2004-717 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: P20040717 Date Issued: Wednesday, September 15, 2004
This is to certify that work requested to be done as shown by Permit Number P20040717
has been completed.
Tax Map Number: 523400-295-018-0002-001-000-0000
Location: 95 AVIATION Rd
Owner: JOSEPH KELLEHER
Applicant: JOSEPH KELLEHER
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QuEElvssuRY
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: P20040717 Application Number: A20040717
Tax Map No: 523400-295-018-0002-001-000-0000
Permission is hereby granted to: JOSF,PH KF,T,T,F,HFR
For property located at: 95 AVIATION Rd
in the Town of Qtieensbury,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. f ) `Tyke of Construction Value
Owner Address: JOSEPH KELLEHER
95 AVIATION Rd Septic Alteration Residential
Total Value
QUEENSBURY,NY 12804-0000
Contractor or Builder's Name /Address ; ; Electrical Inspection Agency
OTTEENSBTTRY SEWER
JAY SWEET
Plans&Specifications
2004-717
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday, September 14,2005
(If a longer period is required,an application for an extension,mu be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the wn of Q ensbury; Tuesday; September 14, 2004
SIGNED B for the Town of Queensbury.
Director of Buil�ing& de Enforcement
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:
t
File Permit No.
Tax Map No.
Fee Paid
Owner's Name: 7�—o C
..................................................................•.........................................................
Address:
2. INSTALLER'S NAME di2-A)V1.1 SPHONE NO.
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
4 1980 or older x 150 gal/bdrm = e-z)
ffO— 1 9�9�1� x 130 gal/bdrm =
1991 —present X 110 gal/bdrm =
Garbage Grinder Installed yes_ /�- RELZI
Spa or Hot Tub Installed yes_ 6T v LJ
SEP 13 2004
4. PARCEL INFORMATION: (circle applicable information&indicate measulM&QUEENSBURY
ILDIN D C D
Too graiphv Soil Nature Ground Water Bedrock or Impervious a eria ater SLipi)lv
s n at what depth at what depth =Muiic'—p
Rolling loam. —feet feet well
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.
Septic Tank: lz!2 gallon (min. size 1,000 gal.)
Tile Field: each trench ft. Total System Length: ft.
Seepage Pit(s): number of size of each: _ft. by_ft.
Size of Stone to be used: # depth or thickness feet
Bed,System Size: X
Alternative System/Ayj_/��- ... 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
requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance.
S.ign �r of responsible 'person Date
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sgwcrs and sewsilte Dist>as: l Cllapjrr
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7. SIGNATURE &INFORly ATION POP,msl,6N;swLr.
Septic Inspection Report
Office No. (518)761-8256 Date Insp ction re t re eive .
Queensbury Building&Code Enforcement Arrive: �i a m : V, am/pm
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initia .
NAME: ' PE T NO.: r /
LOCATION: INSPECT ON: -=J
RECHECK.
Comments and/or diagram
Soil TYW Sand/ /Clay
Type of unicipal Well Water
Waterline separa o ce' ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length ft.
Length of each trench 'L- ft.
Depth of trenches 2 ft.
Size of Stone w
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box 1-a�
Distribution Box XTiejd/Pit
Opening Seale Y/" /Partial
Location 1 Separations
Foundation to tank ft.
Foundation to.absorption. ft.
Separation aration of Pits ft.
Conforms as per Plot Plan Y N
Location of System on Property:
Front Rear Left Right Side
Middle Fro Middle Rea
S stem Use tatus•
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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REVIEWED BY
DATE '
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"I have seen or observed, or believe I saw evidence of,
all objects such as houses, wells, trees, fences, etc.,
+ shown on this docum�:it. I Giso represent that I have 1
pe nnaily measured the 'stances :e` forth on the diagram." f
51G�lATl11E DATE
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