2004-348 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development- Building & Codes (518) 761-8256
CE-'uL%."-rLIFI CATE OF COMPLIANCE
Permit Number: P20040348 Date Issued: Tuesday, May 25, 2004
This is to certify that work requested to be done as shown by Permit Number P2004.0348
has been completed.
Tax Map Number: 523400-296-013-0001-005-000-0000
Location: 1 KENDRICK Rd
Owner: GALL DE GREGORIO
Applicant: GAIL DE GREGORIO
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: P20040348 Application Number: A20040348
Tax Map No: 523400-296-013-0001-005-000-0000
Permission is hereby granted to: GAIT.DF, GRFG0RT0
For property located at: 1 KENDRICK 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: GAIL DE GREGORIO Septic Alteration Residential
8 KENDRICK St Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
OITEENSBITRY SEWER
JAY SWEET
Plans&Specifications
2004-348
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Tuesday,May 24, 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. ensbI onday, May 24, 2004
r'
SIGNED I Y /° for the Town of Queensbury.
Director of Bui ding&&de Enforcement
Application for Permit'-Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury, NY 12804 (518) 761-8256
1. OWNER INFORMATION:
f _ f ..............................................................................................:.........................................
Location of installation: / /��P i1 cjy r Office Use��11(
File Permit No. J6 V
Tax Map No.
Fee Paid
as,
Owner's Name:CSC{_ t L�'Li-, rL d
�. .......................................................................................................................................
Address:
2. INSTALLER'S NAME Q PHONE NO., _
r—3. RESIDENCE INFORMATION: (circle year of dwelling, ' icate#bedroom(s) and multipl # ��Lj
bedrooms with applicable gallons per bedroom to equal total dailyow)
7v�y 2 7 200
Year of House: No. of Bedrooms x Com utation = Total Dail -Row 4
wrJ OF c
SU1►�1;�1 Q1J ENSSURy
19;�rjqq,of a �_ x 150 gal/bdrm = S`Z��-- �_D(;ppE
1 — x 130 gal/bdrm =
1991 —present x 110 gal/bdrm =
Garbage Grinder Installed yes_ n
Spa or Hot Tub Installed yes_
4: PARCEL INFORMATION: (circle applicable information&indicate measurements)
Topogrgphy SaiiNature Ground Water Bedrock or Impervious Material . Domestic Water So ply
Fl Qand at what depth at what depth municipa
Rolling loam feet feet
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: /&ZYZ� gallon (min. size 1,000 gal)
Field: each trench 6'� t. Total System Length: t.
.f Y .f
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: 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.
—
Signat e 6f responsible person Date
tr• .
'ti Qwn of Queellsbut•V
sq%vcra alai Sc;w=ij;c: Disposal (:11111)((`1•
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7. SIGNATURE &INFORMATION FOR USYvNMOLro r>✓Pz"z-4 WI-A-.0 aw-%v ' ;
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received: S� 4
Queensbury Building&Code Enforcement Arrive: am/p epart: m/pm
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials: —L=—
NAME: h` PERMIT NO.: �?,06
LOCATION: J INSPECT ON: S- S a
RECHECK:
Continents a>nd/or diagram
Soil T e: arjk Toa lay
TypeofWa • Municipal Well Water
Waterline sepa ation dist ce
Well separation ce ft.
Other wells: ft,
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenches 7i ft.
Size of Stone
-Seepage Pits: Number
Size: x
Stone Size:
Piping Si Type
Building to tank 3
Tank to Distributio Box �' H
Distribution Box o eld/Pit 61
Opening Sealeq Y/ /Partial
Location/Separations
Foundation to tank 0 ft.
Foundation to absorption ft.
Separation of Pits Z ft.
Conforms as per Plot Plan N
Location of System n Property:
Front Rear Left Side Right Side
Middle Fro Middle Rear
S stem Use Sta s:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
LASueHemingway\Buildino.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
PLAN TO Br-
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CIO 'n13UI `NO �
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REVIE ED By
DATE
-.� t U"I'V t c OIJEENSBURY WI►GiNG DEPARTMENT
B -sad on our limited examination, (`t
o c mppliancp with our comments shall
n t be construed as indicating the
pi ns and specifications are in full
c •npiiance with the Building Codes 4�
of'dew York State.
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