2001-760 TOWN OF QUEENSBURY
Fv/ro742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20010760 Date Issued: Friday, October 12, 2001
This is to certify that work requested to be done as shown by Permit Number P20010760
has been completed.
Tax Map Number: 523400-279-019-0001-024-000-0000
Location: SUNNYSIDE Rd
Owner: AMELIA G FULLER
Applicant: AMELIA G FULLER
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: P20010760 Application Number: A20010760
Tax Map No: 523400-279-019-0001-024-000-0000
Permission is hereby granted to: AMELIA G FULLER
For property located at: SUNNYSIDE 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. Type of Construction Value
Owner Address: AMELIA G FULLER Septic Alteration Residential
393 ORDAWA Rd Total Value
SUNDERLAND,VT 05250
Contractor or Builder's Name/ Address Electrical Inspection Agency
Plans &Specifications
2001-760
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID - THIS PERMIT EXPIRES: Friday, October 11,2002
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at own of ueensbury• Thursday, October 11,2001
SIGNED BY for the Town of Queensbury.
Director of ding Code Enforcement
•
' ' Application for i'ermit— Septic Disposal System
Town Of Quce!!sbui y T42 Day Rood Queerrsbury, NY i2804 (518) 761-8236
1. OWNER INFORMATION: •
Office Use
Location of installation: _7 c4,71 S"-. e �2 5 h )_ r
1� Filo Permit N U/ 2{p0
57_Tax Map No. _ 1/ /
• Fee Paida2.5 m
Owner's Name: a Alf 00 f iec
Address: ..5Cft-,0.( 5 (We eE 3 f
2. INSTALLER'S NAME : �dby Fate,-
PHONE NO. 6 q.07 3 r7
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate ll bedroom(s)and multiply II of aid'5/-Z5---2
bedrooms with applicable gallons per bedroom to equal total daily flour)
Year of HHottse: No. of Bedrooms x Coutpulition = TQtal Daily Clore
1980 or older �-� x 150 gal/bdrnl - (r,0 .rcv -�
1980- 1991 x 130 gal/bdrm
1991 —present x 110 gal/bdrm =
Garbage Grinder installed yes / no
PIECE:V
Spa or Whirlpool Installed yes / no OCT o 9
200�
4. PARCEL INFORMATION: (circle applicable information & indicate meas d&ftailOQUEENSSURY
BUiLDING AND CODE
1r�r o____.-.C).round.Wal 11.vsl,r,ot;k,.oc.In pol_vi_vus_M.h.to.dal_ _Uonrps rc_'._salor,$upply
goi at who/ lrN, rrf What(h. nnrnlcl nrl
oiling elan Jirel
Sleep slope clay • r supply
%slope other from any.septic-system
depth: abso►ptlon is ten Jr-
• other
Percolation Test:--=.(To.be_conlpleted 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 Boat approved sutxlivision). Add 250 gallons Ia the size
of the septic lank and leach field ('or each Garbage(hinder, Spa or WhitIpoul Tub.
Septic Tank: ‘7>, -0.gallon (min..size 1,000 gal.)• tbC (�
Tile Field: each trench ` f?: Tout.System Longlh: 2 f1. r OF- UvgJp,
�bp
Seepage Pit(s): number of size of each: J1. by 11.
Size of Stone to be used: II / depth or rhrr;knrxs
Bed System Size; x
Alternative System: length and/or size .
6, HOLDING TANK SYSTEM: (if required)
Number of tanks: ) / Size of each: 1Q2.5e gallons /TOTAL Capacity:/2g c 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 Quoensbury, 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 nit applicant, shall be void. •
i have rend the regulations with respect to this application and agree to abide by those and nil
requirements of the Town of Quceusbury Sanitary Sewage Disposal Ordinance.
r,o
a,
/OA,1/4/
Sl nature of responsibleperson Date
g p
i,' }' 1
TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT )a=��
742 BayRoad
Queensbury NY 12804
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name i-Q/ `‘CI
Locatibn7 \
Date/ 0 .L i 4-0/Permit # ` 7 66)
SOIL T :.,Sand-L am-Clay-
Results of Percolation Test-
(if applicable) Rate-Minute/Inch
TYPE OF SYSTEM: ., 9 - +
ABSORPTION Jlj : o al ength 1 L-b
Length of each tr-nch\ ? -3(Q' ,lp
Depth of trenche Zr IbbaS
Size of stone I
SEEPAGE PITS: Ni1 ber- 1
Size - f i. x 1 ft.
Stone size
PIPING: IISize Type
Bldg. to Tank +a - ro 4" cJi 1-10
Tank to Dist. Box 1-111 tp
Dist. Box to Field!' _t ,- POC_Tb�``Q.
Openings Sealed? v-. • oPartial
LOCATION/SEPARATIO-
Foundation to Tank 74 feet
Foundation to Absorption,. -70 .feet
Separation of Pits feet
Conforms as per Plot Plan Ye�s o
LOCATION OF SYSTEM ON PRO' R'il":
(circle one)
Front - RearJ .Left Side ight Side"
Middle ron t -- M*-ddl a Rear
COMMENTS:
•
\.):) -1_47
SYSTEM.USE APPROVED: . . YES NO
.illii.
Arrived: gosh a
Depa _' /' �
/�./i _ L%/�
a' iTi1 ng nspe� r,
. I .. .. .
.
- . "I hive seen or observed or b3lievE I saw evicence of,
ALI nbiP._ct such.as to_lasek, we! s, trEes, fErices, etc., , •
• shown on this locument. I alS( represent that I hav3 TOW4 (,)1: (12-7-7E'.;::. ouRy
perm: all,/ measuredthe iista ces set forth or the liagr m."
1 0.
BUILDING ..' / 7s 1",', •PT
.
SIGNATURE DATE REVIEWED BY AdVAr,/
DATE _ 7. • 0.-4171 . .
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