2005-517 TOWN OF QUEENSBURY
Foy742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20050517 Date Issued: Wednesday, July 13, 2005
This is to certify that work requested to be done as shown by Permit Number P20050517
has been completed.
Tax Map Number: 523400-289-010-0001-006-000-0000
Location: 16 JAY RD. EAST
Owner: WILLIAM & DIANE GORDON
Applicant: WILLIAM & DIANE GORDON
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 (-- a
property owner of the responsibility for compliance with Site Plan, /d
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
ET 43 I
Community Development-Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20050517 Application Number: A20050517
Tax Map No: 523400-289-010-0001-006-000-0000
Permission is hereby granted to: WIT T TAM& DIANE CORDON
For property located at: 16 JAY RD. EAST
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: WILLIAM&DIANE GORDON
13111 PELMIRA RIDGE Ct Septic Alteration Residential
Total Value
OAK HILL, VA 20171-0000
Contractor or Builder's Name /Address Electrical Inspection Agency
OI JEENSBI JRY SEWER
TAY SWEET
Plans&Specifications
2005-517
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday, July 12, 2006
(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 To ueens , e ay,July 12, 2005
SIGNED BY for the Town of Queensbury.
Director of Building Code forcement
Application for Permit-Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
il4Location of installatit (O,t Office Use
1 f, / C 5/7
Tax MapNoce I'/V / — t File Pe 't No.
Fee Pa Pe,
Owner's Na >) )f //a 44 rCC, ,v i 1
Address: v.� y _A (, ip ,L "- �
2. INSTALLER'S NAME : C.... ..tb o tt_S gi., ,,-l S22_,) e.-ci PHONE NO.7 I 7‘/` d
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
86 or old8r� -2-, 15.0_gal be y _ . RECEIVED
1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm = JUL it 6 2()I,,
/Garbage Grinder Installed yes_ TOWN OF QUEEN Xri
0•
Spa or Hot Tub Installed yes— (—nty BUILDING AND CODE
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
Topopi by Soil Na e Ground Water Bedrock or Impervious Material Domestic Water SuDpl
san at what depth at what depth municipal
Rolling oam feet feet well
Steep slope clay if well; water supply
__%slope other from any septic-system
depth: absorption is/e'v 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.
Septic Tank:/0. . gallon (min. size 1,000 gal.) i4.71. - I v er.)4�
Tile Field: each trench ft. Total System Length: ft. ‘1%.3ElQ\ l S ‘..z.l �
Seepage Pit(s): number of size of each: ft. by ft.
Size of Stone to be used: # / 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 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.
ge S_Lc,,,i 7 7 —
Signat re f responsible person Date
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"I have seen or observed, or believe I saw evidence of,
4 (I) •' all objects such as houses wells, trees 'en� , ^yes, etc.,
shown 6r, his i!irurr;;,ct i a;sif :•,,resent that I have (I
't X personals; rreasu- J the distances set forth on the diagram."
SI -NATURE DATE
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Septic Inspection Report
Office No. (518)761-8256 Date Inspection re. 'est r: •,ved:
Queensbury Building& Code Enforcement Arrive: .m/p •.art: Win . .m
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initial . -- J
NAME: (�GNr IT NO.: ... —Si
LOCATION: 1 4.... eX) C,X PECT ON: -- /
RECHECK: SP
Comments and/or diagram
Soil Type: Sand/Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenches ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank Ey4LiTi a-, .Tc. i.{`' 1-1C) Ev) t cc o CyAL.
Tank to gistribliciondiax t- > '-1" 4102- 3c. --ram V-N S1- ►
Distribution Boxld/Pit _
Opening Seale /Partial
End Caps
Location/Separations
Foundation to tank fl ft. S Z .T-,vtJ 1
Foundation to absorption ft. ��\3L � JELL
Separation of Pits ft.
Conforms as per Plot Plan —Y_N
Engineer Report and As-Built _Y N
Location of System on Property:
Fron Rear Side Right Side
Middle Front Middle Rear
S stem Use St s:
Approved
Partial Approved and needs to be re-inspected, please call the Building&Codes Office
Disapproved
Last revised 1/6/05