2004-978 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: P20040978 -Date Issued: Wednesday, December 22, 2004
This is to certify that work requested to be done as shown by Permit Number. P20040978
has been completed.
Tax Map Number: 523400-309-013-0002-014-000-0000
Location: 455 BIG BAY Rd
Owner: STEVEN & JOANN COURVILLE
Applicant: STEVEN & JOANN COURVILLE
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
Director of Building&Code Enforcement
1 --
T TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20040978 Application Number: A20040978
Tax Map No: 523400-309-013-0002-014-000-0000
Permission is hereby granted to: STF,V FN& JOANN COTTRVTI,T,F
For property located at: 455 BIG BAY Rd
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: STEVEN& JOANN COURVILLE
455 BIG BAY Rd Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
T.B.S. SEPTIC
2 LOWER WARREN STREET
OI TEENSBI TRY_ NY
Plans&Specifications
2004-978
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday, December 22, 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 Tca of Zspryge , December 22, 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: _ .....................................................................................................................................
:
� / Office Use
Location of installation: ` a �! ;
File Permit No. '
p CZ) l�
Tax Ma No. / /
i
,� � Fee Paid i
Owner's Name: (`( CCU r :..........................................................:..............................................
............................�
Address:
2. INSTALLER'S NAME 1,2" 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
r
1980 or older x 150 gal/bdrm = KS 0
1980- 1991 x 130 gal/bdrm = RECEIVED
199191 —presresent x 110 gaUbdrm =
Garbage Grinder Installed yes_ / no
Spa or Hot Tub Installed _ yes_ 1 no
TOWN OF QUEENS13URY
4: PARCEL INFORMATION:` (circle applicable information&indicate measurements) PLANNING OFFICE
a h of tore Ground Water Bedrock or Impervious—Material ter Su 1
Flat sand at t depth at gth municipal
ling oar feet feet
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: l !pe> gallon (min. size 1,000 gal.)
Tile Field: each trench ft. Total System Length: 61� 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.
-dory f�
Signature of respo sibie person Date
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Septic Inspection Report
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: '1 �I ) l PERMIT NO.:
LOCATION: INSPECT ON:
RECHECK: 1
Comments and/or diagram
SoilType S oa / la
Typeof r: unicipa /Well Water
Waterline se arat' n di nce 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 �le
Seepage Pits: Number
Size: x
Stone Size:
Piping Size T e
Building to tank
Tank to Distributio Box l 5
Distribution Box W Aield/Pit k ,
Opening Sealed: Y INI Partial
Location/Separations
Foundation to tank ft.
Foundation to absorption
Separation of Pits ft.
Conforms as per Plot Plan VY N
Location of System on Property:
Front Rear eft 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
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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�nt. 1 also represent that I have
personally measured the distances set forth on the diagram."
SIGNATURE DATE
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