2004-629 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: P20040629 Date Issued: Thursday, August 12, 2004
This is to certify that work requested to be done as shown by Permit Number P2004062.9
has been completed.
Tax Map Number: 523400-309-007-0002-028-000-0000
Location: 34 MALLORY Ave
Owner: WILLIAM & PATRICIA MORRIS
Applicant: DOUGLAS GALVIN
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
Director of Building&Code Enforcement
T TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20040629 Application Number: A20040629
Tax Map No: 523400-309-007-0002-028-000-0000
Permission is hereby granted to: DOUCTT,AS GAI NTN
For property located at: 34 MALLORY 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: WILLIAM&P.ATRICIA MORRIS
MALLORY Ave Septic Alteration Residential
Total Value
QUEENSBURY, N.Y. 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans&Specifications
2004-629 DOUGLAS GALVIN
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday,August 11, 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 Town of Queensbury; Wednesday,August 11, 2004
SIGNED BY for the Town of Queensbury.
trector of Buildin od nforcement
i Application for Permit — Septic Disposal System RECEIVED
Totvn of QneeiisbUly 74211nyRoad Queensbury, NY 12804 (318) 761-8256 AUG 1 ) 2004
1, OWNER INFORMATION:
................................,........................................................................................
�� � "BUILDING
Location of installation: _��S/ ,�,.., . ,��,:! fxia' BUILDING AND CODE
Tax Map No.
File Ponnit No.
/ / GO/ a Fee Paid r
Owner's Name:
Addreac �'�''{ �',)>�;�,/,f`�z%'�r� �? t1l'y�_ _ ....................................................................................................................................
,gyp Y /' P p
2. 'INSTALLER'S NAME - t rfi. { �' '� •-1,r�ro t 4 PHONE NO. ���r
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate 11 bedroonr(s) and multiply it vJ
bedrooms with applicable gallons per bedroom to equal total daily flow)
Year of Homo: No. of Bedrooms x Computation = Total Daily Flow
980 or older S, x 150 gal/bdmi =
1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrmn =
Garbage Grinder Installed yes / no,
Spa or Whirlpool Installed yes_ / no t
4, PARCEL INFORMATION: (circle applicable information & indicate measurements)
IRAQ EAR Xoils{trtslxv Cl"c41���d WntQr. _Uvsli:ack..or�nruo�_x3v►�s tntoti_,�I__nom sl Wat.ar.Sup�,ly
llvl' rlrc nl ►vhcrl cic/Nh cr! rr pert c/cplh m� rlc Intl,
Rolling loam i fire! feel well
Steep slope clay if well; water.supply
slope other from any septic-system
depth: absorption Is fl.
other
Percolation Test; (To be eonrpleted lay licensed prrrfesslonal etigineer or arcliltect)
!late: minute per Inn
5, PROPOSED SYSTEM: For New Conatruclign: All individual sewage disposal systems must be designed by a licensed
professional engineer or architect (unless installed in a ('tanning 13o.ly(l al)provc(i sulxlivision), Add 250 gallons to ilic size
of tic septic lank and leach lield for cads Garbage Grinder, Spa or Whidpool 'l'nb.
,� �; Septic Tank; 4M. 5 gallon (min. ,size 1,000 gal)
Tito Field: each trench f1. Total System Length: � 00 f1.
Seepago Pit(s): number of size of each: _W fl. by fl.
Size of Stone to be used: ll / delrll►or tlrlckruess
Bed System Size: x
Ahernadve 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 eloctrical 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 lho'Town
of Quoonsbury, 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 bohalroran applicant, shall be void.
I have road tbo regulations with rospoct to this application and agree to abide by lLoso and all
roquiroinonts of the Town of Queensbu vtit. Sewage Disposal Ordinance.
Dole—'ST 1 �d
unature of rasp sible per n Date
1 0
Septic Inspection Report
Office No. (518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/ epart: am/pm
742 Bay Rd.,Queensbuty,NY 2804 Inspector's Initials: j_
NAME: ( ) -�t Z 1 �l PERMIT NO.: C 4 — l(J
LOCATION: L \�`.,- ;,., �� INSPECT ON:
RECHECK: -
Comments and/or diagram
Soil T e: S /Clay
Type of Wat r: Municipa /Well Water
Waterline se p nce 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 Type
Building to tank /
Tank to Distribution Box " L
Distribution Box to Field/Pit N K
Opening Sealed: Y/N/Partial
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits Z ft.
Conforms as per,,Plot Plan Y N
Location of Sys m on Property:
Front Rea Left Side Right Side
Middle Front Middle Rear
System Use Stat
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
1 haveseenui Obnived, im believe ! saw rdMIMM',
all objects such as ripuses, wells, trees, fences, etc.,
i
shown tor. this docurn.1--) 1. reni'le ,
, seut that I have
personally rr s ed tht. d.iffitalllp' Set Orth on the di
BUILDING & PT�.— SIGNATUR-
REVIEWED BY
DATE 15
06
Ott
pre)
'77 /q&0qa1 7�
9,T CTOWN OF QUEENSBURY BULDING DRARTMENT
Based on odr limited examination, V)�
corngliance with our comments shall
not e construed as indicating the
plans and specifications are in full RECEIVED ,
compliance with the Building Codes
of New York State. AUG 1 1 200
TOWN OFF QUEENS BURY
BUILDING AND CODE