2005-047 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20050047 Date Issued: Wednesday, February 09, 2005
This is to certify that work requested to be done as shown by Permit Number P20050047
has been completed.
Tax Map Number: 523400-295-018-0002-019-000-0000
Location: 6 DORSET PI
Owner: ANNE GOBBO
Applicant: ANNE GOBBO
This structure may be occupiecdtfiARD ATKINSON
Septic Alteration Residential
By Order 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,
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
Community Development-Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20050047 Application Number: A20050047
Tax Map No: 523400-295-018-0002-019-000-0000
Permission is hereby granted to: RIC;HARD ATKINSON
ANNE GOBBO
For property located at: 6 DORSET PI
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. Tyne of Construction Value
Owner Address: ANNE GOBBO
6 DORSET PI Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
I.B.S. SEPTIC
2 LOWER WARREN STREET
OI JEENSBI TRY_ NY
Plans&Specifications
2005-047
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Saturday, January 21, 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 Town o ueensbu F i a January 21, 2005
SIGNED BY for the Town of Queensbury.
r .7'
ode E rcement Director of Building&
Application for Permit-Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
......................................................................I.............................. .....................
/ Office Use
Location of installation: <c
File Permit No.
Tax Map No. / / y
( Fee Paid
J-
OwnersName: 12� ' c� ....................................................................................................................................
:
Address: / ( e e
2. INSTALLER'S NAME PHONE NO. z
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate#bedroom(s) and multiply#of
bedrooms with applicable gallons per bedroom to equal total daily fl w ,lip�
Year of House: No.of Bedrooms x Computation Total Daily F
1980 or older x 150 gal/bdrm =
1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm =
Garbage Grinder Installed yes_ / no
Spa or Hot Tub Installed yes_ / no
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
�6goaranhv e Ground Water Bedrock or impervious Material me. r Su 1
Flat sand at ha epth at w at epth municipal
ling m �_ et eet
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: 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 ll}each field for each Garbage Grinder,Spa or Whirlpool Tub.
Septic Tank: 1 /C' gallon (min. size 1,000 gal.)
Tile Field: each trench ft. Total System Length: ft.
Seepage Pit(s): number of size of each: _ Z�ft. by �ft.
Size of Stone to be used: # _ 1 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 To of Queensbury Sanitary Sewage Disposal Ordinance.
ignature of responsib a person Date
' . ' °IrptVl� t)r ��itCN1tRI)itt•� '
St;wct•� and c Dixpt)AnI
. Appendix
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Septic Inspection Report
Office No.(518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: ami�art: —my
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials:
NAME: _:,1 PERMIT NO.:
LOCATION: INSPECT ON:
RECHECK:
Comments and/or diagram
Soil T e: Sa o Clay
Type of Water: Municip /Well Water
Waterline sea on (ance 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 Sizee Type
Building to tank
Tank to Distribution Box p�2
Distribution Box to Field!Pit
Opening Sealed: Y/N/Partial
End Caps
Location/Separations
Foundation to tank ✓�- ft.
Foundation to absorption
Separation of Pits ft.
Conforms as per Plot Plan 11 Y N
Engineer Report and As-Built Y N
Location of stem on Property:
Fron Rear Left Side Right Side
Middle Front Middle Rear
System Use Statu
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
Last revised 116105
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