2004-636 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
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Permit Number: P20040636 Date Issued: Monday, August 16, 2004
This is to certify that work requested to be done as shown by Permit Number P20040636
has been completed.
Tax Map Number: 523400-308-011-0001-067-000-0000
Location: 104 VAN DUSEN Rd
Owner: DOROTHY BRUNELLE WOOD
Applicant: DOROTHY BRUNELLE WOOD
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
Director of Building&Code Enforcement
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20040636 Application Number: A20040636
Tax Map No: 523400-308-011-0001-067-000-0000
Permission is hereby granted to: DOROTHY BRI TNF,I,I,F,WOOD
For property located at: 104 VAN DUSEN 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. Tyne of Construction Value
Owner Address: DOROTHY BRUNELLE WOOD
104 VAN DUSEN Rd Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
FRED SMITH
23 VERMONT Ave
OTJEENSBTJRY_ NY 12804
Plans&Specifications
2004-636
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Tuesday,August 16, 2005
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at theC own Que b ; nda ,August 16, 2004
SIGNED BY for the Town of Queensbu
ry.
ry.
Director of Building&Code Enforcement
RECEIVED
Application for Permit—Septic Disposal System
To1Vn of Qlleensbuty 742 Day Road Queensbury,NY 12804 (518) 761-8256 AUG 1 '; 2004.
1. OWNER INFORMATION: ...TOWN-OF-GUEENSBURY
6 O Ii NG AND CODE
- Location of installatio �l �Cl l-)
File Pennit No.
Tax Map No.
Owner's Name:`
Fee Paid
��� �,.5 esc� ...................................................................................................................................
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Address/c1
2. 'INSTALLER'S NAME PHONE NO.
3. RESIDENCE,INFORMATION: (circle year of dwelling, indicate#bedroom(s) and multiply# 0
bedrooms witii applicable gallons per bedroom to equal total daily flow)
Year_of House: No.-of Bedrooms _ x Computation Total.Daily Flow
1980 or older . t x 150 gnVbdrm = j
1980— 1991 x 130 gal/bdrm = _
1991--present
Garbage Grinder Installed yes / no
Spa or Whirlpool Installed yes / no
4. PARCEL INFORMATION: (circle applicable information &indicate measurements)
� » Q1�llttllC9 Ci-rou�.td_Vl�atvr_. _Qvclrock.Qr_linpoCl'avl!$�1t�I4r�,�i__Dom slit Wow r.S4rpply
�r err (it whirl de/nh crt whnl c/c/rllr nnrrNcllrc►
Rolling loam feel feel
Steep slope clay if well; ►vater supply
slope other from any septic-system
depth: absorption is fl.
other
Percolation Test: . (To be completed by licensed professlonal 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 Wltirllx)ol Tub.
Septic Tank: /066 gallon (min. size 1,000 girl.)
Tile Field: each trench _fl. Total System Length:
Seepage Pit(s): number of ry size ofeach: fl. by fl.
-Size of Store to.be used: 11 v'O / clepllr or
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 Qucensbury, any permit or approval granted which is based upon or is granted in
reliance upon any material misrepresentation or failure to 1111ke 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
requiremenWoffli Sanitary Sewage Disposal Ordinance.
Signature of responsible person Date-
.6.
Septic Inspection Report T� l
p p P
Office No. (518)761-8256 Date Inspection request received: Da 'dft
Queensbury Building& Code Enforcement Arrive: am/p Depart: pm
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials:
NAME: PERMIT NO.: Oo " 6" 6
LOCATION: INSPECT ON: 211bloq - ;06 a
RECHECK:
Comments and/or diagram
Soil T e: San L lay
Type of Water icip /Well Water
Waterline sepa1,qioij-diC6nce ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenche ft.
Size of Stone ?/
Seepage Pits: Number _
Size: x
Stone Size:
Piping SizP., Type
Building to tank G
Tank to DistributL' Box
Distribution Bo t Field/Pit vi e ZD
Opening Sealed /N/Partial
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan V7 N
Location of System on Property:
Front Rear Left Side fight Sid
Middle Front Middle Rear
System Use 4Statuproved
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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RECEIVED
"I have seen or observed, or believe I saw evidence of, AUG 1 3 2004
all objects such as houses, wells, trees, fences, etc.,
shown on this document. I also represent that I have TOWN OF QUEENSBURY
person a „d th distances set forth on t e diagram." BUILDING AND CODE
T gJa�d
SIGNATURE DATE
TO I ' ' 0 Q a E N ",' _,
BUILDING & °T.
REVIEWED BY � �`
MATE h.o
a
T0VM OFQUEENSgURYBUJ[DJNG QEPAR
Based on oUr limited TMENT Gomppiiance with our examination
not be construed `sndlcatin shail � .
Plans and specifications 9 the
�mpiiance with the Building codes
of New York State, r`
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