2003-567 L
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: P20030567 Date Issued: Tuesday, July 29, 2003
This is to certify that work requested to be done as shown by Permit Number P20030567
has been completed.
Tax Map Number: 523400-295-011-0001-019-000-0000
Location: 61 SARA-JEN Dr
Owner: STEPBEN& WANDA J GECEWICZ
Applicant: STEPHEN& WANDA J GECEWICZ
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
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: P20030567 Application Number: A20030567
Tax Map No: 523400-295-011-0001-019=000-0000
Permission is hereby granted to: STF,PHFN&WANDA J CTF,CF,WTC Z
For property located at: 61 SARA-JEN 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. Type of Construction Value
Owner Address: STEPHEN& WANDA J GECEWIC
STEPHEN GECEWICZ III Septic Alteration Residential
Total Value
61 SARA-JEN Dr
QUEENSBURY;NY 12804-0000
Contractor or Builder's Name/Address Electrical Inspection Agency
OIJF,F,NSBIJRY SEWER
JAY SWEF,T
Plans.&Specifications
2003-567
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 ' PERMIT FEE PAID-THIS PERMIT EXPIRES: Saturday,July 24,2004
(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 th n of Q ns : h day,July 24,2003
SIGNED B IV NZ 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:
File Permit No03 -,56
Tax Map No.
Owner's Name: AID k /,L) 4,11e Coe k)I C-,>
Fee Paid
...........
Address: C, &
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 Flo
1980 or older x 150 gal/bdrm =
190---j-991 x 130 gallbdrm = 41'
pre�sent x 110 gaVb&m = -RECE,1VFm
Garbage Grinder Installed yes A JUL P 3 2003
Spa or Hot Tub Installed yes TOWN OF QUEL--NSBURY
BUILDING AN
CODE
4.' PARCEL INFORMATION: (circle applicable information&indicate measurements)
Tppoara hy Soil Nature Ground Water Bedrock or hWervious Material Domestic Water S0121y
at s- C at what depth at what depth munic a
'Yd—lling _7oa_! *feet —feet we .
Steep slope clay if well; water supply
%slope other from any septic-system
depth: absorption is
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.
'Asf
Septic Tank: gallon (min. size 1,000 gal.)
Tile Field: each trench d a ft. Total System Length: ft.
SeepagePit(s): number of size ofeach: ft. by ft.
Size of Stone to be used: # depth or thickness feet
Bed System Size: x
Alternative System:, J( 1*206crc1 length and/or size
6. HOLDING TANK SYSTEM: (if required) all
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.
A%
Q,o Lj
Si6nat5re 4f responsible person Date
Septic Inspection Report
Office No. (518)761-8256 Date Inspection re t r e
Queensbury Building&Code Enforcement Arrive: �_ part: a
742 Bay Rd.,Queensbury,NY 1,2804 Inspector's Initi
NAME: �' 1�Z P IT NO.: J " �
LOCATION: PECT ON: s '1
RECHECK: `
Comments an or dia r m
Soil Type:( San oam a
Type of W . Munici ell Water
Waterline sepa En is ante ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length ft. / ��
Length of each trench ���`�
Depth of trenches ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box tA V Q
Distribution Box to Field/Pit rt `gyp
Opening Sealed: Y/N/Partial
Location/Separations
Foundation to tank S
Foundation to absorption
Separation of Pits ft. �
Conforms as per Plot Plan Y N
Location o tem on Pro erty:
Front r Left Side R' lit Side
iddle Fr t Middle Rear
S stem Use St us:
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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