2003-807 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201 .
Community Development-Building&Codes (518)761-8256
CAR1"IFICATE
OF COMPLIANCE
Permit Number: P20030807 Date Issued: Thursday,September 25,2003
Thin s-to certify that work requested to be�done,as shown by Permit Number : 120030807
has been completed. _ _. ..... . . .. ....... . _ _. ...,. . w .
TaxMap Number: 523400-303-016-0001-018-000-0000
Location: 82 QUEENSBURY Ave
Owner: MAR.CIA TYMINSKI
Applicant: CARRIE GREEN
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: P20030807 Application Number: A20030807
Tax Map No: 523400-303-016-0001-018-600-0000
Permission is hereby granted to: CARRTF GREEN
For property located at:
82 QUEENSBURY Ave
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: MARCIA TYMINSKI Septic Alteration Residential
82 QUEENSBURY.Ave Total Value
QUEENSBURY,NY 12804
Contractor or Builders Name Address Electrical Inspection Agency
I.B.S. SEPTIC
2 LOWER WARREN STREET
,OIJEENSBITRY- NY
Plans&Specifications
2003-807
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Saturday, September 25, 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; Thursday, September 25, 2003
SIGNED BY If lllpww� for the Town of Queensbury.
'Director of BuilaWo%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: C-
File Permit No.
Tax Map No.
Owner's Name: r-rr Fee Paid
............................... ...........................................................................
Address: Ac.,-c-
2. INSTALLER'S NAME PHONE NO.
3. RESIDENCE DENCE 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 = �r(f)
1980- 1991 x 130 gallbdrm =
1991 —present x 110 gal/bdrtn = R, E D
Garbage Grinder Installed yes no"[5 SER"2 4 2003
Spa or Hot Tub Installed yes no T a OWN OF QUEENSMMY
BLIILDING All-ID CODE
4: PARCEL INFORMATION: (circle applicable information&indicate measurements)
h S re GroundWater Bedrock or Impervious Material Donw-%tio Water Supply
. (�a C�7a� at h depth at what depth
o Ilin'
lling 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 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: I/,!�Fo a - 91110,(min. size 1,000 gal.)
Tile Field: each trench ft. Total System'Length:-Qo— a
Seepage Pit(s): number of size of each: _j?. by_ft.
Size of 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: 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 To f Queensbury Sanitary Sewage Disposal Ordinance.
0,0P 2--d
Signature of responsible person Date
..„ice ...
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Septic Inspection Report
Office No. (518)761-8256 Date Inspection request received,
Queensbury Building&Code Enforcement Arrive: ani/pin Depart: �' pni
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials: J99C--;1
NAME: QAE, PERMIT NO.:
LOCATION- INSPECT ON:
RECHECK:
Comments and/or diagram
Soil TYP I Sand_44' � Clay
Type of Water:��icif�,al/Well Water
Waterline separa-t1outT9fante
Well separation distance
Other wells: ft.
Absorption Field: Total length ft.
Length of each trench
Depth of trenches
Size of Stone
-Seepage Pits: Number
Size: x
Stone Size:
Piping Si7,q, Type
Building to tank 13-5
Tank to Distribution Box rj• ct
Distribution Box" o Field Pit
Opening Sealen/NI Partial
Location/Separations
Foundation to tank
Foundation to absorption. ft.
Separation of Pits ft.
L Conforms as per Plot Plan
Location of System o
Front (9', CTSid`,ty Right Side
Middle Front Middle Rear
_System Use Statzs-
Approved
Partial Approved and needs to be re-inspected,please call the'Building&Codes Office
Digapproved
L:\SueHen-dngway\Building-Codes.inspection.FORMS\Septic Inspection Report.doc January 28,2003
Tol-OW 4 O (���`���� � ��ve seen or.nbserved, or believe 1 saw evidence of,
bjects such as houses, wells, trees, fences, etc.,
BUILDING on this document. I also'represent that I have
Merally measured the distances set forth on the diagram."
REVIEWED BY J
DATE �7 !IR
SIGNATURE DATE
SEP 2 4 2003 rcr- C
TOWN OF QUEENSBURY
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