2003-889 TOWN OF' QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518)761-8256
EERIRFICATE O.FCOMPLIANCE
Permit Number: P20030889 Date Issued: Thursday, October 30,2003
This is to certify that work requested to be done as shown by Permit Number P20030889
has been completed.
Tax Map Number: 523400-303-020-0002.024.000-0000
Location: 41 BOULEVARD
Owner: DAVID A.JONES
Applicant: DAVID A.JONES
This structure may be occupied as a:
By Ordex of Town Board
Septic Alteration Residential TOWN OF QUEENSBURX
Loa,
Direetor 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: P20030889 Application Number: A20030889
Tax Map No: 523400-303-020-0002-024-000-0000
Permission is hereby granted to: DAVID A. TONES
For property located at: 41 BOULEVARD
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: DAVID A. ZONES Septic Alteration Residential
41 BOULEVARD Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name Address Electrical Inspection Agency
Plans&Specifications
2003-889
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday, October 27, 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 T f Queen
uee 7ty; 7onday, October 27, 2003
SIGNED BY for the Town of Queensbury.
;'Director of BuildalcN Enforcement
Applfimtion for Permit=Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
Location of installation: e vard -61s' 'Office Use
y!
File Permit No. 03
Tax Map No.
e-S Fee Paid
Owner's Name:
............... ................
Address: L4 --I o ard
2. INSTALLER'S NAME PHONE NO. L7 A 9
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 D Flow%
3 x 150 gal/bdrm
1980-1991. x 130 gal/bdrin P '12003
1991 -present x 110 gallbdrm.
Garbage Grinder Installed yes no- ><'
Spa or Hot Tub Installed yes no
4.' PARCEL INFORMATION: (circle applicable information&indicate measurements)
Topography Soil Nature Ground Water- Bedrock or Impervious Material Domestic Water Supply
an at what depth at what depth
Rolling -To-am J Z feet lJoy- e-feet we-T1-
Steep slope clay if Well; water supply
%slope other from any septic-system
depth: absorption is
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 br'Whirlpool Tub.
Septic Tank: 10#0 ' gallon (min. size 1,000 gal.)
Tile Field: each trench ft. Total System Length. ft.
Seepage Pit(s): number of - size ofeach: ft. by ft.
Size of Stone to be used: "# depth or thickness feet
Bed System Size: x
Alternative System:--Cn VCAJorS length and/or size V 6)
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: 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.
C7 f')L-14 L03
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Septic Inspection Report-
Office No. (518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/ m epart:� am/pm
NY 1,742 Bay Rd., Queensbuiy,N2804 Inspector's Initials m&
NAME: J� � PERMIT NO.: os r e LOCATION: INSPECT ON: U 3U U
RECHECK:
7` Comments and/or diagram
Soil T : Sa lay
Type of 5—ter. un' �%Well Water
Waterline separation distance _ft.
Well separation distance ft.
Other wells: &
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenches ft.
Size of Stone L
Seepage Pits: Nuinber
Size: x
Stone Size:
Piping S i ze,, T e
Building to tank G
Tank to Distribution Box
Distribution Box to Field/Pit U� K
Opening Sealed: Y/N/Partial
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits 7 ft.
Conforms as_per Plot Plan V Y NG '� '7
Location of Sy .Property:
Front (Rear Left Side Right Side
Middle Front Middle Rear
S stem Use Stat/s:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
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