2002-786 1�
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: P20020786 Date Issued: Wednesday, September 18,2002
This is to certify that work requested to be done as shown by Permit Number P20020786
has been completed.
Tax Map Number: 523400.295-014.0002.004.000.0000
Location: 21 WHIPPOORWILL Rd
Owner: MICHAEL&MARY ELLEN HAVERN
Applicant: MICHAEL&MARY ELLEN HAVERN
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: P20020786 Application Number: A20020796
Tax Map No: 523400-295-014-0002-004-000-0000
Permission is hereby granted to: MICHAFT, &MARY FLUN HAVERN
For property located at: 21 WHIPPOORWILL 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: MICHAEL &MARY ELLEN HAVE Septic Alteration Residential
21 WHIPPOORWILL Rd Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
DAN DRELLOS
60 LAUREL T.A
01JEENSBURY.NY 12904
Plans&Specifications
2002-786
Residential septic alteration per plot plan and specifications.
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday, September 17,2003
(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 T<N�n of eern *"-,-September 17,2002
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
.,.518,•,745..4437 '
w„FILE No.638 04i02, '02 ,AM 'SS:25.;III:TOWN OF QUEENSBURY FAX:,518, 745 '4437 PAGE 1
Application-for Permits-8eptlo b1800601 Syetem
Towtt,of,Queettabury 7'42 SaY Road O Wnsbusy,lVY ??804 (318) �67-8?S6
1. OWNER lahaoRMATION, , C►lfice[Tee
. ...� .
Location of installation: �, �/V'��l L=`=--�=L--- ���-7 .
File Permit No..
Tax Map No. f L
C9 fZi� Fee-Paid
Owner's Name` ./`Vl.C/itol.":�/til.- ......................................... .._.. ...... ..._
Address:
2. INSTALLER S NAME' PHONE NO.'
3. RESIDENCE INFORMATION:'(circle year of dwelling,indicate#bedroom(s) and multiply#of
bedrooms with applicable gallons per bedroom to equal total dailyflaw)
Year of House* No.of jagdrooms 2s gQ=UtjWgn, TxW Daft F.
1986 or older x 150 gaal/bdrrn' •`�J
1980-1991 x 130 gallbdrm ?
1991 -present x 110 gaVbdrm
Garbags Grinder Installed yes— / no
Spa or'Whirlpool Installed yes_ / no
4, PARCEL INFORMATION: (circle applicable information indicate measurements)
at sand at what depth at what depth
ng m feet ,1kst' we
Steep slope clay if well;water supply
%slope other from any septtc-system
depth: absorption is
other
Percolation Test: (To be completed by licensed professional engineer or architec(
Rate: minute per inch
S. PROPOSED SYSTEM; All individual**wage disposal systems must be designed by a licensed
professional ieughwor or atchitact(unless installed iu a Planning Board approved subdivision). Add 230 •gallons tc«'the size
of the*optic tank and leach field for tape Garbago Chinder,Spa or Whirlpool Tub, RECEIVED
O ��a
Tank: gl on resin. size 1,OOO.gal)
Septic
Tile Field: each trench fr Total System Length: SEP 112002
Seepage Pit(s): number of size Of each: fZ by
TOWN OF QUEENSBURY
Size of Stacie to be used: # / depth or thickness .feet g ,IZ T)i N� E;OCI
Bed System Size' x
Alternative System: ! � n length and/or size /Q r c3 f
6. HOLDING•TANK SYSTEM: (if required)
Number of tanks: / Sizo of each: gallons /TOTAL Capacity: gallons .
Note: Alarm System and associated electrical work must be inspected by p Town approved
electrical inspection agency.
7. SIGNATURE da INFORMATION FOR RESPONSIBLE PERSON(pleaso read)
For your protection,please note that pursuant to Sedioaa 136-29.ofthe 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 Igiown by or on behalf of an applicant,shall be void.
I have read seguIsiions wi sped to this applicsition.and agree to abide bythese and all
requirem thv•Town of a bury S ry Sewage Disposal Ordinax
o Z..,._
1p atur,6 of reip nalble,person Date
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- TOWN OF QUEEKSBURY
BUXUD.ING A _CODE ENFI?RCEMENY
74a B,a_y Rcracf
Qu'e4--PSb ,L�r _NY M200 -
(518) 761-825<5
SEPTIC DISPOSAU :SYSTEM Imo"' PECYION
N ame
Loca -ti on
D a-t e P i #
SOIL TYPE- Sand oam-Cl ay-
Pesul -ts ercol a -ion Test-
( i -F applicable ) Rate-Minute/inch
TYPE OF SYSTEM.: �
ABSORPTI OH FI EL.1D : Total Length 1
Length o-F each trench
Depth of -trenches
Size o-F stone
SEEPAGE PITS : Number-
Size - ft - x -Ft _
Stone size
PIPING; S i Type
B3 dg _ to Tank
Tank- -to Dist _ Box
Dist _ Boat to Fi el d/Pi
Openings Sealed-?_ es NoY5�a
L-OCA_FI OK jS EPA RAT I Oro
Foundation to Tank ,�-Feet
Foundati can to Ab sorp t.i ors .�-? sue -Feat
Separation o-F Pi -ts eet
Con-For-ms as per PI of Pl an es No
LOCATIOM OF SYSTEM ON PROPERT'
( circle one )
Front - Rear - Le-Ft Side - Right Side
e�Fron -t " - Middle Rear
SYSTEM USE APPROVED = ES no
A r %o ect
D
�Z--7
S '14 OF tii E`l URY c x.G11%G DEPARTMENT
limited
mminafi ,
ompliance with our comments shall
of be construed as indicating the
fans and specifications are in full 0
ornpliance with the code Py
1�
1g� RECEIVED
C7
SEP 17 2002
TOWN OF QUEENS13URY
o 6UIT_ CODE
CJ i
"I have seen or observed, or believe I saw evidence of,
all objects such as houses, wells, trees,fences, etc.,
shown on this document. I also represent that I have
person m asured the distances set forth on the diagram."
IGNATURE DATE
TOWN OF QUE-E- � ' Icy
BUILDING. -�
REVIEWED BY
DATE In
--7 V,& TOWN OF QUEENSBURY CA -- cep :Fb
- BUIEDING A-CODE ENFORCEHEMT-�"V�!$
'742 Ba_V Rconct
NY X2004
SEPTIC DrSPOSAU SYSTEM INSPECTION
Name
Loca -tion ti� CDC-1-
Date >7 P 0 r-M 1 t- �
C�
SOLE TYPE: Sand- Loam-Cl a_N/-
R(--sul -ts o-F Per-cola-tic>n -rest---
( i -F applicable ) Rate-M1nuf--e-/1nch
-TYPE OF SYSTEMz
ABSORP-TrOff FIEt-D: To-tal Le-ng
L#---ngf--h a-F each trench
Depth O-F -tvenches
Size o-F stone
SEEPAGE PITS : Numbt--- r--
S-1ze - -Ft _ -F-t
Stone size
PIPING: T-ype
Bldg . to Tank
Tank- to Dist _ Box
O>c
Dist _ Box -to Fiel /Pj
-7
Openings Yes No Par--tia-l-
L-OCA-VION,/SEPARA OHS :
y :M
Founda-tion -to T nk e e-t
__I on
Fc)unda-t! 4on to A sc�ir-p -t-ion -Fee-t
Separation oV Pits -Feet
Cont orTns as per PI ofPlan Yes No
LOCATION OF Sys-rEm ON PROPERIrY :
( ci r-cl e- one )
Front - Rear Le-Ft Side - Right Side
Middle Front Middle Rea r-
COMMEN-US
SYSTEM USE APPROVED -- YES
Dt--p a V- d
-n-!g InsP to