2005-189 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: P20050189 Date Issued: Monday, April 11, 2005
This is to certify that work requested to be done as shown by Permit Number P20050189
has been completed.
Tax Map Number: 523400-301-017-0002-004-000-0000
Location: 12 CHEROKEE Ln
Owner: DIANE P HAYES
Applicant: DIANE P HAYES
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 /f
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: P20050189 Application Number: A20050189
Tax Map No: 523400-301-017-0002-004-000-0000
Permission is hereby granted to: DIANE P HAYRS
For property located at: 12 CHEROKEE Ln
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: DIANE P HAYES
12 CHEROKEE Ln Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name / Address Electrical Inspection Agency
Plans&Specifications
2005-189
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday, April 07, 2006
(If a longer period is required,an application for an extension must he made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the Tlwn of ueen ryAla
April 07, 2005
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: .....................................................................................................................................:
f Office Use
Location of installation: "1 r/�o l zc C ECEIV
File Perrrn o.
Tax Map No. / /
; Fee ai
Owner's Name:
Address:S I -- Q C_
/ �� I/ PHONE NO..2))l c�
2. INSTALLER'S NAME 3
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 low
1980 or older x 150 gaVbdrm =
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)
o a h oil a e Ground Water Bedrock or Impervious Material ter Su 1
Flat san at wha depth at w a pth municipal
ing oam et t
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 leach field for each Garbage Grinder,Spa or Whirlpool Tub.
Septic Tank:/1 . —gallon (min.size 1,000 gal)
Tile Field: each trench fl. Total System Length: ft.
I
Seepage Pit(s): number of size of each: ft. by JQft.
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
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Septic Inspection Report
Office No. (518)761-8256 Date Inspection request received:
Queensbury Building& Code Enforcement Arrive: am/p part: am/pm
742 Bay Rd., Queensbury, 12804 Inspector's Initials: _
lie
NAME: ;,/
PERMIT NO.;
LOCATION: INSPECT ON: "—
RECHECK:
Comments and/or dia ra
Soil Type: Sand/Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft.
Well separation distance ft.
Other wells: $,
.Absorption Field: Total length ft.
Length of each trench ft. '�
Depth of trenches ft Ga /
Size of Stone
.-Seepage Pits: Number
Size: x
Stone Size:
Pi in Size Type
Building to tank
Tank to Distribution Box
Distribution Box to Field/Pit
Opening Sealed: Y/N/Partial
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as_per Plot Plan Y N
Location of System on Property:
Front Rear Left Side Right Side
Middle Front Middle Rear
System Use Status:
Approved
Patial Approved and needs to be re-inspected,please call the Building&Codes Office
isapproved
U SueHemingway\Building.Codes.[nspection.FORMS\.Septic Inspection Report.doc January 28,2003
J V
Septic Inspection Report
Office No.(518)761-8256 Date Inspection request received: '
Queensbury Building&Code Enforcement Arrive: a 'impart: am/pm
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials: t'/
NAME: Gn�Q_ PERMIT NO.: (3&/R9
LOCATION: INSPECT ON:
RECHECK:
Comments and/or diagram
Soil T :t: San /Loam! lay
Type of unicip /Well Water
Waterline sea tion d' ance ft.
Well separation&strifice 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 5 , �
Tank to Distribution Box
Distribution Box to Field/Pit
Opening Sealed: Y/N/Partial
End Caps
Location/Separations
Foundation to tank X • ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan ;' Y N
En 'neer Report and As-Built Y N
Location of Syste on Property:
;r
Front Rea Left Side Right Side
Middle Front Middle Rear
System Use Stat s•
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
Last revised 1/6/05
Septic Inspection Report
Office No. (518)761-8256 Date Inspection request received: d
Queensbury Building&Code Enforcement Arrive: am/pm Depart: %
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials:
P .f
NAME:
' '� - :._...� PERMIT NO.:
LOCATION: �—
INSPECT ON:
RECHECK: f`
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
Tank to Distribution Box
Distribution Box to Field/Pit
Opening Sealed: Y/N/Partial
End Caps
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Engineer Report and As-Built Y N
Location of System on Property:
Front Rear Left Side Right Side
Middle Front Middle Rear
System Use Status:
pproved
Partial Approved and needs to be re-inspected,please call the Building& Codes Office
Disapproved
Last revised 1/6/05