2002-609 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 .(518)761;8201
Community Development-Building&Codes (518)761-8256
CERT IFICATE OF COMPLIANCE
Permit Number: P20020609 Date Issued: Friday,June 06,2003
This is to certify that work requested to be done as shown by?emut Number P20020609
has been completed.
Tau Map Number: 523400-297-010-0001-032-000-0000
Location: 10 STONEWALL Dr
Owner: THOMAS&CAROL BOLEN
Applicant: THOMAS&CAROL BOLEN
This structure may be occupied as a:
By Otder of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
(01-INN
Nector of Building&Code Edoteement
TOWN OF.QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20020609 Application Number. A20020609
Tax Map No: 5234400-297-010-0001-032-000-0000
Permission is hereby granted to:
For property located at: 10 STONEWALL Dr
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: THOMAS &CAROL BOLEN
10 STONEWALL Dr Septic Alteration Residential
Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans&Specifications
BP 2002-609
Septic Alteration for residence as per plot plan and specifications.
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Friday,July 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 Town sbury. Thursiday,July 18,2002
SIGNED BY for the Town of Queensbury.
Director of Building& e E cement_
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ApplicAtion for Pernik—Septic Disposal-System
Town of Queehsbwy 742 Bay Road Queensl7my,MY 1 A0-41518) 761-8256
1. OWNER INFORMATION:
..... ......
Location of installation:
Tax Map No. _5_6 3 File PC liitNf-
Owrier's Name: Fee Paid
.......... ........................................... ..............
Address: =D VF_
- 16 JUL 6 2
2. INSTALLER'S NAME ;Lq I PHONENO. .1
7'011 002
�q_Pr
-3. RESIDENCE INFORMATION. (circle year of dwelling, indicate 9 bedroom(y)and irififtiql,y)#q jo yn_6 c8m=
bedrooms with applicable gallons per bedroom to equal total
Year of House: No. of Bedrooms x Computation Total Daily Flow
98 0�or o I(de x 150 gal/bdrm ej
1980— 1991 x 130 gallbdrm
1991 —present x I 10 gal/bdrm
Garbage Grinder Installed yes no
Spa or Whirlpool Installed j yes no
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
o-ra
Nature Ground Water Bedrock or Impervious Material Domestic Water Supply
1,71at sand at w la I
Rolling town �depth at what depth municipal
feet
—feet well
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 etjgineer or architect)
--Rdlbe—. V in-7inute—per inch —77 7 5,c- /0 A) 2
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: gallon (min. size 1,000 gal.)
Tile Field: each trench- J'V Total System Length: ,2
Seepage Pit(s): number of size of each: fl. by_ .
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: 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 A INFORMATION FOR RESPONSIBLE PERSON(please read)
For your protection,pl6ase 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 Qpeensbury Sanitary Sewage Disposal Ordinance.
C)
Signature of responsible person Date
Septic Inspection Report
Office No.(518)761-8256 Date inspection request received: ��
Queensbury Building&Code'Enforcement Arrive: arnlp i , t1
742 Bay Rd.,Queensbury,NY 1,2804 Inspector's Initials: �j
NAME: PERMIT NO.:
LOCATION: r INSPECT ON:
RECHECK: -�
Comments and/or diagram
Soil T e: San Lo /Cla
Type of Water: IMShicipal Well Water
Waterline separation distan e ft.
Well separation distance ft.
Other wells: $,
-Absorption Field: Total length 2 t.
Length of each trench ft.
Depth of trenches ft
Size of Stone 7—,—
Seepage Pits: Number
Size: x
Stone Size: .
P17ping Size Type
Building to tank •. %vim
Tank to Distribution Box c D
Distribution Box to Field/Pit
Opening Sealed: Y/NI Partial
Location/Separations
Foundation to tank
Foundation to absorption Z ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Location stem on Property:
Front ear Left Side Right Side
Middle Front Middle Rear
System Use St is•
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:1SueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
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