2004-051 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:. P20040051 . Date Issued: Monday, February 23, 2004
Thin is-to certify that:workere nested to=be,done-as shown b Permit Number -
ry q _ y- ---__-P20040051
has been completed.
Tax Map Number: 523400-290-000-000 1-001-00 1-0000
Location: 75 HICKS Rd
Owner: BERNARD &LAURIE MC GUIRE
Applicant: -BERNARD &LAURIE MC GUIRE
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
Director of Building&Code Enforcement
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20040051 Application Number: A20040051
Tax Map No: 523400-290-000-0001-001-001-0000
Permission is hereby granted to: 113FRNARD &T,AT TRTF,MC; GI TIRE
For property located at: 75 HICKS 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: BERNARD &LAURIE MC GUIRE
75 HICKS Rd Septic Alteration Residential
Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans&Specifications
2004-051
Septic Tank replacement only
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday, February 23, 2005
(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 of Queensbury; Monday, February 23, 2004
SIGNED BY for the Town of Queensbury.
Director of Build o 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:/ �` �
; File Pe t No'
Tax Map No. , Q
' Ril/�iE�D �C�/ � Fee Paid
Owners Name: Ct
�
Address: �/S� /`ltz)�Gks ► � GUS yQ(l
2. INSTALLER'S NAME �' — ��fV PHONE NO. ��5 �-
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 Flow
1980 0 for de x 150 gal/bdrm =
1980—1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm =
Garbage Grinder Installed yes_ / no
Spa or Hot Tub Installed yes_ ./ no LZ
4.' PARCEL INFORMATION: (circle applicable information&indicate measurements)
Topoa'a-ohy Soil Nature Ground Water Bedrock or Impervious Material Domestic Water Supply
Fat sand at what depth at what depth municipal
Rolling loam feet feet well
Steep slope cla a 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: /,CoO gallon(min. size 1,000 gat)
Tile Field: each trench ft. Total System Length: ft.
Seepage Pit(s): number of size of each: ft. by ft.
Size 9f 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.
01
Signature of responsible pe son Date
itwst of (Itiso-olt'RltuIry
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7. SIGNATURE &INFORMATION FM 1CLSiI'VNMOL4 rz"%.Fj,-4\Yuen•%o•....\:;
Septic Inspection Report
Office No. (518)761-8256 Date Inspectionceiv
Queensbury Building&Code Enforcement Arrive: at
art: a p
742 Bay Rd., Queensbury,NY 1,2804 Inspector's Initi
NAME: �j '� '� NO.:
LOCATION: ON: -- —
RECHECK:
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:,
A
Piping , 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 S tus:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:'SueHemingNvay\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
I have seen or observed, or believe I aw eviu'ence of, I
%il objects such as houses, wells, trees, fences, etc., �
s11,�ivn on this dOCUM ri, l also represent that I have
personally rn:asu fed the distances set forth on the di,--,gram."
RECEI
VED
SIGNATO—RE DATE
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TOWN OF QUEENSBURY
BUILDING AND CODE
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