2004-817 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building &Codes (518) 761-8256
CERTIFICATE (-).UE7 COMPLIANCE
Pernut Number. P20040817 Date Issued: Thursday, October 21, 2004
This is to certify that work requested to be done as shown by Permit Number P20040817.
has been completed.
Tax Map Number: 523400-301-008-0002-069-000-0000
Location: 12 MIDNIGHT Dr
Owner. THOMAS HALL III
Applicant: THOMAS HALL III
This structure maybe occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
Director of Building&Code Enforcement
L
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20040817 Application Number: A20040817
Tax Map No: 523400-301-008-0002-069-000-0000
Permission is hereby granted to: THOMAS HAT,T,TTT
For property located at: 12 MIDNIGHT Dr
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. ? i Type of Construction Value
Owner Address: THOMAS HALL III
11 RICHARDSON St Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804-0000
Contractor or Builder's Name /Address Electrical Inspection Agency
OTTEENSBTTRY SEWER
JAY SWEET
, i
Plans&Specifications
2004-817
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID -THIS PERMIT EXPIRES: Tuesday, October 18, 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 Towy, October 18, 2004
SIGNED BYn" 7r;w
for the Town of Queensbury.
Director of Building&Code Enforcement
1
Application for Permit-Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury, NY 12804 (518) 761-8256
1. OWNER INFORMATION:
,{ J jr
Office Use
Location of installation: ��"/ 1/J���ii�c y
File Permit No.
Tax Map No. .
Owner's Name: �/ - ; Fee Paid -
1 ,��
Address:
f
2. INSTALLER'S NAME PHONE 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 low
1980 or older x 150 gal/bdrm = -5',:::�-a
1980- 1991 x 130 gal/bdrm =
1991 -present x 110 gal/bdrm =
r
Garbage Grinder Installed yes E_ rl�' CE:iv
Spa or Hot Tub Installed yes_ / 3, _
OC ( 1. 8 2004
4. PARCEL INFORMATION: (circle applicable information&indicate measurementp��IV d Oi= SBURY
BUIL INC j N0 CODE
ToDovraDhv Soil-Nature Ground Water Bedrock or bp pervious Material . Domestic Water Su 1
la" and at what depth at what depth munici a
olling 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 22 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: 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.
- U
Sign r of responsible person Date
• r � 'l'n�vt�`cif t2t,I�c:�I�I�ui•y '
�rwcrs atul .4�wsi�;c: Disposal (Iltaptel.
Appitilclix t
t
i I+;I;L)
SEA" 1 RATIO N Iti. i.Y!l.t NI I N'I';i
POND
• 1AlFUt_ to 1imr'R• .. rt «•r44 .
't><+rttt c�St•irx ••- •
ILova� G m u�•' III:?vs>: G
Awl
Mom)
' �rrer
7• SIGN,E#"I'tJRE &INFORMAMON FOR USVONMOLZ r>✓"vw4\V„9n0%0 AV-,;;:'•
Septic Inspection Report
N'00n-
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building& Code Enforcement Arrive: am/p epart: am/pm
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials: -
NAME: Cfi1n PERMIT NO.:
LOCATION: ' ` ; INSPECT ON:
RECHECK: /
Comments and/or diagram
Soil Type: Sand/ -Clay
Type of Wate : Mumcij�a Weil Water
Waterline sepkation dicta e
Well separation is ance
Other wells: ft.
Absorption Field: Total length ft. `
Length of each trench ft. �t%L�'J d
Depth of trenches ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
-Building to tank
Tank to Distribution Box t1 14---
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 Y N
Locati n of System on Property:
VonRear Left Side Right Side
Middle Front Middle Rear
System Use Stat
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:\SueHemingway\Building.Codes.Inspeetion.FORMS\Septic Inspection Report.doc January 28,2003
t
i
1
a�
1 r
UILDING &
m
EVIEWED-BY
SATE
RECEIVED TOWN OF QUEEMSPuRY BUILDING DEPARTMENT
Based on odr limited examination,
pCT 18 Z004 0� camgliance with our comments shall � --
not. e construed as indicating theplan S
TO��li�0F,i:tLi6.Et�SBURY
compliance with he Building Co es
6 W CODE of New York Statetk
aV1. p
0
o �
EIVED
OCT 1. 8 Z004 `
TOWN OF uLIEENSBURY
BUiLDINU AND CODE
"I have seen or observed, or believe 1 saw evidence of, All"
ail objects such as hOUses, wells, trees, fences, etc.,
shown on this document. I also represent that I have �
Personally measured the distances set forth on the diagram."
S, �0
fGi�ATURE � /�---��—