2005-559 TOWN OF QUEENSBURY
742 Bay Road,Queensburp,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFI CATE OF COMPLIANCE
Permit Number: P20050559 Date Issued: Wednesday, August 10, 2005
This is to certify that work requested to be done as shown by Permit Number P20050559
has been completed.
Tax Map Number: 523400-295-006-0001-025-000-0000
Location: 8 JACQUELINE Dr
Owner: WILLIAM & MEREBETH VANDERMINDEN
Applicant: WILLIAM & MEREBETH VANDERMINDEN
This structure may be occupied as a:
Septic Alteration Residential
By Order of Town Board
OF EENSBURx
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: P20050559 Application Number: A20050559
Tax Map No: 523400-295-006-0001-025-000-0000
Permission is hereby granted to: WILLTAM& MF,REBETH VANDF,RMTNDF,N
For property located at: 8 JACQUELINE Dr
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: WILLIAM&MEREBETH VANDER
8 JACQUELINE Dr Septic Alteration Residential
Total Value
QUEENSBURY,NY 12804-0000
Contractor or Builders Name /Address Electrical Inspection Agency
OT TEENSBT TRY SEWER
NY 12804-0000
Plans&Specifications
2005-559
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday,August 02, 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 T wn of M711
AILV*August 02, 2005
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
.2-(--�0 5_ S-
Application for Permit— Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury, NY 12804 (518) 761-8256
1. OWNER INFORMATION:
:.....................................................................................................................................
114
Location of installation: �1 ,
File Permit No,
Tax Map No.
�- -!
Fee Paid t t
Owner's Name. ` .I r [l t W-- cd K n j- jyl� i rr
:......... ,, ... ..... .... .
Address: ��� r � r-2 U e f/ yLQ p �. _---
— �jJ �/
2. INSTALLER'S NAME PHONE NO. �T �,? ,
3. RESIDENCE INFORMATION: (circle year of dwel ing, 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 =
l9-&L---L991 x 130 gal/bdrm =
eLP--r:eS:e:n3 x 110 gal/bdrm =
Garbage Grinder Installed yes_ / no
Spa or Hot Tub Installed yes, J no
4. PARCEL INFORMATION: (circle applicable information& indicate measurements)
Topog_raihy Soil Nature Ground Water Bedrock or Impervious Material Domestic Water Supply
Fl san at what depth at what depth unicipal
--------------
Rolling loam feet feet well
Steep slope clay if well; water supply
^%slope other from any septic-.system
depth: absorption is f t.
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 sceptic tank and leach field for each Garbage Grinder. Spa or Whirlpool Tub,
kl
Septic Tank: gallon (min. size 1,000 gal.)
Tile Field: each trench-!G`-t—�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: 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.
1 74o f - s
Signatl4re P1 responsib e person Date
" r
Septic Inspection Report
Office No. (518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/ epart: am/pm
742 Bay Rd., Queensbury NY 12804 ector's Initials:
NAME: VA� G �/1 'Ins PERMIT NO.:
LOCATION: \ /Z - INSPECT ON: to 0,
RECHECK:
Comments and/or diagram
Soil T *eMunicipaj/.
m/ la
T e ofWell Water
Waterline sea tion djsdnoe ft.
Well separation distance ft.
Other wells. $,
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 ` lS
Tank to DistributA Box
Distribution Box A rield/Pit •+ Eye r�
Opening Sealed: Nrtial
End Caps
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
En ineer Report and As-Built Y N
Location of System on Property:
Front Rear Left Side Right Side
Middle Front Middle Rear
S stem Use Stat 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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