2004-675 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: P20040675 Date Issued: Friday, September 03, 2004
This is to certify that work requested to be done as shown by Permit Number P20040675
has,been completed.
Tax Map Number: 523400-309-010-0001-043-000-0000
Location: 12 PINE St
Owner: MARIE A VALLEE
Applicant: MARIE A VALLEE,
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: P20040675 Application Number: A20040675
Tax Map No: 523400-309-010-0001-043-000-0000
Permission is hereby granted to: MARIE AVALLEE
For property located at: 12 PINE St
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. Tvoe of Construction Value
Owner Address: MARIE A VALLEE Septic Alteration Residential
12 PINE ST. Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
SMITH EXCAVATING
Plans&Specifications ' i i
2004-675
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Saturday, September 03, 2005
(lf 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`)Gown.of Qu�isbury; F 'day, September 03, 2004
SIGNED BY( % r,� zz for the Town of Queensbury.
Director of Building&Co e Enforcement
Application for Permit—Septic Disposal System
Towlt of Qtteensbiuy 742 Bay Road Queemsbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION: aPjwg Office UseLocation of installation: ,n J
Tax Map No.
File Permit No. y' (p
/ /
�r C� V,/l L� g Foe Paid
Owner's Name: /vl I
................................... . ..........................................................................................
Address:.! a I-,9Afe ��
2. INSTALLER'S NAME : /� � S�YI/� PHONE NO.
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate #bedroom(s) and multiply ll 0
bedrooms with applicable gallons per bedroom to equal total daily flow)-
Year of House; No. of Bedrooms x Colnputatign = Total Daily Flow
x 150 B aVbdnn =
1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gal/Wrin. = l' �
Garbage Grinder Installed yes i / no p 0 1 2004
Spa or Whirlpool Installed yes / no Sc
TOWN OF QUEENSBURY
4. PARCEL INFORMATION: (circle applicable information & indicate measurementQUILDING AND CODE
o1J9 vi tstro .Cl.tou�.!d V.l�atvr_. _acsl.rock..vr�.���pory�vu��l_e.tcta;!I_ .. �c_Wat.4r.Supt�ly .
(It rk'"I depth crt ► at depth n Ica rcr
c72 llin loan ce! eet well
g l . � f
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 l)rofessiotial engineer or arclillect)
!late: mhnde per Inch
S. 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 Board approved subdivision). Add 250 gallons to the size
of the septic lank and leach field for each Garbage Grinder, Spa or Whirlpool Tub.
Septic Tank: L.�gallon (min. size 1,000 gal.)
Tile Field: each trench Jl. Total System Length:
Seepage Pit(s): number of size of each: fl. by fl.
Size of Stone to be used: U �;:Z� / depth or Ilrlckrress ________ _Jeer
Bed System Size: x
Akernadve 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 those and all
requirements of the own of Queens ury Sanitary Sewage Disposal Ordinance.
Signature responsible person bate
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection eq s e' ed-
Queensbuly Building&Code Enforcement Arrive: 170 p art• ' • —arnffm-)
742 Bay Rd., Queensbuly,NY 12804 Inspector's Initia s: L-/
�� 1 I _
NAME: �,`' C- U ate_ P 1tMIT NO.:
LOCATION: j cn o fl SPECT ON: - 0
RECHECK:
Comments and/or diagram
Soil Type: Sand/ _Clay
Type of Water: unici ell Water
Waterline separatlon istance 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 �fc
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank a
Tank to Distribution Box
Distribution Box to Field/Pit
Opening Sealed: Y/N/Partial
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan v Y N
Location of System on Property:
Front Rear L I e t Side
Middle Fro Middle Rear
System Use Sta s:
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
r
RECEIVED
SEP 0 12004
TOWN OF QUEENSBURY
BUILDING AND CODE
I laad_y
BUILD INIG C'OD s-1 'PT.
REVIEWED BY
DATE --
W have seen or observed, or believe I saw evidence of,
all objects such as houses, wells, trees, fences, etc.,
shown on this document. 1 also represent that I have
personall ..measuyed the distances set forth on the diagram."
++j� /rK
SIGNATURE D d iATE
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