2004-923 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: P20040923 Date Issued: Wednesday; November 24, 2004
..This is.to certify that work requested to be done as shown by Permit Number P20040923..
has been completed.
Tax Map Number: 523400-289-009-0001-051-000-0000
Location: 11 SULLIVAN Dr
Owner: HENRY & HELEN SANDER
Applicant: HENRY &HELEN SANDER
This structure may be occupied as a:
Septic Alteration Residential
By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the
property owner of the responsibility for compliance with Site Plan,
Variance, or other issues and conditions as a result of approvals by the Director of Building&Code Enforcement
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20040923 Application Number: A20040923
Tax 1\/Iap No: 523400-289-009-0001-051-000-0000
Permission is hereby granted to: HF,NRY&HELEN SANDER
For property located at: 11 SULLIVAN Dr
in die Town of Queensbury, to constrict or place
at die above location uh accordance with application together with plot plans and other information hereto filed
and approved and in compliance with the NYS Uniform Building_Code's and the Queensbury Zoning
Ordinance. Tyne of Construction Value
Owner Address: BENRY&HELEN SANDER
344 GLEN LAKE Rd Septic Alteration Residential
Total Value
LAKE GEORGE, NY 12845-0000
Contractor or Builder's Name /Address Electrical Inspection Agency
OiTEENSBITRY SEWER . 1
JAY SWEET
Plans&Specifications
2004-923
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID -THIS PERMIT EXPIRES: Thursday, November 24, 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 f Quee bury,; dnesday, November 24, 2004
SIGNED BY / y for the Town of Queensbury.
Director of Building&Co Enforcement
Application for Permit=Septic'Disposai System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION: l ..............................
` Office Use
Location of installation:. I�dri>
File Permit No. `
Tax Map No.
f r Fee Paid
Owner's Name: f1�1 F� '................................:......................................................................................................
Address, ��
w �-
2. INSTALLER'S NAME .1' 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 Flow
-9 x 150 gal/bdrm =
1980- 1991 x 130 gal/bdrm = I`�/S�
1991 -present x 110 gallbdrm =
Garbage Grinder Installed yes__-_ 7 NOV 2 2 2004
Spa or Hot Tub Installed yes` /� 1 OWN OF®UEENSBURY
1° BUILDING AND CODE
4: PARCEL INFORMATION: (circle applicable information&indicate measurements
ToDoaraDhv Soil Nature Ground Water Bedrock or impervious Material . Domestic Water Supply
� sand at what depth at what depth municipal
--Polling -loam feet feet well
Steep slope clay if well; water supply
%slope other from.any septic-systeni-
depth: absorption iys 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/- 25 gallon (min. size 1,000 gal.)
Tile Field: each trench—�`=ft. Total System Length: 1,2- 6' ft.
Seepage Pit(s): number of size of each: ft. by ft.
Size%f Stone to be used: # / depth`6r'thickness feet
Bed System Size: x
Alternative System:,��� /��ac length and/or size
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: 1 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.
Si na`e of esponsible person Date
So
5c;wc:rs :uttl 5owsige Disposal Climpter.
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7. SIGNATURE &INFORIvIATIO FOR msruN;sxoLr-rz"vj.'' \',a040.+.""w
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received: ( 0
Queensbury Building&Code Enforcement Arrive: Z%�Depart:
am/pm
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initial '
NAME: PERMIT NO.:
LOCATION: INSPECT ON: z 1 o 4-
RECHECK:
Comments and/or diagram
Soil T Sand oar/Cla
Type of Water: Munici a Well Wate
Waterline separation distan 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 rl L
Seepage Pits: Number
Size: x
Stone Size:
Piping Si Type
Building to tank
Tank to DistributiW Box
Distribution Box ield/Pit OA
Opening Sealed: /N/Partial
Location/Separations
Foundation to tank ft.
Foundation to absorption
Separation of Pits ft.
Conforms as per Plot Plan VY N
4
Location of System on Property:
Front Rear Left Side Right Side
.o
Middle Front Middle Rear C:4 r
System Us4Stat :
proved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved