2004-166 TOWN OFQUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development- Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE.' , '. .
Permit Number: P20040166 Date Issued: Thursday, APriL 15, 2004
-This-is to certify thavwork requested to.be done-as shown by Permit Number P20040166
has been completed.
Tax Map Number: 523400-301-012-0001-047-000-0000
Location: 21 BELEN Dr
Owner: MARILYN & JACK MERRY
Applicant: MARILYN& JACK MERRY
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: P20040166 Application Number: A20040166
Tax Map No: 523400-301-012-0001-047-000-0000
Permission is hereby granted to: MARILYN& JACK MF,RRY
For property located at: 21 HELEN 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: MARILYN& JACK MERRY
21 HELEN Dr Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
SANITARY SEWER
DAN DRELLOS
PO BOX 224
GLENS FALLS NY
Plans&Specifications
2004-166
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday,April 15, 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 own o uee s ury� rsda ,April 15, 2004
SIGNED BY 11 for the Town of Queensbury.
Director of Building&Code Enforcement,
Application for Permit--Septic DiSposal System
Town of Queensbury 742 Bay.toad Queensbury,NY 12804 (S18) 761-8256
1. OWNER INFORMATION: /
Location of installation: Office Use
Tax Map No. File Permit No.
/ /
�L t G�}
Owner's Name:� !� � Fee Paid�_._..,,___...__....�....._....._.........._�..._..._......�....._.._.....—..
Address: / PNP,l Ll
2. INSTALLER'S NAME ��/1 %7-P-R, Q•c. A/Lt t'CC- PHONE NO. 767.�-74
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate#bedroom(;) 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 ol.�.-.r I x 150 galibdrm =
1980— 1991 I x 130 gallbdrm - _ 3 Z3
1991 —present II x 110 galibdrax — I
Garbage Grinder Installed yes` / no
Spa or Hot Tub Installed yes / no
APR 0 8 2004
4. PARCEL INFORMATION: (circle applicable information&indicate measuremen
ttbWP10f OutEIdSBURY
T' o Sgil hkturc g1bndYLatqXc I ervi Bulgy, "\Ml, .\." u ]
sa at what depth at what depth unieipa
Rolling oam feet ______feet w
Steep slope clay 'if well;water supply
`%SXope other from anysepdc-system
depth: absorption is ft.
other
Percolation Test:. (To be completed by licensed professional engineer or architect)
Rate. minute per inch
S. PROPOSED SYSTEM; For New Constructign: 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 oach Garbage Grinder,Spa or Whirlpool Tub.
Septic Tank: I gallon(min. size 1,000 gal.)
'Isle 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: # N .l4 / depth or thickness feet
Bed System Size: NI4' x
Alternative System: �� � length and/or size ��/x' 2,0 0 S y^'/71C J
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: I Size of each: gallons /TOTA.L Capacity: gallons
Note: Alarm System and associated electrical work must be inspected by a Town approved
electrical inspection agency.
7. SIGNA71ME &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 wi respect to this application and agree to abide by these and all
req menu f the Town of zee ;bury Sanitary Sewage Disposal Ordinance.
00011, ,��-�
i9 a ure of respoinsible person Date
T00/TOOIn - %dd CC:CT 3II.L COOZ/TO/LO
Septic Inspection Report
Office No. (518)761-8256 Date Inspection reques rec ive
Queensbury Building& Code Enforcement Arrive: arli/pm ./D part:��La m
742 Bay Rd., Queensbury,NY 12804 Inspector's Initi
NAME: �Q ( �--� � P IT NO.: �-
LOCATION: n, rj '�-- 1 I'ECT ON: 44, — — "
RECHECK: r c
Comments and/or diagram
Soil T"e: and /Clay
Type of Wate . Municipa /Well Water
Waterline se •rkfion Istance ft.
Well separation distance ft.
Other.wells: ft.
Absorption Field: Total length ft.
Length of each trench ft. �
Depth of trenches
Size of Stone `
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank ,
Tank to Distribution Box
Distribution Box t ield/.Pit
Opening Seale Y Partial
Location/Separations
Foundation to tank Aft.
Foundation to absorption t.
Separation of Pits ft.
Conforms as er Plot Plan VY N
Location of System on Property:
Front Rear Left Side Right Side
Middle F Middle Rear
System Use Statu .
Approved
Partial Approved and needs to be re-inspected, please call the Building&Codes Office
Disapproved
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