2003-217 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: P20030217 Date Issued: Wednesday, April 30, 2003
This is to certify that work requested to be done as shown by Permit Number P20030217
has been completed.
Tax Map Number: 523400-308-019-0001-047-000-0000
Location: 53 PINELLO Rd
Owner: NANCY ANN INGLESTON
Applicant: NANCY ANN INGLESTON _
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
Director of Building&Code Enfor ment
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number:. P20030217 Application Number: A20030217
Tax Map No: 523400-308-019-0001-047-000-0000
Permission is hereby granted to: NANCY ANN 1NCTUSTON
For property located at: 53 PINELLO 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. Twe of Construction Value
Owner Address: NANCY ANN INGLESTON
53 PINELLO Rd Septic Alteration Residential
Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
T.R.S. SEPTIC
2 LOWER.WARREN STREET
OIJF,F,NSBIJRY.NY
Plans&Specifications
2003-217 NANCY.HEWITT/INGLESTON
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday,April 30,2004
(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 the ,pwit.Qf Quee ury; dnesday,April 30,2003
SIGNED BY for the Town of Queensbury.
Director of Buildin &Cog Enforcement
Application for Permit-Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
......................................................I.................. ..............................................
Office Use
Location of installation:
File Permit
Tax Map No.
Fee Paid
Owner's Name:
....................................................................................................... ..........................
Address: 4 IVA4P C.)
2. INSTALLER'S NAME —:2: /7 K- PHONE NO.-Z?X-
i
3. RESIDENCE INFORMATION: (circle year o f 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
1980 or older x 150 gal/bdrrn = C)
1980- 1991 x 130 gallbdnn =
1991-present x 110 gal/bdrm =
Garbage Grinder Installed yes no
Spa or Hot Tub Installed yes no
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
Tevop-raDhv z'SZE-11�ature- Ground Water Bedrock or impervious Material D.GmZ91e,-Water So ply
(Fla sand--) at what depth at what depth �`municipal
-R-olling sand et -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: 1-z��gallon(min. size 1,000 gal.)
TileField: each trench -50 ft. Total System Lengtld
Seepage Pit(s): number of size of each: ft. by_ft.
Size of Stone to be used: # depth or thickness feet/,A-,F.
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 T Arn of Queensbury Sanitary Sewage Disposal Ordinance.
Signature of responsibFe person Date
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7. SIGNATURE &iNFORNIAnON FOR V6r4;s.kSLr,rrvlY \►,v%4&%p ..%v ,
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Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received: -P
Queensbuiy Building&Code Enforcement Arrive: anl/p , epa t ` am/pm
742 Bay Rd., Queensbuiy,NY 12804 Inspector's Initials:
NAME: '�' lv PERMIT
LOCATION: INSPECT ON: �d O_ ,
RECHECK:
Comments and/or diagram
Soil T : Sa , 1-roam/Clay
T e of : Munic� al/Well Water
Waterline separ 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 The
Building to tank
Tank to Distribution Boxog
Distribution Bo o]Field/Pit ac K
Opening Seal : V/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 Sy �on Prop�ert
Front Re Left Sid Right Side
Middle Front Middle/Rear
System Use Stag
Approved -
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:tSueHemingway\Building.Codes.Inspection.FORMS\,Septic Inspection Report.doc January 28,2003
ao' .
59
1
"1 have seen or observed, or believe I saw evidence of,
19biects such as houses, wells, trees, fences, etc.,
s wn on this document. I also represent that 1 have
00��u� p rsonail measured the d' tances set forth on the diagram."
SIGNATIJ DATE
l
BUILDING &
REVIEWED t79
DATE D c,.,t �r r
I have seen or.observed, or believe I saw evidence of,
gbjects such.as houses, wells, trees, fences, etc.,
���►' s wn on this document. I also reCresent That i have
p rsos;ail measured the d" tarces set forth on the diagram."
SIGNATl1R DATE
T0M C
BUILDING &
REVIEWED BY 4r.t )'<r
DATE L� L�