94-391 -
. CERTIFICATE OF COMPLIANCE
TOWN OF QUEENSBURY
WARREN COUNTY, NEW YORK
Date at91/ /9 19
This is to certify that work requested to be done as shown by Permit No. 4'/-,39/J
has been completed.
This structure may be used as a . tv/i7c —1/5+ 'o
Location e7k,yerelaje A9d.
Owner A.A. -BrneAL
��_�,/� By Order of Town Board
TOW F QUEENSBURY
f —
Director of Building & Code Enforcement
BUILDING PERMIT
TOWN OF QUEENSBURY No. gy_39/
WARREN COUNTY, NEW YORK
PERMISSION is hereby granted to J2W4/ A H/ecex (4
OWNER of property located at C)/everda/e- X?7 Street,Road or Ave. °0
in the Town of Queensbury,To Construct or place a /7 C fe-/V- /0/? '1
at the above location in accordance to application together with plot plans and other information hereto filed and •
approved and in compliance with the Town of Queensbury Building and Zoning Ordinance.
1. OWNER'S Address is
/e;® OA' .Zog
e/eyes-da/e. /v)/ / Z 2 )
2. CONTRACTOR or BUILDER'S Name k
"f� �'l2/9/77//
3. CONTRACTOR or BUILDER'S Address
4. ARCHITECT'S Name
5. ARCHITECTS Address
6. TYPE of Construction—(Please indicate by X)
1 )Wood Frame ( ) Masonry ( )Steel ( ) t\
7. PLANS and Specifications
.5EP.77 XL — M'770/✓ Ta //1/CGt,C.dE -Se/ohL
No. 250 f of T1Pt4� a}' ' /en?y/4 s its %/ply'Plai7
a rc/ 4,2/i`cet io'
8. Proposed Use
$4 i' c ,sys/ 7
(11
PERMIT FEE PAID —THIS PERMIT EXPIRES Jell/ 20 19 94, (l`
(If a longer period is required an application for an extension must be made to the Building and Zoning inspector of the
town of Queensbury before the expiration date.)
Dated at the Town of Queensbury this 20 a f ✓ ' 19 Q
SIGNED BY for the Town of Queensbury
Building and Zoning In r
�� /3-3-/I
Avj TOWN OF QUEENSBURY 3y /
APPLICATION FOR SEPTIC DISPOSAL PERMIT Perms #
Fee/Paid ,
r 1994
Date: / Rev awed By� -
Receivefd
LOCATI OF PROPERTY FOR INSTALLATION: �I,�LL�/�I�.q�,� / QUecns���ry
Owner' s Name: .JGfi(ti , 4 G.
Owner's Mailing Address: PC, lty / 2 if"-ZG
Installers Name: Cart IS C, - 'o' " Phone #: 733-- oYJI
Number of bedrooms (if residential ):
Total daily flow (residential-compute @ 150 gal . per bedroom) : DSO
Topography-Circle One: Rolling Steep Slope % of Slope
Soil Nature-Circle One: Sand �oam Clay Other /Depth:
Ground Water-At What Depth? y( Feet
Bedrock or Impervious Material-At What Depth? Lt,Qk,vo tJJ Feet
Percolation Test-Circle One: Not Required Required/Rate CP- Min. Per Inch
Domestic Water Supply-Circle One: Municipal Well Other _ G 1/TC C eo4-0 C
If domestic water supply is a well -
Separation: Water supply from any septic absorption 3Oo feet
PROPOSED SYSTEM: Septic Tank 45-ggal . (Minimum size: 1,000 gal . )
Tile Field: Each Trench se) feet//Total System Length _,_'a feet
Seepage Pit(s) : Number of / Size each: — ft. x
Size of Stone to be used: # / Depth or Thickness / feet
**************
HOLDING TANK SYSTEM IF REQUIRED
No. of Tanks Size\of Each Gal .
Alarm system and associated electrical work to be inspected by a certified
agency.
****************
I have read the regulation on the reverse side of this sheet and agree to abide
by these and all requirements of the Town of Queensbury Sanitary Sewage Disposal
Ordinance.
SIGNATURE OF RESPONSIBLE PERSON: DATE: �� l
\/
I
Septic System Inspections:
A. All applications for septic system installation, alteration or repair,
as required by the Town of Queensbury Sanitary Sewage Ordinance, shall
be submitted to the Building Department at least 24 hours before start
of construction and shall include a plot plan showing:
1) the proposed location of the system
2) location and distance to lot lines
3) location and distance to structures
4) location and distance to any water supply
5) size and dimensions of all tanks, distribution boxes, tile fields
and/or drywells
B. No system shall be covered before inspection and approval by the Building
Inspector. Failure to comply with this requirement may result in the
uncovering of the system by the installer and a fine of up to $250.00.
C. An approved copy of the plot plan shall be available on the construction
site. Failure to produce said plot plan at time of inspection may result
in an immediate work stoppage.
D. Should unforeseen problems during construction prevent proper installation,
alteration or repair of an approved system, a new proposal must be submitted
to the Queensbury Building Department before further construction.
Town of Queensbury
Building & Code Enforcement
Department
531 Bay Road
Queensbury NY 12804
Remarks:
TOWN OF QUEENSBURY ).7
BUILDING & CODE ENFORCEMENT
531 Bay Road
Queensbury NY 12804
518-745-4447
SEPTIC DISPOSAL SYSTEM INSPECTION
Name '
Location
Date , f lgII { Permit # 4174-3V/
SOIL TYPE: Sand-Loam-Clay-
Results of Percolation Test-
(if applicable) Rate-Minute/Inch
TYPE OF SYSTEM:
ABSORPTION FIELD: Total Len th ,2 a )
Length of each trench )b`
Depth of trenches
Size of stone 3
SEEPAGE PITS: Num r
Size - f � ft.
Stone size , /Y
PIPING: Size Type
Bldg. to Tank : Size
Tank to Dist. Box -
Dist. Box to Field/Pi 'C�<-
Openings Sealed? 40 No,- Partial
LOCATION/SEPARATIONS: 1,
Foundation to Tank feet
Foundation to Absorption feet
Separation of Pits
Conforms as per Plof P1 -- ' i;)feet
No
LOCATION OF SYSTEM ON POPERTY:
(circle , /
Front -Re.-"- Left Side - Right Side,/
Middle Front - Middl'e Rear
COMMENTS: ,4
SYS USE APPROVED: a
Arrived: n,_.W
Departed: /cL
Building Inspector
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'1c TOWN OF QUEENSBURY
BUILDING COD DEPT..
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DATE
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