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TOWN OF QUEENSBURY TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
BUILDING & CODE ENFORCEMENT
742 Bay Road 742 Bay Road
Queensbury NY 12804 Queensbury NY 12804
(518) 761-8256 (518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION SEPTIC DISPOSAL SYSTEM INSPECTION
Name 1 1-1-;i�-1A� Name �ETF T`11t�N1
Location —AigL)F �; �- f�D Location R���MC-�L'� P�i1 ,p
Date Date 12_—a °( Permi t # )
10—C6-'� Permit # on—L ;C
SOIL TYPE: San.-Lo.m-Clay- SOIL TYPE.aan Loa - 1
Results of Per olation Test- Results of Percolation Test-
(if applicable) Rate-Minute/Inch
(if applicable Rate-Minute/Inch TYPE OF SYSTEM:
TYPE OF SYSTEM ABSORPTION FIELD: Total Length
ABSORPTION FIE 1 : Total Length Length of each trench
Length of -;ch rench Depth of trenches
Depth of tre h-s Size of stone
Size of stone SEEPAGE PITS:• Number-
SEEPAGE PITS: umber- Size - ft. x Aigmh ft.
Size - 't. x ft. Stone size ` —
Stone size PIPING: ze ype
PIPING: Size Type Bldg. to Tank
Bldg. to Tank Tank to Dist. Bo
Tank. to Dist. Bo Dist. Box to Fie . '
Dist. Box to Fie d/Pit Openings Sealed? Yes No Partial
Openings Sealed? Yes No Partial LOCATION/SEPARA IONS:
LOCATION/SEPARATIONS: Foundation to T.nk feet
Foundation to Tank feet Foundation to ' ,sorption feet
Foundation to Absorption feet Separation of 'its _ feet
Separation of Pits _ feet Conforms as pe Plot Plan Yes No
Conforms as per Plot Plan 7i) No
LOCATION OF SYSTEM ON PROPERTY: LOCATION OF SYSTEM ON PROPERTY:
(circle one) (circle one)
Front - Rear - Left Side - Right Side
Front - Rear - Left Side - Right Side Middle Front - Middle Rear
Middle Front - Middle Rear COMMENTS:
COMMENTS:
PE.RCoLT1OtO I E6T
RECE,1\ E.CJ ITT TE3T ILL:Liz_ wU)JiTF-4)
R�--����-T Z-t‘D-1--E.J5T
1-052... m ii.)01-F€
3 RD TF6T rOiotiobr.)T E eCY
SYSTEM USE APPROVED: YES NO 51ZE tf
SYSTEM USE APPROVED: ES 0p - _Ft��
Arrived: Arrive d `
Depar �. Depar ed _ (CALL_ 1►.5b�)
3,5v �F
:3 epvet.
wilding n ec or
/ 1dini4aØto
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