2004-696 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: P20040696 Date Issued: Wednesday, September 08, 2004
This is to certify that work requested to be done as shown by Permit Number_ P2. 0040696
has been completed,
Tax Map Number: 523400-308-016-0001-018-000-0000
Location: 18 STEPHANIE Ln
Owner:. JOHN M. WHITE
Applicant: JOHN WHITE
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: P20040696 Application Number: A20040696
Tax Map No: 523400-308-016-0001-018-000-0000
Permission is hereby granted to: JOHN WHITE
For property located at: 18 STEPHANIE Ln
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: JOHN M. WHITE Septic Alteration Residential
18 STEPHANIE Ln Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
SANITARY SEWER
DAN DRELLOS
PO BOX 224
GLENS FALLS NY
Plans&Specifications
2004-696
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday, September 07, 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 Tov -of,Queens(7
�jes ay, September 07, 2004
SIGNED BY ! {° for the Town of Queensbury.
Vol-N
Director of Building&Code forcement
r 3 _�+► 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: S'Te ��/'i V/e- L Ai f rr
File Permit No.
Tax Map No.
r_
Fee Paid a
Owner's Name: 0 ` iJ �� ►'1 1��-
Address: 1 ,�' 2.P/
2. INSTALLER'S NAME :�Ff�1 t%7�/ �e,�r�.ti-J �' "2 t�//Cc- PHONE NO. -7 9
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 •-3 x 150 gal/bdrrn = � 'o
1980- 1991 x 130 gandrm =
1991 -present x 110 gaUbdrm =
Garbage Grinder Installed yes_ / no"'-'� E
CEIVED
Spa or Hot Tub Installed yes_ / no S E P 0 7 2004
TOWN OF QUEENSBURY
4: PARCEL INFORMATION: (circle applicable information&indicate measurements) BUILDING AND CODE
Tono2ra-Dhv SoiLNature Ground Water Bedrock or Impervious Material . Domestic Water So ply
lat sand at what depth at at depth unicip
Rolling loam feet feet we
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.
fi�y-t ST/"j&
Septic Tank: gallon (min. size 1,000 gal.) _
Tile Field: each trench `� O ft. Total System Length: P-0 O ft.
Seepage Pit(s): number of tJ size of each: ft. by ft.
Size of Stone to be used: # N 1A / depth or thickness feet
Bed System Size: x
Alternative System: N 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
requirern the Town of Queensbury Sanitary Sewage Disposal Ordinance.
igna ure of responsible person Date
Sc;lv(:t':1 :tncl 8CW;l);c: Dispogal (.hater
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7. SIQ4N,A►TURE &INFORMATION FOIE SYVr;$,U*.. rzx'*Dvi. w"mov..u%v
> fill
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/p art: am/pm
742 Bay Rd., Queensbuiy,NY 12804 Inspector's Initials:
NAME: PERMIT NO.: tl^ l
LOCATION: m t` �� INSPECT ON:
.RECHECK:
Comments and/or diagram
Soil Type: Sa / / lay
Type of Water: unici /Well Water
Waterline separation distance 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 ize Type
Building to tank
Tank to Distributio i Box
Distribution Bo Field/Pit l
Opening Seale . /N/Partial
Location/Separations
Foundation to tank r f/ f
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Location of Sy a on Property:
Front(!jIa Left Side Right Side
Middle Front iddle Rear
S 'stem Use Sta s•
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:SueHemingway\Building.Codes.Inspection.FORMS\.Septic Inspection Report.doc January 28,2003
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N OF Q1�EEN pp Y
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REVIEWED BY iR
DATE
"I have seen or observed, or believe I saw evidence of,
all objects such as houses, wells, trees, fences, etc.,
shown on this document. I also represent that I have
q-eonaily measured the di ces set forth n th,e diagram."
`St NA RE v DATE