SEP-000596-2017 TOWN OF QUEENSBURY
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742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development-Building&Codes (518)761-8256
BUILDING PERMIT
Permit Number: SEP-000596-2017
Tax Map No: 240.5-1-12
Permission is hereby granted to: Sameh Ghobrial
For property located at: - 66 RUSSELL HARRIS 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
Tvve of Construction
Owner Name: Sameh Ghobrial Septic Disposal-Residential $0.00
Owner Address: 4469 Whispering Oak DR Total Value $0.00
North Port,FL 34287
Contractor or Builder's Name/Address Electrical Inspection Agency
Chris Crandall
63 Woodchuck Hill
Lake George,NY 12845
Plans&Specifications
Residential Septic Alteration
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday,September 21,2018
(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 Town of Q ensbury Tirsda , e 1,2017
SIGNED BY: 0%�d for the Town of Queensbury.
Director of Building&Code Enforcement
SEPTIC DISPOSAL PERMIT APPLICATION Office Use Univ
742 Bay Road,Queensbury,NY 12504 G
n 11 4 Que, i;hi m Permit#:
P:518-761-8256 www.gueensbury.ne#
Tax Map ID M p Permit Fee: $ invoice#: 2216
Project Location: �O(o i�-IJ�S��R.11� {�C �IY 1� Septic Variance? Yes No
Primary Owner(s)
Mailing Address RvSSC—t. (U 0C-C-A)
Phone & Email C7
Installer/Builder �h} ( S C Cn�r If U-)Q i p t\\-)
Mailing Address
Phone & Email
Engineer
Mailing Address SEP 21 2017
Phone & Email
MAI A 11
10614 OF OUEENSBURY
Contact Person for Building&Code Compliance: BUILDING&CODES Phone:
RESIDENCE INFORMATION:
Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yeso
1980 or older '71Installed? (circle one)
1981-1991 Spa or Hot Tub Yes No
Installed? (circle one) }
1992-Present
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Naturey1 Sand Loam l.�Clay Other
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply —Municipal _Well (if well, water supply from any septic system absorption is_ft.)
Percolation Test Rate: per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone Total length ft.; Each Trench ft.
Seepage Pit with#3 stone How many: ; Size:
Alternative System Bed or other type:
Holding Tank System Total required capacity?7;0c'-f-) tank size 154Q#of tanks
NOTES: 1.Alarm system &associated electrical work must be inspected by a Town approved electrical inspection
agency; 2.We will no longer allow systems to be covered until such time as an as-built plan is received and approved.
The installed system must match the septic layout on file—no exceptions.
Declaration:Any permit or approval granted which is based upon or is granted in reliance upon any material
representation 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 and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage
Disposal Ordinance. /y
PRINT NAME: S rnE 4� DATE:
SIGNATURE: - DATE:
Town of Queensbury Building&Code Enforcement Revised February 2017
COMMONWEALTH ELECTRICAL INSPECTION SERVICE,INC.
Main Office 176 Doe Run Road-Manheim,PA 17545
MUNICIPAL CERTIFICATE - ELECTRICAL APPROVAL
596 - 20 1-+ 44981
Permit No........................
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Owner..........7...... ? .. ..1.4.......L................................................................................................
Location.
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Installation Consisting
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InstalledBy.... :.... '' ..................................................Lic.No...................................................
The conditions following governed the issuance of this certificate,and any certificate previously issued is
cancelled:-
This certificate only covers the electrical equipment and installation conditions as of date. Upon the
introduction of additional equipment or alterations,application shall be pr y made for inspection.
Inspectors of this Company shall have the privilege o a in g in
ctio s at any time, and if its
rules are viol,the Company shall have th^right to rev tis ce
Date....`... ......... ../......................... INSPECTOR.......................`........................................................................
Member N.F.P.A.,I.A.E.I.
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