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2004-934 ,r 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: P20040934 Date Issued: _ Friday, December 03, 2004 This is to certify that work requested to be done as shown by Permit Number _ P20040934 has been completed. Tax Map Number: 523400-288-016-0001-009-000-0000 Location: 63 NORTHWOOD Dr Owner: JAMES DONNELLY JR Applicant: JAMES DONNELLY JR This structure may be occupied as a: By Order of Town Board Septic Alteration Residential TOWN OF QUEENSBURY Director of Building&Co&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: P20040934 Application Number: A20040934 Tax Map No: 523400-288-016-0001-009-000-0000 Permission is hereby granted to: JAMF,S DONNF,T,T,Y JR For property located at: 63 NORTH WOOD Dr t ui 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 die Queensbury Zoning Ordinance. Type of Construction _ Value Owner Address: JAMES DONNELLY JR JACQUELINE SIMPSON Septic Alteration Residential Total Value 63 NORTHWOOD Dr QUEENSBURY, NY 12804-0000 Contractor or Builder's Name /Address Electrical Inspection Agency Plans&Specifications 2004-934 SEPTIC ALTERATION $25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday, December 02, 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 q Quee ury �/�'h , ecember 02, 2004 SIGNED BY for the Town of Queensbury. Director of Building&Code Enforcement Application for Permit-Septic Disposal System Town of Queensbury 742 Bay Road Queensbury, NY 12804 (518) 761-8256 1. OWNER INFORMATION: ....................... ........................I............ .................................................... Location of installation: (9 Office Use File Permit No. Tax Map No. Fee Paid Owner's Name: �/I--7 ........................................................................... ....................................................... Address: .--.. . 2. INSTALLER'S NAME : C- PHONE NO. 3. RESIDENCE INFORMATION:' (circle year of dwelling, indicate 4 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 x 150 gal/bdrm = 1980- 1991 T— x 130 gal/bdrm 1991 -present x 110 gal/bdrin Garbage Grinder Installed yes no Spa or Whirlpool Installe d yes no 4. PARCEL INFORMATION: (circle applicable information&indicate measurements) Soil Nature Ground Water Bedrock or knRervious Material DoMptiLW_ater Supply sand at what depth at what depth -j-iTWunn ici a Rolling m 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). Add250 gallons to the size of the septic tank and leach field for each Garbage Grinder, Spa or Whirlpool T Septic Tank: /006) Tub. R5CEVVED gallon (min. size 1,000 gal) NOV 3 0 2004 Tile Field: each trench ft. Total System Length ft - TOWN OF QUEENSBURY Seepage Pit(s): number of :21 size ze of each: ft. by Z ft BUILDING AND CODE Size of Stone to be used: depth or thickness. feet Bed System Size: x Alternative System: length andlor 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 inspe6tion agency. 7. SIGNATURE &INFORMATION FOR RESPONSIBLE PERSON(please read) For your protection,please note that pursuant to Section 136-29 ofthe 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 requirement e Town of et ns ury Sanitary Sewage Disposal Ordinance. Signature of Town person D to Septic Inspection Report Office No.(518) 761-8256 Date Inspection request received: Queensbury Building&Code Enforcement Arrive: ►•3D am/pm Depart: am/pm 742 Bay Rd., Queensbury,NY 12804 Inspector's Initials: zkL NAME: PERMIT NO.: LOCATION: INSPECT ON: - n RECHECK: Comments and/or diagram Soil Type: Sand/Loam/Clay Type of Water: Municipal/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 Size Type Building to tank Tank to Distribution Box 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 Location of System on Property: Front Rear Left Side Right Side Middle Front Middle Rear System Use Status: X Approved Partial Approved and needs to be re-inspected,please call the Building&Codes Office Disapproved L:\SueHemingway\Building.Codes.Inspection.FORMSISeptic Inspection Report.doc January 28,2003 Septic Inspection Report Office No. (518) 761-8256 Date Inspection request received: Queensbury Building&Code Enforcement Arrive: 1b0 am/p Depart: am/pm 742 Bay Rd., Queensbuly,NY 12804 Inspector's Initials: ///-, NAME: 3! Cj1-,,ke,115PERMIT NO.: 0 5/_5 3/V LOCATION: A INSPECT ON: 2. 7iG RECHECK: Comments and/or diagram Soil Type: Sand/Loam/Clay Type of Water: Municipal/Well Water Waterline separation distance 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 Size Type Building,to tank Tank to Distribution Box 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 Location of System on Property: lVe d 11244 Front Rear Left Side Right Side Middle Front Middle Rear _System Use Status: 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 i Septic Inspection Report Office No.(518)761-8256 Date Inspection request received: Queensbury Building&Code Enforcement Arrive: 31 r J am/pm Depart: am/pm 742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials: _I C NAME: in, PERMIT NO.: L�- l3 LOCATION: INSPECT ON: - RECHECK: Comments and/or diagram Soil Type: (Sand1/Loam-/,Cla Type of Water: Munici. d/Well Water Waterline se arahori distance ft. Well separation distance ft. Other wells: ft. Absorption Field: Total length ft. Len th of each trench ft. Depth of trenches ft. Size of Stone Seepage Pits: Number Size: x Stone Size: 3 2 Piping Size Type Building to tank Tank to Distribution Box =j" Distribution Box to�Field/Pit /« Opening Sealed Y' N/Partial Location/Separations Foundation to tank ft. Foundation to absorption Separation of Pits 2A ft. Conforms as per Plot Plan n1 Y N Location of System on Property: Front Rear Left Side Right Side Middle Front Middle Rear System Use Status: Approved X 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 i -- ____ __�______.. -- ---�� -�� /�'�� .,-,�� Cab dl� ✓ C9 r AJif 5 �46 JKY I ON A COD RE t itEPT E GATE J NOV 200I � of QUEENS@�� "I have seen or observed, or believe 1 saw evidence of, jvVN COUt all objects such as houses, wells, trees, fences, etc., p,ND shown on this document. I also represent that I have pe easur the istan es et forth on the diagram." r ^ 7 " dd SIGNATURE DA