS. 0 ,
WALLS . . 'i; •
•CEILING lh,
/FINAL INSPECTION: / ¶
CHIMNEY HEIGHT / 4'
e
ROOFING I ,�; JC
SIDING • I '0 'C
EXTERNAL PORCHES/STEPS`' ‘ Di.
STAIRS—CLEARANCE & RAILS ‘ DC
PLUMBING FIXTURES/REIEF VALVE K
INTERIOR TRIM/PRIVACY DOORS 1i. ex,
FINISHED FLOORS I "qt, x
GARAGE FIREPROOFING/ x
DOOR CLOSER(S) 1
SMOKE DETECTORS 1 `.
FINAL ELECTRICAL INSPECTION \.
.FINAL APPROVAL OF CONSTRUC ION \, x
OK TO ISSUE C/O OR G/C \
A SIGNED CERTIFICATE OF OCCUPANCY MUST BS'.
OBTAINED FROM THE BUILDING DEPARTMENT BEFORE
THESE PREMISES ARE OCCUPIED!
REMARKS: ,5( ' .(��(J��
(V---
1107-
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ARRIVE /d;•c?f
DEPART JU-40
INS ECTOR
ELECTRICAL INSPECTIONS
DUPLICATE MUNICIPAL RECORD
/�
Permit No. 1.V✓
n
Owner 1`C-S--f LLB--(j-G-d JA e5
.. Occupant
Location /6 G2Ct_..-e-.12 S £ h
No. Street
Town or City State
Installation as itemized on reverse side has been visually inspected pursuant to applicable
codes.
Installed by
�� No
Date if—J J q`� Inspector
MIDDLE DEPARTMENT INSPECTION AGENCY INC.
FORM NO.18 EL. 900 Haddon Ave.,Collingswood,NJ 08108
ROUGH WIRING OUTLETS H.P.AIR CONDITIONER
OUTLETS WIRING &CONTROLS FOR BURNER
RECEPTACLES H.P.PUMP
FIXTURES K.W.OVEN
AMP.SERVICE EQUIPMENT H.P.GARBAGE DISPOSAL UNIT
AMP.SERVICE CONDUCTORS K.W. DISHWASHER
K.W.SURFACE UNIT K.W. DRYER
K.W.RANGE AMP. RECEPbACLE
K.W.WATER HEATER FRAC. H.P.VENT FANS
.MOTORS H.P. 1/20 1/l2 I/10 1/e I/c % I/a % % 1 11/2 2 3 5 71/2 10 15 20 25 30 40 50 75 100
.MARK NUMBER
JF EACH SIZE
APPARATUS
awn olf QueenThury
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road, R.D. 1 Box 98
Queensbury, New York 12801
•
SEPTIC DISPOSAL SYSTEM
^ INSPECTION/
NAME c AL -G G //d. d^CX 479-Cia\, •
LOCATION ,1 5 7 54/2 44f;' ,/il —/ .
DATE`ii /z 77/ PERMIT NO. �') -‘;/6
SOIL TYPE - Sand - Loam -% Clay -
Percolation Test Required? YES - NO
Percolation rate - Min/Inch
•
TYPE of SYSTEM:
Absorption field, total `length 2_j-00
Length of each trench • -c •..
Depth of trenches ' -2=-•3 i— ;;`
Size of gravel _ _--- _
SEEPAGE PITS-Numbef of) ___.— r'
Size- , --�ft. X f_,. .,. ....--"
Gravel size , - ,�-----"
PIPING: Size Type .
Bld to tank % i .
Tank to dist. box ,i.47 ,12ts
Dist. box to field/pit 4 pi-L.
Openings sealed? ES NO Partial
LOCATION/SEPARATIONS:
Foundation to tank ,76 ft`"
Foundation to absorption ;20 ft.-r- .
Absorption to lot line tC?,K ft.
•
Separation of pits . .41/4-ft.
LOCATION OF SYSTEM ON PROPERTY(circle one)
Front - Rear - Left side - Right side -
COMMENTS: J �1
/N.,) l& 12►'�12 l- G)7 ,i' i1Y A- i_c 'D I>C
/r6-6-0 I--07 PZ.-A-4 S f f-0 i:)i 4.-16)
-c_;6� 'L L-() �.. r-t o J< 0 i _7.�-- i L
11;-1 e) .
SYSTEM USE .APPROVED YES NOS
/ /1
1
J
Building Inspector
L
01/86 and vl
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT
BAY & HAVILAND ROADS � n/�
QUEENSBURY, NEW YORK 1280� /'/
TELEPHONE (518) 792-5832
BUILDING INSPECTOR'S REPORT 7�
REQUEST FOR INSPECTION RECEIVED
r/ 1O1c� lg(J
NAME J�OI.e any 7��-Q`�. V v 1TTQiI
LOCATION I 1- % �,I,LL&'�/,!' >64'C�
DATE / 7 f`4I9O PERMIT # QG"G` /.
7`��
APPROVED
I YES NO
FOOTING/PIERS
MONOLITHIC POUR FORMS
FOUNDATION/DAMP-PROOFING)
BACKFILL APPROVAL, /
ROUGH PLUMBING !;, I
FRAMING / '
ELECTRICAL ROUGH-IN Y
INSULATION:
FOUNDATION �; /
FLOORS v /
WALLS "a• R 1/ (/
CEILING 1 `i,, R'30
FINAL INSPECTION: 1 \,
CHIMNEY HEIGHT
ROOFING j
SIDING I
EXTERNAL PORCHES/STEPS„
STAIRS-CLEARANCE & RAMS
PLUMBING FIXTURES/RELIEF VALVE
INTERIOR TRIM%PRIVACY DOORS
FINISHED FLOORS
GARAGE FIREPROOFING
DOOR CLOSERJ(S) ‘,
SMOKE DETECTORS 1
FINAL ELECTRICAL INSPECTION\
FINAL APPRO AL OF CONSTRUCTION
OK TO ISSUE C/O OR C/C
A SIGNED RTIFICATE OF OCCUPANCY MUST BE
i
OBTAINED ROM THE BUILDING DEPARTMENT BEFORE
THESE PRE ISES ARE OCCUPIED! \
1 . .
1
REMARKS:
mob -
ARRIVE i:: ;
DEPART ! �' "
_ f INSPE OR
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT
BAY & HAVILAND ROADS
QUEENSBURY, NEW YORK 12801 2
TELEPHONE (518) 792-5832
BUILDING INSPECTOR'S REPORT
'
REQUEST FOR INSPECTION RECEIVED /9 s 4
NAME vg4-1- ; � � 7. 1////,Y
LOCATION Q : 27 'j,,QQ�tA 41�.
DATE /7J-/f,.�45 PERMIT '# - ��
APPROVED
YES NO
FOOTING/PIERS ,
MONOLITHIC POU' FORMS /
FOUNDATION/DAM'-PROOFING I
BACKFILL APPRO AL / . . . .
/`
ROUGH PLUMBING 1 /
FRAMING / 1
ELECTRICAL ROUG .-IN /
INSULATION: /
FOUNDATION
FLOORS \ i
WALLS \ . /
CEILING \ /
FINAL INSPECTION: �l\ /I
CHIMNEY HEIGHT
ROOFING / \
SIDING \. . . . . .
EXTERNAL PORCHES/STEPS
STAIRS-CLEARAN E & RAILS
PLUMBING FIXT RES/RELIEF VALVE
INTERIOR TRI /PRIVACY DOORS
FINISHED F ORS
GARAGE FIRE)J ROOFING \
DOOR CLOSERS)
SMOKE DETECTORS
FINAL ELEC RICAL INSPECTION \
FINAL APPROVAL OF CONSTRUCTION
OK TO ISSUE C/O OR •C/C -- --
A SIGNED 'CERTIFICATE OF OCCUPANCY MUST BE
OBTAINED [FROM THE BUILDING DEPARTMENT\BEFORE
THESE PREMISES ARE OCCUPIED!• \
REMARKS:
/ J�
ARRIVE lG
DEPART``
/ INSPECTOR
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT
BAY & HAVILAND ROADS
QUEENSBURY, NEW YORK 1280g-
TELEPHONE (518) 792-5832 /1
BUILDING INSPECTOR'S REPORT
REQUEST FOR INSPECTION RECEIVED ��/0//fCJ
NAME (4 y�C 7� `T S 'i"''i-c2 2
LOCATION 3/7 4 p y_ (.4 // �// /j
DATE / U J//� ) PERMIT # i0-( 7.9R
9 .
APPROVED
�(l d C P / Y/ NO
I
FOOTING/PIER I t
MONOLITHIC PO R FORMS J
FOUNDATION/DAM -PROOFING 1
BACKFILL APPRO . L
ROUGH PLUMBING 1
FRAMING 1 "
ELECTRICAL ROUGH N r •
INSULATION:
FOUNDATION
FLOORS
WALLS 1
CEILING r
FINAL INSPECTION:
CHIMNEY HEIGHT
ROOFING
SIDING 1
EXTERNAL PORCHES/STE S
STAIRS-CLEARANCE & LS
PLUMBING FIXTURES/RELIEF VALVE
INTERIOR TRIM/PRIVACY OORS
FINISHED FLOORS 1
GARAGE FIREPROOFING
DOOR CLOSER(S) /
SMOKE DETECTORS!
FINAL ELECTRICAL /INSPECTIO
FINAL APPROVAL Or CONSTRUC ON: "
OK TO ISSUE C/OJOR C/C
A SIGNED CERTIF/CATE OF OCCU ANCY MUST BE
OBTAINED FROM THE BUILDING D ARTMENT BEFORE
THESE PREMISESARE OCCUPIED!
REMARKS: li
i , .
i
i
0 6
ARRIVE
� O' ,
DEPART If6
INSPECTOR
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT
BAY & HAVILAND ROADS Ain
QUEENSBURY, NEW YORK 12804.
TELEPHONE (518) 792-5832
BUILDING INSPECTOR'S REPORT
REQUEST FOR INSPECTION RECEIVED
NAME 4tgl l�/
LOCATION of 04. j/ ja(,Q,(/J(4 (4,,,
DATE fat
5196 PERMIT a 90 6 //a
APPRO ED
YES NO
FOOTING/PIERS
MONOLITHIC POUR FORMS
FOUNDATION/DAMP-PROOFING
BACKFILL APPROVAL 1
ROUGH PLUMBING
FRAMING
ELECTRICAL ROUGH-IN
INSULATION:
FOUNDATION
FLOORS
WALLS
CEILING •
FINAL INSPECTION:
CHIMNEY HEIGHT
ROOFING
SIDING 7
EXTERNAL PORCHES/STEPS
STAIRS-CLEARANCE & RAILS I
PLUMBING FIXTURES/RELIEF ,[TALVE
INTERIOR TRIM/PRIVACY DOORS
FINISHED FLOORS I
GARAGE FIREPROOFING /
DOOR CLOSER(S) l'
SMOKE DETECTORS
FINAL ELECTRICAL INSPECTION ?
_FINAL APPROVAL OF CONSTRUCTION
- OK TO ISSUE C/O OR C/C
A SIGNED CERTIFICATE OF OCCUPANCY MUST BE
OBTAINED FROM THE4BUILDING DEPARTMENT BEFORE
THESE PREMISES ARE OCCUPIED!•
/V
REMARKS: •
•
•
ARRIVE
9
DEPART 7
INS ECTOR
5ouin o/ Queeniur,
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road, R.D. 1 Box 98
Queensbury, New York 12801
SEPTIC DISPOSAL SYSTEM INSPECTION
NAME
LOCAT I ON In- '5.) Jr,427.4- .C,
DATE el li / Co PERMIT NO. iO Z'ON
I
SOIL TYPE - Sand - Lo'am - Clay -
Percolation Test Required? YES - NOr
Percolation rate - Miin/Inch
TYPE of SYSTEM: 1
Absorption field, total length _
Length of each trench'
Depth of trenches ' ,
Size of gravel
SEEPAGE PITS4Number of)
Size- ft. X f;t.
Gravel size rr
PIPING: Size Type
Bldg. to tank
Tank to dist. box
Dist. box to field/pit.:
Openings sealed? YES NO Partial
LOCATION/SEPARATIONS:'
Foundation to tank ft.
Foundation to absorption ft.
Absorption to lot ,line ft.
Separation of pits ft.
LOCATION OF SYSTEM ON PROPERTY(circle one)
Front - Rear - Left side - Right side -
COMMENTS:
Pk()),V6 \IL_
SYSTEM USE APPROVED ES 2)()
) +�
Bui ding Inspector
01/86 and vl
1
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REV i EMI ED BY
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Zoning Administr toy ,.._
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