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2003-863 'TOWN OF UEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201 Community Development-Building&Codes (518)761-8256 CERTI F I CATE -OF COMPLIANCE Permit Number: P20030863 Date Issued: Tuesday, October 14,2003 - This is-to certif that wotictequested.to-be"done as shown,by Permit Number has'npen completed, Tax Map Dumber: 523400-295-013-0001,041.000.0000 Location: 920 WEST MT. Rd Owner: ROBERT&DONNA PALMER Applicant: ROBERT&DONNA PALMER This structure may be occupied as a: By Ordet of Town Board Septic Alteration Residential TOWN OF QUEENSBURY Director of Building&Coe 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: P200308 63 Application Number: A20030863 Tax Map No: 523400-295-013-0001-041-000-0000 Permission is hereby granted to: ROBERT&DONNA PALW.R For property located at: 920 WEST MY 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: ROBERT &DONNA PALMER Septic Alteration Residential 920 WEST MOUNTAIN Rd Total Value QUEENSBURY, NY 12804 Contractor or Builder's Name/Address Electrical Inspection Agency I.B.S. SEPTIC 2 LOWER WARREN STREET OIJEENSBITRY- NY Plans&Specifications 1003-863 SEPTIC ALTERATION AS PER APPLICATION $25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday, October 14, 2004 (Ifa 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 October 14,2003 SIGNED BY mn for the Town of Queensbury. Director of Building&Code Enforcement Applibation for Permit-Septic Disposal System Town of Queensbury'742 Bay Road Queensbury,NY 12804 (518) 761-8256 1. OWNER INFORMATION: ........... Offlee Use Location of installation: C File Permit Noc-q�,3= Tax Map Noa% o13 --r Owner's Name: T-- ..................... Address: d CZ, -P003 Suit Q�'EFZJV-r)ftV0.ivo saUR, 2. INSTALLER'S NAME AH'%* 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 Comp utation putation Total Daily Flo 1980 or older x 150 gal/bdrm = -1980- 1991. x 130 galfbdrm = 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) X-d6;6�ra-ohy SAiLZTature Ground Water Bedrock or Irni3ervious Material Do �esti, at,,SWDIV CFI�� ,(sand at ha depth at what 4epth nicipal )�—olling 11"affeet 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: jL1&d gallon(min.size.1,000 gal.) Tile Field: each trench� ft. Total System Length:c--)L,9 C9 Seepage Pit(s): number of sizeI of each: —ft. by_ft. to-to Size of Stone to be used: W TA, 6 / depth or thickness feet Bed.System Size: x Alternative System: length and/or size 6. HOLDING TANK SYSTEM: (if required) Number of tanks: t Size of each: gallons TOTAL Capacity: gallons Mote: 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. Signature of-respcMigfi e person Date ... , . . � ' . 'i'ativ�i`tyr cZ�irc+ii�l�tit•�r � • �:4�;wc;rs sititl :ic:wsi7:� I}i�j>�t�stl t.listt�{t i'. • - A'1�.`'it)ILI''�1'ICIT�`d. Ii'II�I.,I.) '. �I�;I'/l1tA'I'IL)1`�1 ItI�LZ1.3i It1rw Il.N'TS �.'�• rt tt'rvt . .01 I L .} � .••,'. ''�' 5c t*tic. ��. w� I.�r*... � �i;*�tiL•.tlnr•ti p�ytTR,f+twr 1 - i_...._r---"" ....�-- •..."""'"ter �,�.w,,,.,,.....--='""""_"".. ?. slr,N,kTup,B 8a INFopuv noig Foli. aYvriaiursL 1-� `.s.ty►oss.•+.•.•••:; t4AJ Septic Inspection Report Office No.(518)761-8256 Date Inspection requ c Date Inspect ion n Queensbuiy Building&Code Enforcement Arrive: a ppart: 4 742 Bay Rd., Queensbuiy,NY 12804 Inspector's Initials NAME: T NO.: LOCATION: S ECTON: 10& Cj3 RECHECK: Comments and/or diagram Soil DY Sandg lay Type of unicipa jjWell Water Waterline se par �Tance Well separation distance ft. Other wells: ft, Absorption Field: Total length --ft. Length of each trench Depth of trenches Size of Stone P-M b Q--L, Seepage Pits: Number Size: x Stone Size: Piping Size Type Building to tank Tank to Distribution Box. Distribution BoxP6-Vield git W. 8DEZ55 Opening Seale)K IV/-wpartial Location/Separations Foundation to tank ft. Foundation to..absorption ft. Separation of Pits ft. Conforms as per Plot Plan V Y N Location of System on Property: Front Rear Left Side Right Side Middle Front Middle Rear System Use Sta s-:_ Approved Partial Approved and needs to be re-inspected,please call the Building&Codes Office --Disapproved L:\SueHomingway\Btiilding.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003 THIS PLANTO 823 ON PROJECT SITE AT ALL TIMES FOR SIln or obs".." all d flu Cc's Such a elleve I sa -` --�, . s V1 THE DURATION OIIlhouses, v CCN etlidence of, UIT s -'fso etc z)Trn dVION eo, s I"d mj��dis'nce es en th cl tt set hauc 1.0 th o n the uji�gram T TONN' 0'r 'RY BUILDING REVIEWED BY a]0 C DATE o 0 26 Z 11 —1 00 m �d ?v5 4c z n, 0 m < 0 m o m C