2003-611 r
r 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: P20030611 Date Issued:. Wednesday,August 27,2003
This is.to certify that work requested to be done As,shown by Permit Number P20030611
has been completed
Tax Map Number: '5234007309-013.0001-015.000.0000
Location: 27 OHIO Ave
Owner: ROBERT&TINA COVER
Applicant: ROBERT&TINA GOVER
This structure may be occupied as a:
By Otdet of Town Boatd
Septic Alteration Residential TOWN of QUEENSBURY
Nectot 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: P20030611 Application Number: A20030611
Tax Map No: 523400-309-013-0001-015-000-0000
Permission is hereby granted to: ROBF,RT&TINA GOVER
For property located at: 27 OHIO Ave
in the Town of Queensbury,to construct or*place 1
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'&TINA GOVER
22 CLARK St Septic Alteration Residential
Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
I.B.S. SEPTIC
2 I,OWF,R WARREN STREET
OIIEFNSBURY.NY
Plans&Specifications
2003-611
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25,00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Saturday,August 07,2004
(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 Town of Que sbury; ursday,August 07,2003
SIGNED B Jfor the Town of Queensbury.
Director of Buil g&C e 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: LC-
File Permit No. ✓3 (c)
Tax Map No.
Fee Paid
Owner's Name:
.................................... .................................................
Address: c'*7
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 Flow
1980 or older t3l x 150 gal/bdrm =
1980- 1991
x 130 gal/bdrm = MM-CROVED
1991—present x 110 gal/bdrm =
AUG '0 5 2003
Garbage Grinder Installed yes / no'—,1�1
Spa or Hot Tub Installed yes_ / no TOWN OF QUEE[qSBURY
BUILDING AND CODE
4.' PARCEL INFORMATION: (circle applicable information&indicate measurements)
Lyranhv Soil-Nature Ground Water Bedrock or impervious Material D ater Supply
Flat"' at what depth a hhatdepth municLpal.. -
olling (450IMP =jeet
�et well
Steep slope clay if well; water supply
%slope o I ther from any septic-system
depth: absorption is_j?.
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). Add250 gallons to the size
of the septic tank and leach field for each Garbage Grinder,Spa or Whirlpool Tub.
Septic Tank: lb 0 C�` gallon (min. size 1,000 gal.)
Tile Field: each trench ft. Total System"Length:
Seepage Pit(s): number Of-----.I-- size ofeach: ft. by ft.
Size 1f Stone to be used: # t depth or thickness feet
Bed System Size: x
Alternative System: length and/or size
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: 1 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.
Signature 6Yres'p 'ns e person Date
Appolldix t: ;
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Septic Inspection Report
Office No.(518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement 'Arrive: 06— m/ M. Depart; am/pm
742 Bay Rd., Queensbuiy,NY 12804 Inspector's Initials:
NAME: - it
PERMIT NO.0 C-0
LOCATION: INSPECT ON:
RECHECK:
Comments and/or diagram
Soil Type: an SV Loapz,/,Clay
Type of Water: unici:pg/Well Water
Waterline separation distanceft.
Well separation distance ft.
Other wells: ft,
Absorption Field: Total length ft.
Length of each trench ft.
De th of trenches ft.
Size of Stone
Seepage Pits: Number
Size: G x 2-'
Stone Size:
Piping Size
ae
Building to tank J�V<
Tank to x fiy:
Distribution Box t ield Pit
Opening Y
Location/Separations
-Foundation to tank
Foundation to abs2Eption 23 ft.
Separation of Pits
Conforms as per Plot.Plan
Location of System on Property:
Front Rear Left Side Right Side
Middle Front Middle Rear
System Use tatu
_Approved
Partial Approved and needs to be re-inspected,please call the*Building&Codes Office
Disapproved
L:\SueHemingway\Building-Codes.Inspection.FORMS\Sepfic Inspection Report.doc January 28,2003
BUILDING D T.
REVIEWED BY /
DATE
RECEIVED
AUG '0 5 2003
JCS f TOWN OF QUEENSBURY
BUILDING AND CODE
V/
Lah
seen or observed, or believe I saw evidence of,
cts such as houses, wells, trees, fences, etc.,
oo this document. I also represent that I have
4SIGNA
sured the-distances set forth on the diagram.,,
. TU
DATE
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