2008-383 TOWN OF QUEENSBURY
Foro742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building &Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number. P20080383 Date Issued: Monday, July 21, 2008
This is to certify that work requested to be done as shown by Permit Number P20080383
has been completed.
Tax Map Number. 523400-309-011-0001-076-000-0000
Location: 201 FIFTH St EXT
Owner: RONALD & GAYLE LA CROSS
Applicant: RONALD & GAYLE LA CROSS
This structure may be occupied as a:
Septic Alteration Residential
By Onder of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the
property owner of the responsibility for compliance with Site Plan, i. avd)
Variance, or other issues and conditions as a result of approvals by the Director of Building&Co e Enfo ement
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
LT 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20080383 Application Number: A20080383
Tax Map No: 523400-309-011-0001-076-000-0000
Permission is hereby granted to: RONALD & GAYLE LA CROSS
For property located at: 201 FIFTH St EXT
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: RONALD & GAYLE LA CROSS
201 FIFTH STREET EXT Septic Alteration Residential
QUEENSBURY, NY 12804 Total Value
Contractor or Builder's Name/ Address Electrical Inspection Agency
QUEENSBURY SEWER
JAY SWEET
Plans &Specifications
2008-383
septic alteration residential
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Friday,July 17, 2009
(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 Teri ofQueen%bury; h sda , July 17, 2008
SIGNED BY -i a for the Town of Queensbury.
Director of Building&Code Enforcement
Application for Permit-Septic Disposal System
Town of Queensbnty 742 Boy Road Queensbury, NY 12804 (518) 761-8256
1. OWNER INFORMATION:
7 Office Use `-
Location of installation: e. f. / \ c5/'
File Permit No.
Tax Map No.
Fee Paid ` J
Owner's Name: la Cr d .4
s� {
Address: _2 0 / 41 71
2. INSTALLER'S NAME : &jej,4 , u PHONE NO.
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate #bedroom(s) and multiply it of
bedrooms with applicable gallons per bedroom to equal Total daily flow)
Year of House: No. of Bedrooms x Computation = Total Dail Flow
1980 or older x 150 gal/bdrm =
1980- 1991 x 130 gal/bdrm =
1991 -present x 110 gal/bdrm =
Garbage Grinder Installed yes / no X
Spa or Whirlpool Installed yes J / no y
4. PARCEL INFORMATION: (circle applicable information &indicate measurements)
Tozogra lry So' attire _ Ct_a,►d Water Bedrock or impervious Material _Domestic Water Su pjly
(11 .sand s at w at depth at wh fit— depth no�ici
eng own /t' feet _,y-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)
Rale: t- '»mute 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 Hoard approved subdivision). Add 250 gallons to the sin
of the septic lank and leach field for each Garbage Grinder, Spa or Whirlpool Tub.
k./
Septic Tank: gallon (min. size 1,000 gal.)
Tile Field: each trench , ft. Total System Length: fl.
Seepage Pit(s): number of size of each: ft. by ft.
Size of Stone to be used: Il / depth or thickness_ l _feet
Bed System Size: _ x
Alternative System: le gth and/or size
6. HOLDING TANK SYSTEM: (if (fr.uire )
Number of tanks: / Si e o ch: allons /TOTAL Capacity: gallons
Note: Alarm System and asso•iated electr' a wo 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 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.
7- / vg
Sigatu a �f responsible person Date
F-I fir+ (-/ • c'`7
_,.f.
- A
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection quest received:
Queensbury Building &Code Enforcement Arrive: ` am/ rp /Depart: am/pm
742 Bay Rd., Queensbury, NY 12804 Inspect is Ynitials: .l •
Y/`-�
NAME: dre)SS PERMIT NO.:
LOCATION: ___„,141nl Ste"` S7 INSPECT ON:
RECHECK:
Comments and/or diagram
Soil Type: San•%Loam/ Clay
Type of Water: un c pal Well Water
Water'ae - ation distance ft.
Well separation distance ft.
Other wells: ft.
Well Casing Length 50' + / - Y / N N/A
Absorption Field: Total length / ;° ft.
Length of each trench 9" ft.
Depth of trenches �ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Siz l Type
Buildin to tank
Tank to Distrib • :• 7>2 3 3--
Distribution Box to Field/ Pit `° is
Opening Sealed: N
End Cap _N
Inlet/Outlet Pipes &Baffles Y!N
Location/ Separations
Foundation to tank 4'' ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Engineer Report and As-Built —Y!N
Location of Syste s' • Property:
Front Re-r Left Side Right Side Middle Front Middle Rear
S st-m se at r:
Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
Last revised 06/18/07 L:\Building&Codes Forms-OLD\Building&Codes\Inspection Forms\Septic Inspection Reportdoc
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TOWN OF QUE N3BURY BUILDING DEPARTMEt S.
Based on our limited examination, (N.
oomolianc, with our comments shall
rim be c ictrued as indicating the
plans and specifications are in full 4\.
comollanc, with the Building Codes of
New York State.
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