2005-739 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development- Building & Codes (518) 761-8256
CERTIFI CATE OF COMPLIANCE
Permit Number: P20050739 Date Issued: Thursday, September 22, 2005
This is to certify that work requested to be done as shown by Permit Number P20050739
has been completed.
Tax Map Number: 523400-296-009-0002-053-000-0000
Location: 17 OAKWOOD Dr
Owner: JEANNE NIVARD
Applicant: JEANNE NIVARD
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,
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: P20050739 Application Number: A20050739
Tax Map No: 523400-296-009-0002-053-000-0000
Permission is hereby granted to: JF:ANNF.NIVARD
For property located at: 17 OAKWOOD 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. Type of Construction Value
Owner Address: JEANNE NIVARD
GREGORY RUNKEL Septic Alteration Residential
Total Value
17 OAKWOOD Dr
QUEENSBURY, NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
SIGNORELLI& SON
589 WEST MOUNTAIN ROAD
Oi TEENSBI TRY. NY
Plans&Specifications
2005-739
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Saturday, September 16, 2006
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at th7T0—WftNf Qu sby�y; ida September 16, 2005
SIGNED BY l for the Town of Queensbury.
Director of Building&Code Enforcement
Application for- 1'crrrrit —Septic Disposal System
I6;P11 of QNee11sbill y 74211ay Road Queenslittty, NY 12604 (518) 761-8236
I, OWNER INFORMATION:
.................................................................,.............,..,..................................
.......,.,,...
- Location of installation: .7 �,���t/ac:�J Q,Qlve orrice Use
Tax Map No. / /
irilo I'onnit No.a 1 J � / 3;
Owner's Name:__---,AI4401� 1 eo Paid Qs`
Addreor: 17 �i,44 cLlchi.] ,U,.e t a if ......................................................................................................
2. 'INSTALLER'S NAME : G All/ f , ��`��'�
PHONE NO.
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate 0 bedroom(s) and multiply 11 of
bedrooms with applicable gallons per bedroom to equal total daily flow)
Y_oar of House: No o Bvdrqqips_ x Com r11 tion = Total Daily Flow
1980 or older x 1 SO gal/bdnll = S Q
1980— 1991 x 130 gal/bdnn =
1991 —present x 110 gal/bdrnr = S
Garbage Grinder Installed yes / no
Spa or Whirlpool Installed yes / no --
y '.'s.e.l...
4. PARCEL INFORMATION: (circle applicable information & indicate measurements)
tttty tll.t9_�_ .�1lVUnd.Walvr. __ .QSI�<tCk,vr_��truaCvaV.U.a_M.a.lot.i.nl_ I c lOr,$upply
lIrrl tnrrrl rrt ►rhrN rle/►rh fit ►rlrut rlepN► n►rr►►I<1per!
Rollltrg uarrt fc'ct Jcct
Steep slope clay _ — -- I/well; tvaler suplrly
slope other f-oar any,eyrie-system
depth: absotplion Is f1.
other
Percolation Test: (To be completed by llcelr.ted llrt fe.rslonal engineer or areltitect)
Rate: tnInute per Inch
5, PROPOSED SYSTEM: for Newv Condtrucilm All individual sewage disposal systems must be designed by it licensed
professional engineer or architect (unless hlsinlled in a l'lmllliny,iltrltd al>lmrved solAivisioll), Add 250 gallatls Io the size
of llic septic lank Ind loch lield [or each Garbage(;tinder, 81);1 or Whil livol Tub,
Septic Tank: gallon (min, size 1,000 gal) j!�-K/Si
Tile Field: each trench fl. Total Systotn Length: f1.
Seepage Pit(s): number of size cfeach: r___Jt. by Jl.
Size of Stone to be toed; It / rle/►tlr or thlck►re.r,t __.__._. ...._._!i'i't
Bed System Size: x
Altemative System: 6 �L) length and/or size
6, HOLDING TANK SYSTEM: (if required)
Number of tanks: / Size of each: gallons /TOTAL Capacity: gallons
Note: Alann System send associated electrical work must be inspected by a Town approved
electrical inspection agoncy.
7. SIGNATURE & INFORMATION FOR RESPONSIBLE PERSON (please read)
For your protoction, plonse note tint pursunnt to Section 136-29 of tiro Code of ate,rowtt
of Quoonsbtrry, nny pormit or npprovnl !;ranted which is based upon or is grunted in
rolinnce upon nny rttatorial III is tell Iesentation or faituro to mnko n material fact or
cir•cumstnnco known by or on betrnlf of art applicant, shall lie void.
I have rand the roguintions with toapect to this npplicr►tion and ngroo to nliido by those and nil
roq'u'iromonts of tho Town of Queettsbury Sanitary Sowago Disposal ordinatrce.
Slgnatui- of ponsible person Date ��
Septic Inspection Report
Office No.(J18)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/ r}a�, Depart: am/pm
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials: _
NAME: ` PERMIT NO.: _ 7
3
LOCATION: INSPECT ON:
RECHECK:
Comments and/or diagram
Soil Type: o Clay
Type of Water: Municip 1/Well Water
Waterline separakonjAwrice
Well separation distance _ ft• / l ` '� ��
Other wells: 0 ft.
Absorption Field: Total len h ft. v�
Length of each trench %` ft.
Depth of trenches ft.
Size of Stone
See pa e Pits: Number
Size: x
Stone Size:
piping Size T
Building to tank /
Tank to Distribution Box .4 0
Distribution Box to Field/Pit v'
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 VY N
Engineer Report and As-Built Y N
Location of System on Property:
Front Rear Left Side ®RightSid
Middle Front Middle Rear
System Use Stat .
Use
Partial Approved and needs to be re-inspected, please call the Building&Codes Office
Disapproved
Last revised 116105
�J
Septic Inspection Report
Office No. (518)761-8256 Date Inspection request received: ' S
Queensbury Building&Code Enforcement Arrive: am/ epart: 5 a pm
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials:
NAME: �/ y r'►/L PERMIT NO.: 2 t �S�
LOCATION: 1—2 LC� CAL) L7 INSPECT ON:
RECHECK:
Comments and/or diagram
Soil Type: and Clay
T e of Wate uGniWpUf Well Water
Waterline separation istance
Well separation distance ft.Other wells:wells: ft.
Absorption Field: Total length ft.
Length of each trench ft•
Depth of trenches ft.
Size of Stone �n �
See age Pits: Number Pe-���
Size: x
Stone Size:
Piping Size Type
Building to tank 'E7>115 j l
Tank to Distribution Box '-.b Zc>
stribution Box to Field/Pit w `�
"Opening Sealed: Y/N/Partial
End Ca 3
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 Si
i
Middle Front Middle ar W• t
System Use Status:
pproved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
Last revised 116105
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SIGNORELt.I PUMING AND HEATING
DATE: NAME
ADDRESS: PHONE: ( )
ESTIMATE GIVEN FOR JOB: PAID BY: CASH CHECK ( )
TOTAL AM7 W OF JOB: JOB COMPLEMD:
DATE PLIM M TIME/PER HOUR PURIM TIME/PER HOUR DATE HELPER TIME/PER HOUR
I
MATERIAL ON 0'MM SIDE