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TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development-Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20030862 Application Number: A20030862
Tax Map No: 523400-301-019-0001-055-000-0000
Permission is hereby granted to: JOSEPH&T,ORT O'SHAT TCTI NF.SSY
For property located at: 33 FERRISS 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. Tyne of Construction Value
Owner Address: JOSEPH& LORI O'SHAUGHNESS
33 FERRISS Dr Septic Alteration Residential
Total Value
QUEENSBURY, N.Y. 12804
Contractor or Builders Name / Address Electrical Inspection Agency
OTTEENSBTTRY SEWER
JAY SWEET
Plans& Specifications
2003-862
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday, October 15, 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 TaVM If Queen ury a nesday, October 15, 2003
SIGNED BY for the Town of Queensbury.
Director of Building&Code nforcement
Application for Permit-Septic Disposal System 3ol.
Town of Queensbury 742 Bay Road Queensbury, NY 12804 (518) 761-8256
1. OWNER INFORMATION:
..............................................................................................................�� \ .�....
�Location of installation: P���� Office Use
Tax Map No. _/_/_ File Permit No.
Q ; Fee Paid
Owner's Name:
H
Address:
�� G �uuo
2. INSTALLER'S NAME : Q V,IL C,�,c ee ¢, PHONE NO ! � Co
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate#bedroom(s) and multiply #of
bedrooms with applicable gallons per bedroom to equal total dailyflow)
Year of House: No of Bedrooms x Computation = Total Daily Flow
1980 or older _ x 150 gal/bdrm =
1980— 1991 x 130 =
1991 —present 0 al/bdrm —
Garbage Grinder Installed yes_ 11no
Spa or Hot Tub Installed yes
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
o a h Soil Nature Ground Water Bedrock or Im ervious Material Domestic Water Supl3lv
lai sap at what depth at what depth munici
Rolling loam feet feet we
Steep slope clay if well; water supply
slope other other from any septic-system
depth:_ absorption is
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:/ Z72 —O gallon (min. size 1,000gal.) 7
Tile Field: each trench �� ft. Total System Length: o� tl.
Seepage Pit(s): number of size of each: ft. by ft.
Size of Stone to be used: # / depth or thickness feet
Bed System Size: x
Alternative System: / /1 {i/f rg f�i.J 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 Town of Queensbury Sanitary Sewage Disposal Ordinance.
V le, - / 2 0,3
Signature of r sponsible person Date
Septic Inspection Report
Office No. (518) 761-8256 Date in ection request 1V d: a
a art:
Queensbury Building& Code Enforcement Arrive*.
Inspector's N
742 Bay Rd., Queensbury,NY 12804 P
i _ P RMIT NO.:
NAME: — SPECT ON: —�
LOCATION:
RECHECK:
Comments andlor diaeram
Soil T San
T e of Munici ell Water
'
Waterline se nce ft
Well separation distance ft
Other wells: ft
Abso tion Field: Total len ft.
Len th of each trench ft
De th of trenches _ >7
Size of Stone
See a e Pits: Number x
Size:
Stone Size: _
Size T e
Pi in - D
Buildin to tank
Tank to Distribution Box 1 TO VD F\�Tl�fl C p(L�j
Distribution Box t ield/Pit
enin Sealed: Partial
waration
arations ft
tank ft L
abso tion
Pitij
s er Plot Plan Y N
Location of System on Property:
Front Rear t Side Right Side
Middle F nt Middle Rear
System Use S tus:
Approved lease call the Building&Codes Office
Partial Approved and needs to be re-inspected,p
Disapproved
L:\SueHemingwway\nuilding.Codes.tnspection.FORMS\4eptic Inspection Report.doc January 2g,2003
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