2005-200 A1� QUEENSBURY
TOWN OF
Foiro
742 BayRoad,Queensbury, 12804-5902 (518)761-8201
Que ury,
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20050200 Date Issued: Tuesday, April 19, 2005
This is to certify that work requested to be done as shown by Permit Number P20050200
has been completed.
Tax Map Number: 523400-302-014-0001-074-000-0000
Location: 34 PERSHING Rd
Owner: JAMES & PATRICIA ROUND
Applicant: JAMES & PATRICIA ROUND
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
(341211 4
Director of Building&Code nforc ent
Al*k
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Kiwi!
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20050200 Application Number: A20050200
Tax Map No: 523400-302-014-0001-074-000-0000
Permission is hereby granted to: JAMES &PATRICIA ROT TNT)
For property located at: 34 PERSHING 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. Type of Construction Value
Owner Address: JAMES & PATRICIA ROUND
34 PERSHING Rd Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804-0000
Contractor or Builder's Name /Address Electrical Inspection Agency
OT TEENSBT TRY SEWER
NY 12804-0000
Plans&Specifications
A2005-200
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID -THIS PERMIT EXPIRES: Tuesday, April 18, 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 Tow eensb • Monday, April 18, 2005
SIGNED BY for the Town of Queensbury.
Director of Building& f•.e orcement
Application for Permit-Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
Office Use
Location of installation: 7,47 r j I n /}�
Tax Ma No. File Pe No. l.V7�`�.J
p Fee Pai
Owner's Name: -3 / ,�,� �t r /j
,r
Address: 3 `/ , r c I kt �� /<) 4)L(e ti
2. INSTALLER'S NAME : ,(c_ r ;,, PHONE NO. / .11
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 x 150 gal/bdrm =
x 130 gal/bdrm = f7 C o
1991 —present x 110 gal/bdrm =
Garbage Grinder Installed yes
Spa or Hot Tub Installed yes /
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
Topography Soil Nature Ground Water Bedrock or Impervious Material . Domestic Water Supply
ai sa at what depth at what depth f
Rolling oam feet feet we 1
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: c 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.
57'
Septic Tank: /0 o v gallon (min. size 1,000 gal.)
Tile Field: each trench ft. Total System Length: ft.
Seepage Pit(s): number of size of each: ft. by ft.
Size of Stone to be used: # / depth or thickness feet
Bed System Size: /p x
Alternative System: 44-,7c7 A) length and/or size / -- 2 ?-
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)
Septic Inspection Report /G
Office No.(518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/ depart: am/pm
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials:`�'!`
NAME: t _ Ik. ' , � PERMIT NO.: 3 005"--��
LOCATION: r _ _s2, INSPECT ON: 41 (9-0
RECHECK: N,
Comments and/or diagram
Soil T e: San 4.1.43,Vlay
Type o er: uniWell Water
Waterline separation distance ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total lengths LJC-, 6 ft. 14 (- ivG -5
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 6)6/4T/a&'
Tank to Distribution Box �,< < ZF)
Distribution Box to Field/Pit — ,`t ` _
Opening Sealed: Y/N/Partial
End Caps
Location/Separations
Foundation to tank ,6 ft.
Foundation to absorption ft.
Separation of Pits �ft.
Conforms as per Plot Plan N
Engineer Report and As-Built _Y_N
Locati stem on Property:
Front Rear Left Side Right Side
y
Middle Front Middle Rear
System Use Stat :
7
Approved
Partial Approved and needs to be re-inspected, please call the Building& Codes Office
Disapproved
Last revised 1/6/05
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BUILDING &
REVIEWED BY
DATE