2004-267 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: P20040267 Date Issued: Thursday, May 06, 2004
- _ This is to certify that work requested to be done as shown by Permit Number P20040267 has been completed.
Tax Map Number: 523400-301-006-0001-008-000-0000
Location: 2 VAN Ct
Owner: ROBERT &NARY SEARS
Applicant: ROBERT &MARY SEARS
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
Director of Building&Code Egforcenl&t
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20040267 Application Number: A20040267
Tax Map No: 523400-301-006-0001-008-000-0000
Permission is hereby granted to: ROBERT &MARY,SRARS
For property located at: 2 VAN Ct
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: ROBERT &MARY SEARS
HEATHER FAIR-SEARS Septic Alteration Residential
• Total Value
2 VAN Ct
QUEENSBURY,NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
SANITARY SEWER
DAN DRELLOS
PO BOX 224
GLENS FALLS NY
Plans&Specifications
2004-267
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday, May 04, 2006
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the wn b 0,ee*
ug$ , May 04,2004
SIGNED BY �VI for the Town of Queensbury.
Director of Building&Code Enforcement
Application for permit—Septle Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (S18) 761-8256
I. OWNER INFORMATION:
f Office Use
Location of installation—
Tax Map No. / / File Permit No: ()
Fee Paid' a2� rrl
Owner's Name: J'O,4-A.r-
�/'7gi.._N �UR-t� � _.__......__.._...,.._......._.....
Address: � _........_�_.._:.....�_...._.._......—..
2. INSTALLER'S NAME : JAAJ lew,U/Z,e PHONENO. 79a-Ids 7
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 or older x 150 gal/bdnn =
1980— 1991 x 130 gal/bdrm 4 t O C ��
1991 —present x 110 gal/bdrrn
Garbage Grinder Installed yes— / no "
Spa or Hot Tub Installed yes` / no0 3 2004
4. PARCEL INFORMATION: (circle applicable information&indicate measurements) TOWN OF QUEENSBURY
li
Topography d cIevi BUILDING AND CODE
lc or
a Su
at sand® at what depth at what depth muniei a
o Ing oam
feet
{eet well
.Steep slope clay 'if well;water supply
—%slope other from any sepric.-system
depth: absor
ption is ft.
other
Percolation Test:. (7'o be completed by licensed professional engineer or architect)
Rate; minute per inch
5. PROPOSED SYSTEM; Vor New Constructf2n: 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 Ieach f ld for each Garbage Grinder,Spa or Whirlpool Tub.
. zd'T/N6
Septic Tank: /00gallon(min. size 1,000 gal)
Tile Field: each trench ft. Total System Length: ft.
Seepage Pit(s)s number of size of each: fk. by fr.
Size 9f Stonc to be.used: # / depth or thickness feet
Bed System Size: x
Alternative Systems Et ep-` 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 ritake a material fact or
circumstance known by or on behalf of an applicant,shall be void.
I have a e regulations with respect to this application and agree to abide by these and all
req cments f the To o ccnsbury S tary Sewage Disposal Ordinance.
. 5 /3L .
Si na ure of re nsible person Date
T00/T00 Q21 Yv3 ec:CT 311.E CUOZ/TO/LO
�'Q�J"ti or- QUEENS" �liRY o ,mom Q�
IF
se pr,
BUILDING & O T
REVIEWED BY
DATE �f----
a
(4 1 -
2,- VW Gam ' RECEIVED
1viAY 0 3 2004
VIIN OF QUEENSBURY
"I have seen or observed, or believe I saw evidence of, UILDING AND GODS
all objects such as houses, wells, trees, fences, etc.,
gperall
his document. I also represent that I have.
measuig he distances set forth on the diagram."
S`-3-0 y
SIGNATURE DATE
,,
Septic Inspection Report
Office No. (518)761-8256 Date Inspection request eceived:
Queensbury Building& Code.Enforcement Arrive: a p epart � am/pm
742 Bay Rd., Queensbuly,NY 1,2804 Inspector's Initials:
NAME: PERMIT NO.:
LOCATION: Cil — INSPECT ON:
RECHECK:
Comments and/or diagram
Soil T e: ay
T e of Watel Munici Well Water
Waterline separation distance ft.
Well separation distance ft.
Other wells: ft,
Absorption Field: Total length ft.
Length of each trench UN ft.
Depth of trenches ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping S i,7.eT e
Building to tank
Tank to Distributio4 Box
Distribution Bo to field/Pit v L
Opening Seale l Y/N/Partial
Location/Separations
Foundation to tank
Foundation to absorption ft.
Separation of Pits ft.
Conforms as_per Plot Plan VY N
Locatio ystem on Property:
Fron Rear Left Side Right Side
Middle Front iddle Rear
S stem Use Stat
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:\SueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003