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2003-768 TOWN OF QUEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201 Community Development-Building&Codes (518)761-8256 CEPTIFICATEOF COMPLIANCE Permit Number: P20030768 Date Issued: Thursday, September 18,2003 This is to certify that work requested to be done as shown by Permit Number P20030768 fas been:completed, _. Tax Map Number: 523400-308-018-0001-072-000-0000 Location: 97 REVERE Rd owner: CHARLES&LINDA WILLMS Applicant: CHARLES&LINDA WILLIAMS This structure may be occupied as a: By Order of Town Board Septic Alteration Residential TOWN OF QUEENSBURY Director of Building&Code Enforcement 7 X., TOWN OF QUEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518)161-8201 Community Development-Building&Codes (518) 761-8256 BUILDING PERMIT Permit Number: P20030768 Application Number: A20030768 Tax Map No: 523400-308-018-0001-072-000-0000 Permission is hereby granted to: CHARURS &TJNDA WIl J JAMS For property located at: 97 REVERE Rd 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: CHARLES &LINDA WILLIAMS Septic Alteration Residential 97 REVERE Rd Total Value QUEENSBURY,NY 12804 Contractor or Builder's Name./Address Electrical Inspection Agency I.B.S- SEPTIC 2 LOWER WARREN STREET 01JEENSBURY. NY Plans&Specifications 2003-768 SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS $25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday, September 17, 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 Queensbury; Wednesday, September 17, 2003 SIGNED BY for the Town of Queensbury. Director of Mild Enforcement Application for Permit Septic Disposal System .Town of Queensbury 742 Bay Road Queensbury,NY 12804 (SIS)"761-8256 1. OWNER INFORMATION: � rC �� Office Use Location of installation: ram, File Permit No. Tax.Map No. Owner's Name: i '"2 c ,c 1� C.✓ "Fee`Paid......................... . ....................................................................... Address; ` 2. INSTALLER'S NAME ; `>- 3< r , 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 = Y 1980—1991 x 130 gal/bdrm = 1991 —present x 110 gal/bdrm = - Garbage Grinder Installed yes_ / no' _ Spa or Hot Tub Installed yes _ / no �Q133 4: PARCEL INFORMATION: (circle applicable information&indicate xneasurrQzis) O� �ra�s� C3J 1Ji tlFAl ®O T a h Sei ature Ground Water Bedrock or Im ervious Material .Darnestic Water Su 1 ITIat-7 san at ha depth at h t depth municipal - L-Rolling oam .feet feet well Steep slope clay if well; water supply _%slope other from any septic-system depth: absorption is ft. Percolation Test: (To be completed by Iicen_sed 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 Planning Board approved . Add 250 subdivision of the septic tank and leach field for each Garbage Grinder,Spa or Whirlpool Tub. ) gallons to the size Septic Tank: ©C 6 ' gallon (min. size 1,000 gal.) l_. ��` n 47 Tile Field: each trench ft. Total System Length; ft. Seepage Pit(s): number of_�— size of each: ft. by911, ft. Size/of Stone to be used: # / depth or thickness 1 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 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 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. SignaturMre�spons�ible erson Date `I'azvn of tZtiec+stxat�tti-y •:ic.Lvt:r:c St11tT i1'4`LVSt�;c: I}ist;lartstt (.1la;�irr Altl�rtttltx �: ! . POND ' SI�;i'.1�1tA'I'It?P+I I�:I�i.�t:�t'II.I!i1•]It;t�l'1`:� . ._. ►Souk Ci t� ,� - , ��,,y♦ 11�.>txt�. G � `,�� . . ` •♦��,,,♦•-'ter ! �t;,�t21:.tljtr•f t ......... ?. SIGNP►'7.'LTRE &.ll�tB�RMATIS por,T `ak't�i�t.`s7tks� ':cawvLr�+:�..•♦•••••,•, Septic Inspection Report Office No. (518)761-8256 Date Inspection request received: 11,11". !' am/pin Queensbury Building&Code Enforcement Arrive: a -p Depart: 742 Bay Rd., Queensbuiy,NY 12804 Inspector's Initial NAME: PERMIT NO.: (0 0 LOCATION: C>,::�j k!� t INSPECT ON: RECHECK. Comments and/or diagram Soil Type: S ! lay Type of Water: Ounicipa If Well Water Waterline separati-off-distance Well separation distance Other wells: ft, Absorption Field: Total length ft, Length of each trench Depth of trenches ft. --Size of Stone Seepage Pits: Number Size: x Stone Size: Piping Size DTe Building to tank Tank to Distributioi Box Distribution Box f ield Pit Opening S I Partial Location/Separations Foundation to tank Foundation to absorption Separation of Pits 4ft. Conforms as per Plot Plan VY N Location of Sys 7 on Property: Front (j 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 L:\SueHerningway\Btiilding.Codes.Inspection,FORMS\Septic Inspection Roport.doc January 28,2003 ko V 2r a "I have seen or observed, or believe I saw evil nee of, (� all objects such as houses, wells, trees, fences, tc., t shown on this document. I also represent that I have personally measured the distances set forth on the diagram." SIGNATURE DATE RLVJ AG C13M3IA3 I? ONialine N M7 no