2004-179 � 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: ._ .P-20040179 Date Issued: Wednesday, April 21, 2004
__. - --.This-is,to:certify thatwork re-quested-to-be-.-done as shown-by:Permit Number P20040179
has been completed.
Tax Map Number: 523400-301-007-0002-028-000-0000 i
Location: 244 AVIATION Rd
Owner: DAVID BOWMAN
Applicant: DAVID BOVINLAN .
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: P20040179 Application Number: A20040179
Tax Map No: 523400-301-007-0002-028-000-0000
Permission is hereby granted to: DAV D BOWMAN
For property located at: 244 AVIATION 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: SANDRA L REARDON
55 DREAM LAKE Rd Septic Alteration Residential
Total Value
LAKE GEORGE, NY 12845
Contractor or Builder's Name /Address Electrical Inspection Agency
OTTEENSBITRY SEWER
JAY SWEET
Plans&Specifications
2004-179 SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday, April 14, 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 o nsbury; We s y,April 14, 2004
SIGNED BY for the Town of Queensbury.
r .Y
Director of Building&Co e En ement
Application for Permit-Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
Location of installation:
Office Use
f File Permit No.
Tax Map No.
Fee Paid c2, . '
Owner's Name:
.....................................................................................................,.
t F`
Address
2. INSTALLER'S NAME : PHONE NO.
3. RESIDENCE INFORMAT (ca- e year of dwelling, indicate#bedroom(s) and multipC L�z Vet)
fwrF
bedrooms with applicable gallons per bedroom to equal total daily f tow)
Year of House: No. of Bedrooms x Com utation = Total Dad' Flow APR J poi
owiv OF�aUc
1980 o 991r x 130 g IIal/bdrm = �/�®/�' C0U RY
E
1991 —present x 110 gal/bdrm =
Garbage Grinder Installed yes ( c�
Spa or Hot Tub Installed yes_ /
4: PARCEL INFORMATION: (circle applicable information&indicate measurements)
Topography Soil Nature Ground Water Bedrock or Impervious Material Domestic Water Supply
sa at what depth at what depth unici
Rolling loam feet feet well
Steep slope clay if 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: /j1�gallon (min. size ],000 gal.)
Tile Field: each trench ft. Total System Length: 42 ) 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: /11 Ti •fC(S 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 woik 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.
Signs tar of responsible person Date
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection re est r eiv d:
Queensbury Building&Code Enforcement Arrive: m/p epart: j- am m
742 Bay Rd., Queensbury,NY 12804 Inspector's Initial : G
NAME: (�(�1.1 PE' IT NO.: 7�O�— —7
LOCATION: ��j�} �� _� IN ECT ON:
RECHECK:
Comments and/or diagram
Soil Type: an Loam/Clay
Type of Water• Municipa /Well Water
Waterline separation distance _ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length
Length of each trench ft.
Depth of trenches —
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank r
Tank to Distribution Box io
Distribution Box 5x�
ield/Pit ati _ -MOpening Sealed /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 C.ightde
Middle Front E=iddleRear
System Use St_a��is:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
LASueHemingway\Building.Codes.Inspection.FORMS\,Septic Inspection Report.doc Januaiy 28,2003
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"I have seen or observed, or believe I save evidence of,
all obiects such as houses, wells, trees, fences, etc.,
shown on this document. I also represent that I have
personally measured the di, Prices set 'orth on the diagram."
S GNATURE DATE
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i have seen or observed or belie5ie I saw evidec?ce of,
fail F,i-31 ects such as houses, yells, trees, fences, ?tc.,
on this document, I also represent tha- I have �
nor ally measured tl� istances set s rth on the di{s� am,"
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SIGNATURE DATA _._..� \
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