2003-671 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: P20030671 Date Issued: Monday, September 01,2003
This is'to certify that work requested to be done as shown by Permit Number P20030.671 -
has been,coinpleted.
Tax Map Number: 523400-302-005-0001-021-000-0000
Location: 12 VISTA Ct .
Owner: MEN BLAKE
Applicant: BELEN BLAKE
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: P20030671 Application Number: A20030671
Tax Map No: 523400-302-005-0001-021-000-0000
Permission is hereby granted to: HF,I.FN BLAKE
For property located at: 12 VISTA Ct
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: HELEN BLAKE
12 VISTA Ct Septic Alteration Residential
Total Value
QUEENSBURY,NY 12804-0000
Contractor or Builder's Name J Address Electrical Inspection Agency
I.B.S. SEPTIC
2 LOWER WARREN STREET
0IJEENSBIJRY.NY
Plans&Specifications
2003-671
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Sunday,August 15,2004
(I£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 T Queen ury r' ay,August 15,2003
SIGNED BY for the Town of Queensbury.
Director of Building&Code nforcement
Application for Permit-Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
.........................................................................................................................
Use
Location of installation: C-/ % Office
Tax Map No. File Permit No.-03-67/
Fee Paid Owner's Name:
......................... .......... ......................... ....................
Address:
2. INSTALLER'S NA.1v1E 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 x 150 gal/bdrm =
1980- 1991 x 130 gal/bdrm =
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)
rT 1:a�hh . SbgNature Ground Water Bedrock or Impervious Material Domestir-Water Sunn1v
1ati. at what depth at what depth 'Intrn—icipal
11
olling loam —feet —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 U architect)
engineer or architec
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.
SepticTank: gallon (min. size 1,000 gal.)
Tile Field: each trench ft. Total System'Length: ft.
Seepage Pit(s): number of size of each: ---�ffft. by
Size�f Stone to be used: # depth or thickness. feet
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 13 6-29 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
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Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/ >)(�depart: *PM
Bay Rd.,Queensbury,NY 1,2" Inspector's.Initials: _g
NAME: Vx PERMIT NO,.: 0.1„317�1
LOCATION: INSPECT ON: 'Q—
:RECHECK:
Comments and/or diagram
Soil Type: Clay
Type of Water Municip I/Well Water
Waterline sep ation ` tance ft.
Well separationdtgInce = ft.
Other wells: ft.
Abso Lion 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 T e
Building to tank
Tank to Distributio Box j -2715
Distribution Bo ield t Pit t&
Opening Sealed Y/NI Partial
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Location o ystern on Property:
Front . Rear Left Side Right Side
e Front Middle Rear
System Use Statu .
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
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