2001-166 TOWN OF QUEENSBURY
cos 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building & Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20010166 Application Number: A20010166
Tax Map No: 523400-048-000-0003-042-000-0000
Permission is hereby granted to: HAROLD & DOROTHY KEECH LE
For property located at: 817 BAY 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: HAROLD & DOROTHY KEECH LE Septic Alteration Residential
D KEECH N ANDERSON B HERN� Total Value
817 BAY Rd
QUEENSBURY,NY 12804
Contractor or Builder's Name/ Address Electrical Inspection Agency
OUEENSBURY SEWER
JAY SWEET
Plans &Specifications
2001-166
SEPTIC ALTERATION AS PER APPLICATION
$25.00 PERMIT FEE PAID - THIS PERMIT EXPIRES: Thursday,April 17,2003
(If a bnger 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 u nsbu lues• . ,, pril 17,2001
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:
® e`• (ram Office Use
- P
Location of installation: ) / "_� a / 11
/ File Permit Nd:: r Afe)
Tax Map No. / _/ e b
j Fee Paid •
Owner's Name: ----4 + t 7 h L. •\. •* c' k
Address: 1 / I-) 6 L ( i-2) xry-�
2. INSTALLER'S NAME , C , �, �. ,,.� <�__r— PHONE NO. f < . �'
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 Z-, cx 150 gal/bdrtn-
1980— 1991 x 130 gal/bdrm = ,
1991 —present x 110 gal/bdrm = - vED
,,..-. :, ; ,.
Garbage Grinder Installed yes / no 2001
Spa or Whirlpool Installed yes I ne---,- it.,-,,A,
4. PARCEL INFORMATION: (circle applicable information&indicate measurements) w„.,,„
Topography Soil..fature Ground Water Bedrock or Impervious Material Domestic Water Supply
Mat ) "secret') at what depth at what depth municipal
Rolling `loam feet _ feet we TC..,
Steep slope clay if well; water supply
_%slope other from any septic-system
depth: absorption is Jt.
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 25() gallons to the size
of the septic tank and leach field for each Garbage Grinder,Spa or Whirlpool Tub.
Septic Tank:/0 c' '1 gallon (min. size 1,000 gal) � L" 04te
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: I/ / 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.
..
Signature of responsible person Date
TOWN OF QUEENSBURY
BUILDING_& CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804
(518)761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name •
Location _
Dat6A1 Abj Permi # /v/(o(D
SOIL TYPE: Sand-Loam-Clay-
Results of Percolation Test-
(if applicable) Rate-Minute/Inch
TYPE OF SYSTEM:
ABSORPTION FIELD: Total Length
Length of each trench
Depth of trenches
Size of stone
SEEPAGE PITS: Number
Size - ft. x ft.
Stone size
PIPING: Size Type
Bldg. to Tank /Ai , ( LID
Tank to Dist. Bo: tie_ ti -TE §
Dist. Box • eld/Pit
Openings Sealed? 41111Ei- No Pa) tia
LOCATION/SEPARATIi ' :
Foundation to Tank fir,-+- feet
Foundation to Absorp ,ion _ feet
Separation of Pits feet
Conforms as per Plot Plan ;;;;7=2No
LOCATION OF SYSTEM ! PROP
(circle one)
Front - Rear - Left ide - Right Side
Middle Fro - Midd e Rear
COMMENTS: r
R
SYSTEM.USE APPROVED: YES ,.,.. NO
Arrived:
Depar, ': t
ui di n I`bspector
Q
Wmof QG z, cam.iy,
co
1 Liu, T-+ 0 0 "I have seen or observed, or believe I saw evidence of,
z 9CIC
all ohlects such as houses, wells, trees, lends, etc.,
oshown oil +Ills decum'�nt. I also reores'nt that I have
�: personally measured t`te distances set forth on the diagram."
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SIGVCATUI1E DATE I
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