2004-781 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development- Building &Codes (518) 761-8256
CERTIFICATE (31"r' COMPLIANCE
Permit Number. P20040781 Date Issued: Tuesday, October 12, 2004
This is to certify that work requested to be done as shown by Permit Number P20040781
has been completed. - - -
Tax Map Number. 523400-309-014-0001-059-000-0000
Location: 16 RIVER St
Owner. JAMES & LINDA HAVENS
Applicant: JAMES & LINDA HAVENS
This structure maybe occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
it✓ � I
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: P20040781 Application Number. A20040781
Tax Map No: 523400-309-014-0001-059-000-0000
Permission is hereby granted to: JAMES &LINDA HAVE
For property located at: 16 RIVER 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. Type of Construction Value
Owner Address: JAMES &LINDA HAVENS
16 RIVER St Septic Alteration Residential
Total Value
QUEENSBURY,NY 12804
Contractor or Builders Name/Address Electrical Inspection Agency
SANTTARY SEWER
DAN DRELLOS
PO BOX 224
GLENS FALLS NY
Plans &.Specifications
2004-781
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday, October 05,2005
(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 Town zPQu bury Tue 'ay October 05,2004
SIGNED BY 6 for the Town of Queensbury.
Director of Building&Co Ye 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:
C3 File Permit No.
Tax Map No.
Fee Paid
Owner's Name: M Qr #A A-V-e-AIS
i .....................................................................................................................................
Address- VGA- 1��r
2. IN TALLER'S NAME AA M i 1—AAjd-%- 6k PHONE NO. 7 9ca -707,5-;7
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate#bedroom(s) and multiply 9 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 2 x 150 gal/bdnn = 0 0
1980- 1991 x 130 galfbdrrn =
1991 -present X 110 gal/bdrrn =
Garbage Grinder Installed yes— no ✓
-
Spa or Hot Tub Installed yes— no
4.' PARCEL INFORMATION: (circle applicable information&indicate measurements)
Too graphy Soil Nature Ground Water Bedrock or Impervious Material Domestic Water Saply
at at what depth at what depth Z9 Luni�cia
7511-ing loam feet feet we
Steepslope 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.
ITX I sy/W 6
Septic Tand 0-0-D ,_gallon(min. size 1,000 gal.)
Tile Field: each trench !(2--ft. Total System Length:
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: 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 re regulations W th t to this application and agree to abide by these and all
re�juir ents of e Town of with
ensb Sanitary Sewage Disposal Ordinance.
0 V 6/51
i nWure of responusiKle person Date
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7. SICxNATLTRE &INFORMATION FOR. SFVr=J-r-����1'+ �,��•�•�...:;: '••:;r
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Septic Inspection Report
Office No.(5I8)761-8256 Date Inspection re t V41Qw,Queensbury Building&Code Enforcement Arrive: art: 1
742 Bay Rd.,Queensbury,NY 12804 Inspectors Initials..
NAME: P&ECT
IT NO.: '-ZJ
LOCATION: J / rO I ON: — L
RECHECK:
Comments and/or dia ram
Soil T : San am/Cla
Type of Munici a /Well Water
Waterline se aratlo dis ance ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length V ft,
Length of each trench ft.
_Depth of trenches ft.
Size of Stone
-Seepage Pits: Number
Size: x ,
Stone Size: i
piping Size Type
Building to tank
Tank to Distribution Box
Distribution Bo to Field./Pit
Opening Seale fPartial '"'r =P
i
Location/Separations 4r�`
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as_per Plot Plan Y N
Location of System on Property:
Front Re eft Sid ight Side
Middle Fr t Middle Re
System Use St tags:
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
�LDI t
p,rVIEWED DY
11 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
personally measured the distances se o '®n the diagram."
SIGNATURE DATE
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