2003-402 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: P20030402 Date Issued: Tuesday,June 10,2003
This is to certify that work requested to be done as shown by Permit Number P20030402
has been completed.
Tax Map Number: 523400-309-010.0002-052.000.0000
Location: 4 RICHARDSON St
Owner: ROBERT NELSON
Applicant: ROBERT NELSON
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: P20030402 Application Number: A20030402
Tax Map No: 523400-309-010-0002-052-000-0000
Permission is hereby granted to: ROBFRT NELSON
For property located at: 4 RICHARDSON St
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: ROBERT NELSON
Septic Alteration Residential
15 THIRD Ave Total Value
WARRENSBURG,NY 12885
Contractor or Builder's Name Address Electrical inspection Agency
Plans&Specifications
2003-402
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday,June 10,2004
(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 To Queens)Try; Tiaesday,June 10,2003
1 —SIGNED BY 44 for the Town of Queensbury.
Director of'Building" Cod nforcement
Application for Permit—Septic Disposal System
Town of Queensbury 742 Bdy Rbad Queensbury,NY 12804 (516) 761-82S6
1. OWNER INFORMATION:
...........
Office Use
Location of installation:Ll
Tax Ma No. File Permit No.0
p
Fee Paid
Owner's Name:
............................ .................................................
Address:
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 Plow
1980 or older -2 x 150 gal/bdrin =
1980- 1991 x 130 gai/bdrm =
1991 —present x 110 gal/bdrm, =
Garbage Grinder Installed yes._ no—e��
Spa or Hot Tub Installed yes no R ' CEIVED
JUV 1 0 2003
4: PARCEL INFORMATION: (circle applicable information&indicate measurements) TOWN 0"-
QL'LENSBURy
SUILDING
anhv S&L-Neture Ground Water Bedrock or Inxivenvious Material C,
Flat <'4san -
at.whqt depth at whyt depth -?munlc`ipal�,/
ling oam feet feet
Steep slope clay if well,water supply
slope other from any septic-system
depth: absorption is_ft.
Percolation Test: (To be completed by licensed professional architect)engineer or architec other
Rate: minute per inch
S. 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: gallon(min.size 1,000 gal.)
Tile Field: each trench t. Total System Length:aO o ft.
Seepage Pit(s): number of size of each: ft. by_j?.
Size of Stone to be used: # l 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 I 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.
Signature of responsible person Date
Septic Inspection Report
Office No. (518)761-8256 Date Inspection equest
Queensbury Building&Code Enforcement Arrive: a pa a
742 Bay Rd., Queensbury,NY 12804 InspActor's Initials,
sm/
NAME:
PE IT NO.: 05
LOCAT10N
IN ECT ON:
RECHECI<
Comments and/or diagram
Soil T Sand
Type o ftnicipajZ-Well Water
Waterline separathn�istaiice
Well separation distance
Other.wells:
Absorption Field: Total length
Length of each trench ft
Depth of trenches r ft.
Size of Stone
-Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box
Distribution Box t ield Pit
OpeningPartial
Location/Separations
Foundation to tank AD ft.
Foundation to absorption
Separation of Pits
Conforms as_per Plot Plan _VY—N
Location of System on Property:
Front Rear Left Side Right Side
Middle/F- - Middle Rear
System Use S tus:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
--.Disapproved
L:\SueHemingway\Building.Codes,lnspection.FORMS\SepUc Inspection Report.doc January 28,2003
1
"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
personal -measured.the distances set.forth,on the diagram."
RECD� G7 �aoa
I SIGNAT R DATE
,lUcv =0 20D3 0
TOWN pURY
RECEIVED
au�LDI�G nl� .
JUN 1 '0 2003
TOWN OF QUEEN SBI RY.
BUILDING AND CO E
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