2003-747 r r
1 44\\ TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518)761-8256
C ERTI F ICATE O F UP-0M P L IAN C E
Permit Number: ' P20030747 Date.Issued: .Tuesday, September 09,2003
This is to certify that-work requested.to be done as shown by.Permit`Number P20030741
has been completed.
Tax Map Number; 523400-302-014-0003-044-000-0000
Location: 20 JEROME Ave
Owner: MARY JANE CANALS
Applicant: MARY JANE CANALS
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential = TOWN OF QUEENSBURY
Director of Building&Code Enforcement
Application for Permit--Septic Disposal System
Town o.f Queensbury 742 Bay Road Queensbury,NY 12eo4 (S18) 761-8256
OWNER INFORMATION:
.,.._.....�....,,...,,. ................_......._.._..._ ......_....._,.,.......�.
(� (2 Office Use �
Location of installation: //''��
Tax Map No. / / - Fide Perini W `".
Owner's Name: (�,.J%�,�// :%
�,dtr Fee Paid 4,'".
Address: 4:)-r- <U' ,- C�//m c,,I LAN 1..,_......_ ... .............._...... _ ._...._ .._,._..... _.
2. INSTALLER'S NAME
PHONE NO.
3. RESIDENCE INPORMATI;ON: (circle year of dwelling,indicate.#bedroom(s) and multiply#o
bedrooms with applicable gallons per bedroom to equal total daily,; O
Year of H use: od
No. of Bedrooms x -:g=utation = Total Dail T Off` 2003
1980 or older
x 150 galibdrmIJ
,
19911 -pr sent x 110 gallbdrm = � 1D Cl}
Garbage Grinder Installed yes` / no
Spa or Hot Tub Installed yes / no
4. PARCEL rNFORMA,TION: (circle applicable information&indicate measurements)
T o So' afore ound Water Bedrock r Im ervious Material Domestic
Water Su ]
laz and ai what depth at what depth unicipal
o ling . oam feet feet
Steep slope clay if well;water supply
/oslope other from anysepdc-system
depth: 'absorption is ft.
other
Percolation Test: (To be completed by licensed professional engineer or architect)
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: I C)0 c) gallon(min.size 1,000 gal,)
Tile Field: each trench�. Total System Length: ft.
Seepage Pit(s): number of �A- size of each: -- ft, by ft•
Size 9f Stone to be used. # / depth or thickness _,feet
Bed System Size: x
Alternative System; length and/or size 0 oX,J0 i �9
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: / Size of oath: 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.
I have read the regulations with respect to this application and agree to abide by these and all
requir ents the Town of Que bury Sanitary Sewage Disposal Or ea.
� 0
ign ture of respons a person vDate
TOO/TOO 01 YVA CC:CT 917U 'COOZ/TO/LO
Septic Inspection Report
C�
Office No.(518)761-8256 Date Inspectioneye
Queensbury Building&Code Enforceinent Arrive: rt:
742 Bay Rd., Queensbury,NY 12804 Inspect 's Initi
NAME:, JLOCATION:
RECHECK:
Comments and/or diagram
Sail T e: Sand/Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft.
Well separation distance ft.
Other,wells: ft.
Absorption Field: Total length
Length of each trench -y .
Depth of trenches
Size of Stone
See a e Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank o,.
Tank to Distribution Box
Distribution Box to' 'Field/Pit o`
Opening Sealed: Y/N/Partial
Location/Separations
Foundation to tank ,rft,
Foundation to absorption ft,
Separation of Pits ft.
Conforms as_per Plot Plan Y N
Location of System on Property.
Front Left Side Right Side
iddle Fro iddle Rear
S stem se S tus:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:\SueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
C) C)IN)
Septic Inspection Report
Office No.(518) 761-8256 Date Inspection request ei quest eiv
r v
r
Queensbury Building&Code Enforcement Arrive: a In e rt: a
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initial
0
NAME: ) C-,A- PE9NO.:
LOCATION: py)R Y--N INSPECT ON:
RECHECK:
Comments and/or diagram
Soil Type: Sand/Loam/Clay
DTe of Water: Municipal/Well Water
Waterline separation distance
Well separation distance
Other wells:
Absorption Field: Total length ft. gv
Length of each trench
Depth of trenches
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box
Distribution Box to Field I Pit
Opening Sealed: Y/NI Partial
Location/Separations
Foundation to tank
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Location of System on Property:
Front Rear Left Side Right Side
Middle Front Middle Rear
System Use Status:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
1
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BUILDING
REVIEWED BY
DATE
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