2002-775 TOWN' OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518)761-8256
CERTIFICATE
FCOMPLIANCE
�
Permit Number: P20020775 Date Issued: Friday, September 20,2002
This is to certify that work requested to be done as shown by Permit Number P20020775
has been completed.
Tax Map Number: 523400-295-019-0001-071-000.0000
Location: 10 WESTMORE Ave
Owner: DARRIN ROBERTS
Applicant: DARRIN ROBERTS
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: P20020775 Application Number: A20020775
Tax Map No: 523400-295-019-0001-071-000-0000
Permission is hereby granted to: DARRTN ROURTS
For property located at: 10 WESTMORE Ave
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: DARRIN ROBERTS
Septic Alteration Residential
10 WESTMORE Ave Total Value
QUEENSBURY,NY 12804-0000
Contractor or Builder's Name/Address Electrical Inspection Agency
STGNORFLIJ. ANT14ONY
Plans&Specifications
2002-775
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 own
0 September 17,2002
SIGNED BY 4�tl for the Town of Queensbury.
Director of Building&Code Enforcement
Application for Permit- Soptic Dispos�USyo-to In
U \,0- ,
Iotvn of Qrteenshttly 742 Jlrrylturrd Qrtee»sGru},NY 12804 (S'/8).7G1=82S.6
1. OWNER INFORMATION:
4 A1e5�V�e _ ' 002 Urtice use
Locution of LtsWllation: �� i 'r.'£�t- ,
w Tax Mnp No. flL?• lo:,I'oititlit`-IVo:�r
20 Z-'77�"
Owner's Natno: /�
4�P-f t3 E' f Fea P n i d '
/J
Address: c'�
f'e. °
2. 'INSTALLER'S NAME : f®"V yl r 5-aja c PPONE NO.
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate 11 bedroom(i) and multiply 11 of
bedroarrrs with applicable galloitr per bedroom to equal total daily floiv)
Xoar of Houses No, of 13odrl2oi is �t�s; p�►IIz►tiou = 'I l Daily Flow
1980 or older x 150 gallbdrnl
1980— 1991 x 130 gal/bdrin
1991 -Present x 110 gni/bdrm
• Garbage Grinder Installed yes i / no
Spa or Whirlpool Installed yes / no 7
4. PARCEL INFORMATION: (circle applicable inforniation 8Z indicate rneasurenterats)
Lilly 11C9._-- t1.t'v.und•VY.ntoi__ �Il.pctrgck.o!'.�lnpw_Ytc�tt&_h't.4.lGraitl . r _ 'it0r'_$41JtJ)fy
1'rr tat:rl fit tr/tfN thdrill ell Sr•hut th-pt/r ntt'r��)t/c//rrrl
lufhny, ortnr "feet
Steep slope clay yr' !fwell; water sujrply
Vo slope other = fi oat a►ry sc/ufc-systcrtr
depth: _.- absolpttan is Ji.
other
Percolation Test: (To be conipleted by licensed pre/esslonal dig neer or architect)
hale: 111111111C Per Inch
5. PROPOSED SYSTEM: For Newt/Constructlon: All individual sewage disposal systenls Iuust,be designed by h licensed
proressiounl cri ineer or archilect (unless inslnlled-ill a 1'lannin1;13uard ah{iroved sulxlivisiori}. Adt1,25(1 galltiils In the sirs
or Ilic septic lack and lcach field for c:1ch(;arbage Cat iuder, Spa or W hil iix)of't'u1). '
Septic Tank: gallotr (rrtin. size I,000 gal.)
Tile Field: each trench J49 fl. 'Total System Length: p � fl,
Seepage Pit(s): number of size of each: by Jt.
Size of Store to bo uaod: it ____„___ f ctrlrrlr err,rhtr knc•.r.c,�_,__,____•____/i'a't
Bed System Size: x
Alternative System: �L / length andlor size
d, HOLDING}TANK SYSTEM: (if required)
Number of tanks: 1 Size of each: gallons /TOTAL Capacity: gallons
Note: Alarm System and associated electrical work must be inspected by a Town approved
electrical inspection agency,
?. SIGNATURE &INFORMATION FOR RESPONSIBLE PERSON (please read)
r°or your protoction, plonse rota flint pursunttt to Section 136-29 of tho Coda of ilia TOWtt.;>;,
of Queotistiury, any portrtit of npprovnt ilrantcd which is bnsed upon or is gr:1/11ted'.J11 ,
rolinnce upon any n.ntotial misrepresentation or faihrro io make a tnatotial tact or U•43-..,., NR }�£'
circtnnstattco kn6wr by or on behntrofar npplicaut, sluill bo void. n• :yr{tyy
I linve rend the roguintions with tespoct to this npltlicntiott nrd ngroo to nbido by those nrd oil*
roquiremonts oftho'l'own ofQueensbtiry Satiitnry Sewaf;e Disposal Ordinance,
Signature f res albie person Date
YOWN OF QUEEKSBURY - t (
BUXL-DXNG- &---CODE ENVORCEMEN-r
742 Bay R"z-14d
Queen mst3pur-y MY X2a04
SEPTIC DISPOSAL SYSTEM INSPEC-rION
N a m e u>
Loca -tion
Da-te P e r-rn I t
SOIt_ TYPE: Sand- Loam-Clay-
Rt_-SUI _tS of Per-COla-tion 'Tes -t-
( ifr' applicable ) Rate-Minute/Inch
-TYPE OF SYSTEM=
ABSORPIrYON FIEL-D: Total Length
Length of each -t r-o n c h
Depth of trenches
Size of stone
SEEPAGE Pr-rS : Number—
S -fze -Ft- x _F_t
Stone size
PIPING: S i ze Type
Bldg . to Tank
Tank- -to Dist - Box
Dist _ Box to Fitald/Pi -t
openings Seale-d ? - Yes No Partial
JLOCA_rrOIW,/SEPAR.A7FIOr4S :
Foundation to Ta-nk feet
Founda-tion to Absorption -feet
Separation o-F Pits "Feet
as per Plol�_ Plan Yes- No
LOCATION OF SYSTEM ON PROPER
circle OMQ
Fr-on t -c-Rea- - LeftSide - Right; Side
Middle Front - Middle Rea r-
COMMEWTS z
SYSTEM USE APPROVED y NO
Ar-r-I 4d= V,
J_ P
EENS BURY -
BUILDING- &--CODE ENFORCE74EMY
74Z Bay R",-a6
�gtt�eeras:�sury NY 12004
SEPTIC DISPOSAU SYS-FEM INSPECTION
Name Q 0 �( �
Location
D a-t te a r-m 1
-SOIL- -"PE- San Loam-Cl ay-
Resul -ts o-fCceir-coola-tion Tes-t-
( ! 'F applicable ) Rate--Minute/Inch
TYPE OF SYS-rEM=
ABSORP-rYON FIEILD :-.-I-ro-tal Length
Length of each ho,
Depth of -ti-e-n S
Size F S-ton _X I
e e
SEEPA E PI iamb
(__ t__
S -1 z e -f-t - x -F-t .
S7tont---
PZPXNG: Size Type
Bldg . 7t -lank
Tank- -t Di s-t Box
D ! s-t - So to Flold/p_ '
opens gs Seal od ? es No Partial
I-OCA 1!?7 SEPARA-Ull1r:
Foesa i n -to Ta-nk feet
Fou da-ti n to Absoi-p -tion feet
Se av-a -ti ran o-F P ! -ts -F e-e*t
Co forms as per PI o-t Plan YlTt;� N o,
t-0 A-Ul ON OF SYS7rIF_=M ON PROPER-Tt-_��
( C - r-cl e- ,c'
Fr- -ht. - (Rea - Le-Ft Side - Right Side
Middle- Front - Middle Rea r-
COMMENTS z k
SYSTEM U5E APPROVED = YES NO
Ar-r-I%rc--cf
Sul _1 no
t_,tf,7k
TOWN OF QUEENSBURY
BUIUDING- &--CODE ENFORCEMENT
742 Ba_y R"act
MY :12004
(518) 761-82�545
SEPTIC DISPOSAL SYS-TEM INSPEC-rIOM
A il
Name- o
- -
f
Da7to
-t
Soyu Fyp<sa7dPL-am-Cl a y-
Rosul is o-F Po -col ant
i ti n Tes-t-
( I V applicable )
R a -
M i nu-te/In ch
TYPE OF SYSTEM:
ABSORPVY FXEL-D - To-tal Length
Le_n9t:h o_F ech rench
Depth OF -tro c es
Size of, S-tone
SEEPAGE PITS ff iamb e r--
Size t
X -F-t
Stone size
PIPING : Type
B 1 ct g . -t o 1a n k-
Tank- to Dist _ Box
Dis-t - Box to Field/Pi -t
Openings Sealed? - Yes ci P a r-t 1 al
L_OCA-FXOf4,/SEPARA-r1ONS :
Found a-tion to Ta-nk -FeetFouncja-tion -to Absor-p -t-ion -F c--e--t
S e.P a rat I on o-F Pi -ts -Feet
Con-Fomns as per PI o-t Plan s No
LOCA-UXOM OF SYSTEM ON PROPERT
( cir-cle- one )
Front - Pear - LeT-t Side Righ-t Side
Middle- Front - Middle Reai-
COMMEWTS
SYSTEM USE APPROVED = YES
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