2003-167 TOWN OF QUEENSBURY
.7.42 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development -Building& Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20030167 Date Issued::' Wednesday, Apri116, 2003
This is to certify that work requested.to be done as shown by Permit.Number -P20030167,
has been completed.
Tax Map Number: 523400-301-012-0003-045-000-0000
Location: 39 ZENAS Dr
Owner: SCOTT &NATALIE BURLINGAME
Applicant: SCOTT &NATALIE BURLINGAME
This structure may be occupied as a:
By Order of Town Board
Septic Alteration_Residential TOWN OF QUEENSBURY
Director of Building&Code Enfo ement
-� TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 .(518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20030167 Application Number: A20030167 .
Tax Map No: 523400-301-012-0003-045-000-0000
Permission is hereby granted to: SCOTT&NATALIF,BURLTNGAMF,
For property located at: 39 ZENAS 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: SCOTT&NATALIE BURLINGAM
39 ZENAS Dr Septic Alteration Residential
Total Value
QUEENSBURY,NY. 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
MORNTNG STAR SEPTIC
Plans&Specifications
2003-167 _
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATION
$25.00 , PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday,April 16,2004
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
0
Dated at the wn o uee urVX sday,April 16,2003
'SIGNED BY for the Town of Queensb
ury.
ury.
Director of Building&Code Enforcement
71
Application foi- Permit— Septic Disposal System
Yi)wn of&eensbtlly 74iBnyltoad Queensbury, NY'12804 (518) 761-8256 r
1; OWNER INFORMATION: '
.......................................................................................................
- -
Location of installation: _�L� 2 2 Olticc Use
Tax Map No.
Milo Pormit No. — 67
/ /
Owner's Name: _ 5 c erh( i3 �I � a�,
Foe raid
y ................................................................................................
Address: 3 7 2_ F3
2. INSTALLER'S NAME : �'lcL^Nn.; 5 70, PHONE NO.
3, RESIDENCE INFORMATION: (circle year of dwelling, indicate It bedroom(,) and multiply II q/
bedrooms with applicable gallons per bedroom to equal total daily flow)
Year of House$ No of Bedrooriis x Computation = Total Daily Flow
J '
1980 or older =3 x 150 gal/bdrnt =
1980— 1991 -- x 130 gal/bdrm = S
1991 —present x 110 gal/bdrin =
Garbage Grinder Installed yes / no RECEIVED
Spa or Whirlpool Installed yes / no
APR i 5 2003
4, PARCEL INFORMATION: (circle applicable information & indicate measurements)
TOWN OF OUEENSBURY
xo 9xtnul oil,LlntlLCv 9.cou�rd Water_ _D9s1.i.ack..vx_.Ilt,vot_v)U.4!$JV1.t�.44Ci.,�l Bt�aliEi �prtl�ly
%a scnrcY nt ►t lrcrt cic�pth ul ►t hcrl dept/r nnrrNcrllicr
ltollb►g vcrm fret fret we ;
Steep slope clay i f)yell; water supply
slope other fivin any septic-system
depth: absorption is, fl,
other
Percolation Test: .,(To be completed by'licensed pri fessional engineer or architect)
Rate; minute per Inch
5, PROPOSED SYSTEM: For New Construction: All Individual sewage disposal systems must be designed by n licensed
professional engineer.or architect (finless in in a I'lanning l3oard approved subdivision). Add 250 gallons to Illc size
of t(te septic lank and leach field for cash Garbage Grinder, Spa or Whirlpool Tub.
Septic Tank: gallon (min. si a 1,000 ga.) Li
Tile Field: each trench S b fT. Total System Length: 26v h APR 15 2003
Seepage Pit(s): number of size ofecrclr: `f). by 70ff�N OF QUEENSBURY
E3UIL.DING AND CODE
Size of Stone to be tined: it / depth or thlckncs.c ____._._....__.✓�'�'t
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: Alann 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, ploas.o note that pursuant to Section 116-29 of the Code of the Town
of Qdoonsbury, nny permit or npprovnl granted which is based upon or is grnnted in
rolianco upon any material misrepresewation or failure to make a material fact or
circumstance known by or on beltnlroran applicant, shall be void.
I havo road thlo rogulntions with respect to this application and agree to nbido by those and all
roquiromonts of tho Town of Quecnsbury Sa6itary Sewage Disposal Ordinance.
(57- a
31g a u e of r pons ble person Dato
110
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/pm Depart . Z, am/pin
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials:
NAME: D I e) A, PERMIT NO.: �3
LOCATION: INSPECT ON:
RECHECK: 02
Comments and/or diagram
Soil Type:(Sa Clay
Type of Wate : Munici /Well Water
Waterline se ara on istance
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 �a .--
Distribution Box' ' Field/,Pit
Opening Sealed:LY N/Partial
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan 1 N
Location of System on Property:
Front (Rear Left Side Right Side
Middle Front Middle Rear
System Use StatL:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:SueHenningway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
MORNING STAR EXCAVATING, INC.
& SEPTIC SERVICE
208 Jewel Road 518-793-2290
Frank Shaw, Pres. Gansevoort, NY 12831-2154 518-695-5505
Fax#.518-793-2115
Date:
N2 10390
INVOICE' Terms: Payment Due Upon Receipt of Invoice
1 1/2% Interest After 30 Days
� 17Z � IJ�
\ , -� s
I"�
3 2
RECEIVED
APR 15..2003
TOWN OF QUEENSBURY
BUILDING AND CODE
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BUILDING &°CODE . LI%.4
REVIEWED BY
DATE - `3
"I have seen or observed, or believe s saw a Bence of,
all obiects such as houses, wells, trees, fences, etc:,.
shown on;this document. I also represent that i have
personally measur the distances set forth on the diagram."
( T RE
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PECEIVED7
APP 1 5 2003
TOWN OF QUEENSgURY
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REVIEWED BY
DATE ,
"I have seen or observed, or believe I saw evidence of,
all objects such as houses, wells, trees, fences, etc.,
shown,on this document. I also represent that I have
personally measur the distance's set forth on the diagram."
T RE AD/K`�
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