2003-586 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: P20030586 Date Issued: Monday, September 01,2003
This is to certify that work requested to be done as shown by Permit Number P20030586
has been completed,
Tax Map Number: 523400-309-606-0001.071-000.0000
Location: 222 SHERMAN Ave
Owner: WILLIAM&URSULA PERRELLI
Applicant: WILLIAM&URSULA PERRELLI
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
Director of Building&Code Enforcement
a
'TOWN OWN OF QUEENSBURY
742 Bay Road,Qucensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20030586 Application Number: A20030586
Tax Map No: 523400-309-006-0001-071-000-0000
Permission is hereby granted to: WILLIAM&URSULAPERRELLT
For property located at: 222 SBERMAN Ave
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. Ti
e of Construction Value
Owner Address: WILLIAM&URSULA PERRELLI
222 SHERMAN Ave Septic Alteration Residential
Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name Address Electrical Inspection Agency
SANITARY SEWFR
DAN DRELLOS
PO BOX 224
CTT,FNS FALLS NY
Plans&Specifications
2003-586
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday,July 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 Ton ensr Wednesday,July 30,2003
;e
SIGNED BY for the Town of Queensbury.
Director of Building&Vode%forcement
Application for Permit-Septic Disposal System
Town of Queensbupy 742 Bay Road QueensbuP34 NY 12804 (S-1 8) 761-8256
I OWNER INFORMATION:
F..........
Location of installation- Q A #/zewow AV-r—
Tax Map NO. File Permit
• Owner's Name:-Q—kLL/6A RO& FecPaid
Address:
2. INSTALLER'S NAME : 64"OE-At PnoNE No. 79.2 -7 S�
3- RESIDENCE INFORMATION: (circle 4-r of dwelling,indtcate#bedroom(s) and multiply#of
bedrooms with applicable gallons pet bedroom to equal total daily flow)
Year of House: Na. of Bedrooms x Computation - Total Daily Flow1980 or older <3 x 150 SaLlbdrm =
x 130 gal/bdrin
1980- 1991 -RFC�ERIED
1991 -present x I IQ gatlbd=
Garbage Grinder Installed yes / no JUL 2 9 2003
Spa or:Rot Tub Installed yes t no
TOWN OF QUEENSBURY
4. PARCEL INFORMATION: (circle applicable information&indicate measurements) BUILDING AND CODE
T o h Soi1 Nature Ground Water -_Bedrock-9r Impervious Material n Domestic Water spnp
Ftaz at what depth at what depth
_&uni S'pa
o ling a
roam feet fee
Steep slope clay ---_ t W
if
—%slope other ' well;water supply
depth. from any se-pric-system
absorption is_jt.
Percolation Test- (7b be completed by licensed professional engineer or architect) other
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 Plazaing Board approved subdivision). Add 250 gallons to the size
of the septic tank and Ieachgeld for each Garbage Grinder,Spa or Whirlpool Tub.
Septic Tank: gallon(min. size J,000 gal)
Tile Field: each trench-1- 3 ft. Total System Length:
Seepage Pit(s): number size of each: • by_ft.
sizCIqf Sterne to be used: # 1 depth or thickness_feet
Red System Size: x
Alternative System-, length andlor size
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: Size of each:_gallons t 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.
1ha . re regulations with respect to this application and agree to abideb these and all
require eats 0 c Town of Sanitary Sewage Disposal Ordinanc'.
nbury
&91c)
ig Mire of r`esp9-n';ible person )bat
Tnn/TAnrB1 TVA 514.1:f.11 WIT COOZITDILO
Septic Inspection Report
Office No. (S 18)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: anl/N�Depart: am/pm
742 Bay Rd., Queensbury,NY 1,2804 Inspector's Initials:
NAME: ti P.Q PERMIT NO.:
LOCATION: INSPECT ON:
RECHECK:
Comments and/or1` is ra
Soil T e: Sa / la
T e of Wa er Municip /Well Water
Waterline sepa tion tance ft.
Well separation distance ft.
Other wells:
Absorption Field: Total lengthft.
Length of each trench ] ft.
Depth of trenches - ft.
Size of Stone
-Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Buildingto tank Sf ('
Tank to Distribution Box
Distribution Box to Field/Pit K ,
Opening Sealed: Y/N/Partial
Location/Separations
Foundation to tank ft.
Foundation to absorption
Separation of Pits ft.
Conforms as er Plot Plan N
Location of Sys n Property;
Front Rear Left Side Right Side
Middle nt Middle Rear
System Use Stat
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
LASueHerningway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doo January 28,2003
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C� m < C
son
r
�7 r
o Lszr�ed,or believe I saw evidence of
sltj� as houses,wells,trees,fences,etc,
r l; s doo anent, l also
sent that I h
ave
J " the list n set forth on t e diagram,'
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