2004-299 0111164,
OF TOWN QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20040299 Date Issued: Wednesday, May 12, 2004
This is to certify that work requested to be done as shown by Permit Number P20040299
has been completed.
Tax Map Number: 523400-295-019-0001-044-000-0000
Location: 9 PINEWOOD Ave
Owner: GAIL HAVERN
Applicant: GAIL HAVERN
This structure may be occupied as a:
Septic Alteration Residential
By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the ("*". ..0 4 _1
property owner of the responsibility for compliance with Site Plan,
Variance, or other issues and conditions as a result of approvals by the Director of Building&Code Enforcement
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
. 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20040299 Application Number: A20040299
Tax Map No: 523400-295-019-0001-044-000-0000
Permission is hereby granted to: GATT, I-TAVERN
For property located at: 9 PINEWOOD Ave
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. Type of Construction Value
Owner Address: GALL HAVERN
9 PINEWOOD Ave Septic Alteration Residential
QUEENSBURY, NY 12804 Total Value
Contractor or Builder's Name /Address Electrical Inspection Agency
SANITARY SEWER
DAN DRELLOS
PO BOX 224
GLENS FALLS NY
Plans&Specifications
2004-299
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday, May 12, 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 Town o uee
Q �yi "Oe ay 12, 2004
SIGNED BY for 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: _ ....._,.......�...__...._.._.._..—_..
[File
^ --_�__. _ Office Use
Location of installation: 9 f3/tj'e.&io D7 l✓� ,� C�
Tax Ma No. / / Permit No. —0 `1
p '7�
i �/ //,q
v e/4_,� i Fee Paid
Owner's Name: c / ( r l `~
Address: f)i /f e c,.....)0 J D 4-tit _
2. INSTALLER'S NAME : J t /V/77K 7 J(7-C✓A..,__✓Ctz.,,,,c k., PHONE NO.l?2-7?c5
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 3 x 150 gal/bdrm = 5-
1980- 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdr ro '
m =
Garbage Grinder Installed yes / no
Spa or Hot Tub Installed yes / no��
j
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
Topography u W ervi '( ,` u ]
y
Flax sand at what depth at what •
depth ltnieipal
Rolling oam 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.
f COO S i( C� (TA).f I z 7'n-z4-Ti� 'S)
Septic Tank: g?allion(min. size I,000 gal.)
Tile Field: each trench 5.. ft. Total System Length: Jo 0 ,ft.
Seepage Pit(s): number of A)
k size of each: ft, by ft.
Size 9f Stone to be used: # /v/k / depth or thickness feet
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 ad the egulations . respect to this application and agree to abide by these and all
requir meats of a Town of()I} nsbury Sani Sewage Disposal Or . cc.
Cam',f Oial-d * 's.5 V ° 1—
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1 TOWN OF QUE._=N"' "r<
. r ....y
BUILDING T.
REVIEWED BY .fr
Z-0 DATE • 7 Ei 11)i t
f\P")19 Q.A11\7 1---licie _I
G`r V- Q\kle
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Septic Inspection Report ,
50
Office No. (518)761-8256 Date Inspection request recei ed:
Queensbury Building& Code Enforcement Arrive: am/ epart:/Z./O am/pm
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials:NAME: ° •'V. ir\, PERMIT NO.: 0 9
LOCATION: ` -- INSPECT ON: _ T/ `Q L/
RECHECK: N.
Comments and/or diagram
Soil Type Sa / am/ lay
Type of er: unicip' /Well Water
Waterline separa on d' ance ft,
Well separation dis ance ft.
Other wells: - ft.
Absorption Field: Total length e (� —__-\ ft.
Length of each trench 5 ft.
Depth of trenches ft.
Size of Stone 1,J p-ILTRac: t�A, '7) •
Seepage Pits: Number
Size: x
Stone Size:
Piping Siz
Building to tank �d
Tank to Distrib 'on Box �' S"D,ype
Distribution Bo Field/PitIA i`
Opening Seale Y/N/Partial
Location/Separations
Foundation to tank 12�ft.
Foundation to absorption 3 ft.
Separation of Pits ft.
Conforms as p t Plan Y N
Location of Sys Property:
Front Rear Left Side Right Side
Middle Front Middle Rear
System Use Stat s:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:\SueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003