2004-566 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20040566 Application Number: A20040566
Tax Map No: 523400-309-009-0003-041-000-0000
Permission is hereby granted to: JACK ALYN RATHBITN
For property located at:. 50 CONNECTICUT Ave
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: JACKALYN RATHBUN
50 CONNECTICUT Ave Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804-0000
Contractor or Builder's Name /Address Electrical Inspection Agency
FREDERICK SMITH
23 VERMONT Ave
OITEENSBITRY_ NY 12804-0000
Plans&Specifications
2004-566
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday, July 22, 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 To ensb T /Sd y, July 22, 2004
SIGNED BY for the Town of Queensbury.
Director of Building& ode En rcement
' Application for Perniit—Septic Disposal System
Town of Queeiisbuty 742 Day Road Queensbury, NY 12604 (518) 761-8256
1. OWNER INFORMATION: '
.........:...................................,.......,..,........,,.......................,,..,,.................... .
orr�e use
- Location of installation:
File Pennit No. L
Tax Map No. sJ ,1 lqOwner aNamer G 01,I!
Foe Paid.....,.... „o`>........................................................
Address: 0 C) nC 2. 'INSTALLERS NAME :„!/�L' U - Stla— PHONE NO. 9 U 0 �
3. RESIDENCE INFORMATION: (circleyear of dwelling, indicate ff bedrooth(s) and multiply N 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 I5O gal/bdnn = 0
1980— 1991 . x 130 gal/bdrm =
1991 —present x l 10 gal/bdrm
Garbage Grinder Installed yes_ / no v , RECEIVED
Spa or Whirlpool Installed yes_ / no
JULA ?004
4. PARCEL INFORMATION: (circle applicable information & indicate measuref@WOF QUEENSSURY
BUILDINGAND COD�F '
96[r!li21 ILLSlt9 .1-9.0 d 1?ti10 . _09drQCk..Qr�inpofYl_4_l! �4Qri�'1 -- W.5411)ply
1la .ran at what depth (it what cJepth �► rntetpa
Ing oam feel feet w
Steep slope clay if well; water supply
slope other from any septic-system
depth: absorption is fl.
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 n licensed
professional engineer or architect(unless installed in a Planning Hoard approved subdivision). Add 250 gallons to Iltc sire
of the septic lank and leach field for each Garbage Grinder, Spa or Whirlpool Tub.
Septic Tank: 0 gallon (min. size 1,000 gal.)
Tile Field: each trench ft. . Total System Length: fl.
Seepage,Pit(s): number of � size of each. 11 fT. by fl.
Size of Stone to be used: It _ / depth or thickness.'___
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 n 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 thelso and all
requirements of th wn of Queensbury Sanitary Sewage Disposal Ordinance.
gna ure of responsible'person Date
I
Septic Inspection Report
p P P
Office No. (518)761-8256 Date Inspection request received: /
Queensbury Building&Code Enforcement Arrive: am/ art: ?,S am/pin
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials:
NAME: L, PERMIT NO.: OLl
LOCATION: r INSPECT ON: f7 �—��{
RECHECK: /
Comments and/or diaEram
Soil Type: Sa o m lay
Type of Wa err: NunicipaV Well Water
Waterline separa ' stance _ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenches ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size,, Typej
Building to tank
Tank to Distribution Box
Distribution Box t Field/Pit
Opening Seale N/Partial
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan VY N
Location of System Property: .
Front Rear eft Side Right Side
Middle Fro t Middle Rear
S stem Use Sta s•
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
LASueHemingway\Building.Codes.In spection.FORMS\Septic Inspection Report.doc January 28,2003
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TOWN OF QUEENS URY
BU LDIN AND C DE
"I have seen or observed, or believe I saw evidence of,
all obiects such as houses, wells, trees, fences, etc.,
sh01MYR r{ urnent. I also represent that I have
ured th distances set forth on the diagram." -�
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