2001-430 i low ,
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20010430 Date.Issued: Thursday, June 28,.2001
This is to certify that work requested to be done as shown by Permit Number P20010430
has been completed.
Tax Map Number: 523400-296-069-0001-010-000-0000
Location: 6 QUEENS Way
Owner: MITCHELL A COHEN
Applicant: MITCHELL A COHEN
This structure may be occupied as a:
By Order of Town Board '
Septic Alteration Residential TOWN OF QUEENSBURY
. (DJ I
Director of Building&Code Enforcement
TOWN OF QUEENSBURY
*AV 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20010430 Application Number: A20010430
Tax Map No: 523400-070-000-0004-006-000-0000
Permission is hereby granted to: MITCHELL A COHEN
For property located at: 6 QUEENS Way
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: MITCHELL A COHEN
PO BOX 21 Septic Alteration Residential
LAKE GEORGE,NY 12845 Total Value
Contractor or Builder's Name/ Address' Electrical Inspection Agency
BATEASE, GLENN
71 BIG BOOM ROAD
OUEENSBURY.NEW YORK
Plans &Specifications
2001-430
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID - THIS PERMIT EXPIRES: Wednesday,June 18,2003
(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 To Queen ury Mo day,June 18,2001
SIGNED BY for the Town of Queensbury.
Director of Building Co nforcement
• ' Application for Permit— Septic Disposal System
T own of Queensbul y 742 Day Road Queenshury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
6 , ..
Office Use
Location of installation: \ 5\--2a File Permit N f O 1— 43°
Tax Map No. / / ` _
`� VIM Foo Paid
Owner's Name:
Address:
2. INSTALLER'S NAME : . . 53\--c 6,..r '-`-N. PHONE NO.
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate If bedroom(s) and multiply II 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 =
1980— 1991 x 130 gal/bdrm = t E�tVED
1991 — resent x 110 gal/bdrm = r '
p JUN182001
Garbage Grinder Installed yes / no 14 TOWN OF QUEENSBUP`
Spa or Whirlpool Installed yes / no >C' BUILDING AND COP .
4. PARCEL INFORMATION: (circle applicable information & indicate measurements)
TlQart9 UI .cQnaill l
a IMP— Qa.It Oh.adt Wnplvr _PQ .aI4t cwkvrtJ cmppN iUU.s._Mt1.tQJsil_.— Wggtcr_Stipply
Rolling loam feel fret we!!
Steep slope clay if well; wafer supply
___%slope other from any septic-system
depth: absorption is ' Ji.
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 it licensed
professional engineer or architect (unless installed in a Maiming Board approved subdivision). Add 250 gallons to the sire
of the septic tank and leach field for each Garbage Grinder, Spa or Whitliwol Tub.
Septic Tank; gallon (min. size 1,000 gal)
Tile Field: each trench fl. Total System Length: fl.
Seepage Pit(s): number of �V- size of each: fl. by f.
Size of Stone to bo used; II ___ ,___ / depth or thickness,__•__•_.__...___fi'L't
. `�
Bed System Size: 1 0 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 Quoonsbu ,any permit or approval granted which is based upon or is granted in
reliance upon any in.tor'd\misrepresentation or failure to make a material fact or •
circumstaico known bor'�`n behalf of an applicant, shall bo void.
I have read the ro:iilntions with rose'44ct to this application and agree to abide by those and all
requirements of th. Town offiuueensbury Sanitary Sewage Disposal Ordinance.
V . -,_'' tl---k iI
Signature if respo'Bible person Date
TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name (de
1.Location 2oeiiJ
Date 1p/2)/Oi Permit # d /—
A-60
SOIL TYPE: Sand-Loam-Clay-
Results of Percol ;t'on Test-
(if applicable) 'ate Minute/Inch
TYPE OF SYSTEM:
ABSORPTION FIELD. To ,al Length
Length of each 'renc
Depth of'' Tench s
Size of stb e
SEEPAGE PITS. ui' e r-
Size - ft. x ft.
Stone size .�
PIPING: Size Type
Bldg. to Tank
Tank to Dist. Box
Dist. Box to ield/Pit
Openings Sealed? Yes No Partial
LOCATION/SEPiRATIONS:
Foundation to Tank feet
Foundation t► Absorption feet . .
Separation • " 'Pits feet
Conforms as per Plot Plan Yes No
LOCATION OF SYSTEM ON PROPERTY:
(circle o e)
Front - Rear - Left Side - Right Side
Middle Front - Middle Rear
COMMENTS: ':.Lj
dk . . 6 cal
,,
y
• //Jai
SYSTEM USE APPROVED: YES NO
Arrived: //
Departed:
Building Sinsitor
, ,Nr '
TOWN OF QUEENSBURY
BUILDING_ & CODE ENFORCEMENT __.).1
742 Bay Road
Queensbury NY 12804
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name (22) I L �1,,o 9
_k
Location //��
Date( ' O 1Permi t #O/ /3O
SOIL TYPE: Sand-Loam-Clay-
Results of Percolation est-
(if applicable) Rte-Min►te/Inch
TYPE OF SYSTEM:
ABSORPTION FIELD: Total L-ngth
Length of each tr:nch
Depth of trenches
Size of stone
SEEPAGE PUS: Num•er- /
Size - 700 ft. c 0 ft.
Stone sizes i ',--ft.--,
PIPING: ze Type
Bldg. to Tank s`,c._
Tank to Dist. Box
Dist. Box to Field/Pit_ C " ,sue.
Openings Sealed? iii-s, No Partial
LOCATION/SEPARATION .
Foundation to Tank feet
Foundation to Absorpt'on . /S .fe.etS%A
Separation of Pits eet
Conforms as per Plot Plan Ye , No
LOCATION OF SYSTEM 0 PROPERT :
(circle
Front - R�a� - Left ide - Right Side
Middle -ront - Middl - Rear
COMMENTS:
•
SYSTEM USE APPROVED: a NO
Arrived: /20/4-
Departed:
0
Building In ector
MITCHELL A. COHEN, D.D.S. Ja6/- lea
48 AMHERST ST. I A'
- P.O. BOX 232 JUN 1 8- 2001
LAKE GEORGE, NEW YORK 12845
TELEPHONE (51 8) 66 -40 4 / ) `�•})�' OF QVEENSB(.i'
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" seen r bbse v�d,or believe I saw evidence of, -
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all objects su h as��house�S,wells,trees,fences,etc., - l. ,.
shown on 'chi docu ent,palso represent that I have -
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