2004-616 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: P20040616 Date Issued: Tuesday, August 10, 2004
This is to certify that work requested to be done as shown by Permit Number P20040616
has been completed.
Tax Map Number: 523400-296-013-0001-077-000-0000
Location: 87 MONTRAY Rd
Owner: LUCILLE A MUNOZ
Applicant: LUCILLE A MUNOZ
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
Director of Building&Co a Enf ement
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20040616 Application Number: A20040616
Tax Map No: 523400-296-013-0001-077-000-0000
Permission is hereby granted to: T J TC;TT,T,F, A MT TNOZ
For property located at: 87 MONTRAY Rd
m 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: LUCILLE A MUNOZ
87 MONTRAY Rd Septic Alteration Residential
Total Value
QUEENSBURY,N.Y. 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
MORNING STAR
Plans&Specifications
2004-616
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Tuesday,August 09, 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 sby; nday,August 09, 2004
SIGNED BY ao for the Town of Queensbury.
Director of Building&Code Enforcement
Application for Permit=Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION: ........... ............................................. ............... .....................
Office Use
Location of installation:
File Permit No. 04-W
Tax Map No.
Fee Paid
Owner's Name:
.................................................................................................... ............................
Address:
2. INSTALLER'S NAME PHONE NO. C-)
LJ
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 q x 150 gal/bdrm. =
1980- 1991 x 130 gal/bdrm. =
1991 —present x 110 gal/bdrrn = rnr-nE:1VELj
Garbage Grinder Installed yes no'--
Spa or Hot Tub Installed yes no AUG 0 6 Z004
TOWN OF QUEENSBURY
4.' PARCEL INFORMATION: (circle applicable information&indicate measureme '2 AND CODE
Tppogrgphy Soil Nature Ground Water Bedrock or Impervious Material Domestic Water Supply
(1
sa at what depth at what depth mu cipal Rolling ga� (2aRF —feet feet s
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.)
Tile Field: each trench 5-0 ft. Total System Length:
Seepage Pit(s): number of size of each: _ft. by_ft.
Size Qf 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 Que sbury Sanitary Sewage Disposal Ordinance.
Signature of rbsponsible person Date
1"owtt of Que(Illsbu,ry
�tnvc:rs :»ul Sewilge Disposal (.l,apiet.
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Septic Inspection Report
I
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: a epart: am/pm
742 Bay Rd., Queen bury,NY CZ Inspector's InitialsNAME: V� 1� PERMIT NO.:
60
LOCATION: INSPECT ON: --0�
RECHECK:
Comments and/or diagram
Soil T : Saa7l'bgm/ lay
Type of to Mumcip /Well Water
Waterline sepa tion di ance _ft.
Well separation attrnce ft.
Other wells: ft.
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenches ft.
Size of Stone ro � p U
Seepage Pits: Number
Size: x
Stone Size:
Piping Sizq Type
Building to tank L
Tank to Distribu • n Box j4 3
Distribution Box field/Pit u
Opening Sealed: N/Partial
Location/Separations
Foundation to tank JV ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Location of Syyew on Property:
Front Rear Left Side Right Side
Middle Front Middle Rear
S stem Use Stat/s:
Approved
Partial Approved and needs to be re-inspected;please call the Building&Codes Office
Disapproved
L:\SueHemingway\Building.Codes.Hispcetion.FORMS\Septic Inspection Report.doc January 28,2003
( . "I have seen or observed, or believe I saw evidence of,
�o, 0-X all obiects such as houses, wells, trees, fences, etc.,
QL �- shown on this document. I also represent That ! have
pk: personally measured the dis ances set forth on the diagram."
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