2004-357 TOWN OF QUEENSBURY
742 Bay Road,Queensburv,NY 12804-5902 (518)761-8201
Community Development - Building& Codes (518) 761-8256
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CERTIFICATE OF COMPLIANCE
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Permit Number: P20040357 Date Issued: Thursday, May 27, 2004
This is to certify that work requested to be done as shown by Permit Number P20040357
has been completed.
Tax Map Number:, 523400-308-005-0001 077-015-0000
Location: 116 LAUREL Ln
Owner: GARY HOWARD
Applicant:
GARY HOWARD
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
Director of Building&Code Enforcement
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TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20040357 Application Number: A20040357
Tax Map No: 523400-308-005-0001-077-015-0000
Permission is hereby granted to: GARY HnWARD
For property located at: 116 LAUREL Ln
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. 1' ! Type of Construction Value
Owner Address: GARY HOWARD
Septic Alteration Residential
NUCHELLE LA ROSE
116 LAUREL Ln Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
OUEENSBI TRY SEWER
JAY SWEET
Plans&Specifications
2004-357
SEPTIC ALTERATION
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$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday, May 26, 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 f Que b Sday, May 26, 2004
( J)
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
RECE
Application for Permit=Septic Disposal System WED
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256 tYiH 2 4 2004
1. OWNER INFORMATION: ,�OWW DF
....................................................... . .. . . ........................
Off s QUEENSBURl
Location of installation: / / �,c�- r / , ) `�iNGN1J GODS
/ ! I �Y�`
File Permit No.
Tax Map No.
Owner's Name: : Fee Paid
Address: �� /-. li �c� 1 ��� ........................................................................................................................................
ep--�k PHONE NO
2. INSTALLER'S NAME �t�.�l(LAc � .
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/bdrm =
1980- 1991 x 130 gal/bdrm =
1991 -p esent x 110 gal/bdrm =
Garbage Grinder Installed (-yes,,'— / no
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 So ply
(::�ND and at what depth at what depth unicipa
Rolling loam feet feet we
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: gallon (min. size 1,000 gal) Z 1 t�Es i✓v� CS t
Tile Field: each trench ft. Total System Length: / (p ft. t
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: f C? "0L) 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 Se age Disposal Ordinance.
Sig atu a of espons- le person Date
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Septic Inspection Report
Office No. (518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: a Depart: '—am/p
742 Bay Rd.,Queensbuty,NY 12804 Ili pector's Initials: m
NAME: PERMIT NO.: 0 11-1 f 35
LOCATION: INSPECT ON: L
RECHECK:
Comments and/or diagram
Soil Type: Clay
T e of Water:, unici 1 -�Well Water
Waterline separation distance _ft.
Well separation distance ft.
Other wells: ft,
Absorption Field: Total len h GL ft.
Length of each trench ft.
Depth of trenches ft.
Size of Stone J 6-
Seepage Pits: Number
Size: x
Stone Size:
Piping Size T e
Building to tank
Tank to Distribu 'on Box t .5
Distribution Bo Field/Pit
Opening Seale /N/Partial
Location/Separations
Foundation to tank 4/
Foundation to_absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan VY N
Location of Syste on Property:
Front ear Left Side Right Side
Middle Front Middle Rear
System Use Sta s:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
LASucHemingway\Building.Codes.Gispection.FORMS\,Septic Inspection Report.doc January 28,2003
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To y i or �� ��l �h� ,� "i have seen or observed, or believe I saw evidence of,
'��'�`"�' I�.,E.�t`4't` all objects such as houses, wells, trees, fences, etc.,
13UILDING C ® Y shown on this document. I also represent that I have
REVIEWED B perso measured the lances set forth on the diagram."
DATE �.� v
I [NATURE DATE
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