2004-505 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:' P20040505 Date Issued: Thursday, July 01, 2004
This is to certify that work requested to be done as shown by Permit Number P20040505
has been completed.
Tax Map Number: 523400-301-007-0002-025-000-0000
Location: 258 AVIATION Rd
Owner: PATRICIA MC GOVERN
Applicant: RAYMOND &PATRICIA MC COY
This structure may be occupied as a:
Septic Alteration Residential
By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the
property owner of the responsibility for compliance with Site Plan,
Variance, or other issues and conditions as a result of approvals by the Director of Building&Code Enforcement
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20040505 Application Number: A20040505
Tax Map No: 523400-301-007-0002-025-000-0000
Permission is hereby granted to: RAYMOND &PATRTC;TA MC; COY
For property located at: 258 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: RAYMOND &PATRICIA MC COY
196 HINDS Rd Septic Alteration Residential
Total Value
FORT EDWARD, NY 12828-0000
Contractor or Builder's Name /Address Electrical Inspection Agency
SANITARY SEWER
DAN DRELLOS
PO BOX 224
GLENS FALLS NY
Plans&Specifications
2004-505
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday, June 30, 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 T n of z
y, June 30, 2004
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
is
s
AppRcation for Per —Septic Disposal system
Town ofQueensbur-y 742 Bay Road Queensbury, pry 12804 (S18) 761-8256
.' 1. OWNER INFORMATION:
Location of installation: �U l �,_J (� Office Use�~
Tax Map No. / / File Permit No.
Owner's Name: GD + Fee Paid
Address: s V ,1-%/- ' 12 b
1,,..__,,,.__..._....._......_....._......___._ ._....�_.._.._....._
2• INSTALLER'S NAME
NO.' 9-a
3• RESIDENCE INFORM,47WN: (circle ear of dwelling,indtcatd#bedroom(s) and multiply#of
bedrooms with applicable gallons per bedroom to equal total daily flow)
Yea Houm h1o, of Bed s C
Oil
1 ail w
1980 or older x 150 gal/bdrm yS�O
1980— 1991 : x 130 gal/bdrm
1991 —present x 110 gal/bdrzn
Garbage Grinder Installed yes / no
Spa or lot Tub Installed yes` / no
4• PARCEL INFORMATION: (circle applicable information&indicate mess
o a and Bedrock Im ervio at
Flat sa at what depth at what depth c Wa Su ]
j oiling o a
feet
Steep slope clay !_ feet wei
%slope other TOWN OF U • Ntersupply
depth: BUILDIN 3A ® sepzlc-system
sorption is ft.
Percolation Test: (To be completed by licensed professional engineer or architect) other
Rate: minute per inch
5. PROPOSED SYSTEM; For New _n.,�t�•Uctpon: 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 field for each Garbage Grinder,Spa or Whirlpool Tub,
Septic Tank:, gallon(min, size 1,000 gal,) �ivLTfL�iTO(ZJ'
Tile Field: each trench ft, Total System Length: d Q
Seepage Pit(s): number of1U /A" size of each: ft• b
— y 'fr.
Size 9f Stone to be used: # /1V A / depth or thicloress feet
Bed System,Size: /! x
Alternative System: JJ /1 length and/or size
6. HOLDING TANK SYSTEM:.(if required)
Number of tanks: l Size of each gallons /TOTAL Capacity: gallons
Nate: Alarm System and associated electrical work must be inspected by a Town approved
electrical inspection agency.
7. SIGNA71YRIS &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 appl' on and agree to abidckhy these and all
requirements of the Town of Queensbury Sanitar§Sewa Disposal Ordinan
Septic Inspection Report
Office No. (518)761-8256. Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/p 0 epart: am/pm
742 Bay Rd., Queensbuly,NY 12804 Inspector's Initials: y�`J"� �l
NAME: PERMIT NO.: v 9 5 `
LOCATION: d INSPECT ON: �
RECHECK: /
Comments and/or diagram
Soil T yp e:k Sa / am/ lay
Type of Wa Municipal/Well Water
Waterline se aration dis ce _ft.
Well separati distanc _ft.
Other wells: ft.
Absorption Field: Total length ft,
Length of each trench ft.
Depth of trenches ft.
Size of Stone & v �v�
Seepage Pits: Number
Size: x
Stone Size:
Piping Sizq Type
Building to tank e.10Q
Tank to Distribution Box •�
Distribution Box Field/Pit
Opening Sealed: Y/N/Partial
Location/Separations /
Foundation to tank
Foundation to absorption ft.
Separation of Pits
Conforms as per Plot Plan Y N
Location of Syste on Property:
Front Rea Left Side Right Side
Middle ront fiddle Rear
S stem TJse Statu
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 January 28,2003
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REVIEWED BY EC B VE®
DATE o JUN 2
2004
�D IN
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"I have seen or observed, or believe I saw evident, of, 1
all objects such as houses, wells,trees, fences, etc ,
shown on this document. I also represent that I ha e
z nall, measu stances set for h on th diagram."
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SIGNATURE ATE