2005-489 TOWN OF QUEENSBURY
742 Bay Road,Queensburq,NY 12804-5902 (518) 761-8201
Community Development -Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20050489 Date Issued: Tuesday, July 05, 2005
This is to certify that work requested to be done as shown by Permit Number P20050489
has been completed.
Tax Map Number: 523400-297-017-0001-078-000-0000
Location: 59 MEADOW VIEW Rd
Owner: DANIEL & THERESA ANDERSON
Applicant: DANIEL & THERESA ANDERSON
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
property owner of the responsibility for compliance with Site Plan, jW
4 t
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: P20050489 Application Number: A20050489
Tax Map No: 523400-297-017-0001-078-000-0000
Permission is hereby granted to: DANIEL & THERESA ANDERSON
For property located at: 59 MEADOW VIEW 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: DANIEL & THERESA ANDERSON
59 MEADOW VIEW Rd Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804-0000
Contractor or Builder's Name /Address Electrical Inspection Agency
IBS SEPTIC & DRAIN
ATTN: IVAN BELL
2 LOWER WARREN St
OITEENSBITRY_ NY 12804
Plans&Specifications
2005-489
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID -THIS PERMIT EXPIRES: Wednesday, July 05, 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 ueen ury; ues , ul 592005
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:
...........................................................................
` Office Use
Location of installation: C'C �f 1`d
File Permit No.
Tax Map No. F1 aQ
Owner's Name: Al
Address: " nJ
TOWN 0I `ri — s'S I3UFZY
BUILDING,� vD ODE
2. INSTALLER'S NAME PHONE NO.
3. RESIDENCE INFORMATION: (circle year of Xelling,indicate#bedroom(s) and multiply#of
bedrooms with applicable gallons per bedroom to equal total daily flow)
Year of House: No. of Bedrooms x Comuutation = Total Daily Flow
1980 or older x 150 gal/bdrm =
1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gaUbdrm =
Garbage Grinder Installed yes_ / no
Spa or Hot Tub Installed yes / no
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
ZP.,.omDhv aa#Nature Ground War Bedrock or Impervious Material Domestic Water So ply
Flat sand at=a� th at w at pth municipal
ang m t eet well
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: 1l on(man. size 1,000 gal.)ga
Tile Field: each trench S ft. Total System Length:_
Seepage Pit(s): number of size of each: ft. by ft.
Size of Stone to be used: # / 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.
Si ure Date
of res n ble perso
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Own of Ouoeliainli•y
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7, SIGNATURE &INFORMATION FM xlUN;sWL4 rz^owo \pAvo"..,..,v
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THIS PLAN TO BE ON .3O � go
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PROJECT SITE'AT One��, ..
ALL TIMES FORoan�
THE DURATION OF �G $ab
CONSTRUCTION
TG fVN 0I+QUEENSK RY BUILDING DER°,RT; NT
y Based on our limited examination,
conliance withour comments aiqg il TOWN OF Q U E E N S B U RY
plans and specifications are in full
compliance with,the Building Codes BUILDING-, & OD S D E P T.
,,f N\�w Yc;rr Sr„te.
REVIEWED Y
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Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/ m Depart: m
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials:
NAME: P PERMIT NO.: l
LOCATION: It<q > INSPECT ON:
RECHECK:
Comments and/or diagram
Soil Typei aadWLoam/Clay
Type of Water: unici al Well Water
Waterline separation distance
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length '2 ft.
Length of each trench - ft.
_Depth of trenches "Z.— ft.
Size of Stone
-Seepage Pits: Number
Size: x
Stone Size:
Piping Size Tyee
Building to tank
Tank to Distribution Box Al IS—
Distribution Box to Field/Pit a`
Opening Sealed: Y/N/Partial
End Cap* tl--
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan V Y N
Engineer Report and As-Built Y N
Location of System on Property:
Front Rear Left Side fight Side
Middle Fro Middle Rear
S stem Use St s•
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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