2002-967 TOWN OF QUEENSBURY ,
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20020967 Application Number: A20020967
Tax Map No: 523400-301-005-0001-006-000-0000
Permission is hereby granted to:
For property located at. 785 WEST MOUNTAIN 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 NICHOLS Septic Alteration Residential
785 WEST MT. Rd QUEENSBURY,NY 12804 Total Value
Contractor or Builder's Name/Address Electrical Inspection Agency
MORNING STAR SEPTIC
Plans&Specifications
2002-967
Residential septic alteration per plot plan and specifications.
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday,November 19,2003
(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 s ay,November 19,2002
SIGNED BY for the Town of Queensbury.
Director of Building&Code En orcenient
Application foi- 11crinit—Septic-Disposal System -c 147
21pivii of Queensbitly 742 Bay l?oa(l Queettsbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
.................................................................................................................................
Location of installation: orrice Use
Tax Map No. Of File 0"llit No.
is 111
FCC Paid
Owner's Name:
. . ................ ............................................ :::�..........
Address: /Vol/ 7
2. 'INSTALLEWS NAME
PHONE NO.
3. RESIDENCE INFORMATION- (circle year of dwelling, indicate It bedrooin(v)and multiply o,/ A D a �e�1'
bedrooms with applicable gallons per bedroom to equal total dail.),flo
You of Houso: No. of Bedwonis x CQn1vutation = Total Daily Flow
1980 or older X . 150gal/bdrin =
1980- 1991 X 130 gil/bdrin =
1991 —present X 110gal/bdrm =
Garbage Grinder Installed yes u t no-X
Spa or Whirlpool Installed yes 1.10 -,.V' 36
4. PARCEL INFORMATION: (circle applicable information & indicate measurements)
stuu at svirtyl depth trf*If-ha/depth c2!�1111'11 1t
feel i feel well
Steep slope clay
if well; water supply
-Vo slope other from any septic-system
depth: absorption is
other
Percolation Test: (To becot?ipletedl)yliceti,vedlt-(!fe.v.vloiialetigiticerorat-clillect)
hate: niltittle per Inch
5. PROPOSED SYSTEM: For New Construction: All individual sewage disposal systems inust be designed tty h licensed
professional ctighicer or architect (unless lus(ttlicd in a I'laiiiiiiig l3oardapprovcd sulAivisioji). Add 2.50 gallows to lite size
or the septic tank and Icacli field for each(jarbage Gthider, Spa or Wititilvol 'I'tib.
Septic Tank: 00U gallon (min. size 1,000gal.)
Tilo Field: each trench fl. Total System Length:
Seepage Pit(s): number af, size cpj'ecych: ft. by_ft.
Size of Stone to be tixed: /I depth cor
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'flispected by a Town approved
electrical inspection agency.
7. SIGNATURE & INFORMATION FOR RESPONSIBLE PERSON (pleaseread)
For your protactiott, plonse noto flint Ittirstintit.to Section 136-29 or the Codo or the'Town
of Quactisbtury. nay pormit or approval granted which is based itpoti or is granted in
ralintice uport any material misrepresentation or rhilieue to make material ract or
circumstatice known by or on beivairorar, appiicniit, sitaii be void.
I linve rand the rag%flntioiis %Yitli respect,to thi's apiflicntion and agroo to abide by th' so and nil
requirements oftho Town of QuectjsM—Iry Sanitary Sewage Disposal Ordinance.
Signature of responsible person Date
I )WH OF QUEENSBURY
BUILDING A -CODE ENFORCEMENT
--14!i BfkY RC30agl
Quat--nsUur--y NY X2804
(518)
SEPTIC DISPOSAL SYSTEM INSPECTION
Name
Location
Date e rm 1 t
SOIL TYPI-- Sand- Loam-Cl ay-
Resul -ts O-F Per-colation Test—
( if' applicable ) Rate-Minu-te/lnch
-TYPE OF SYSTEM:
ABSORPTION FIELD : Total Le-ngt-h
Length of" each trench
Dep ,th o-F trenches
Size of st e ,
SEEPAGE PT - Nubet—
Size - zy� m-Ft -
Stone size
PIPING: Size Typ e
Bldg . to Tank
Tank- -to Dist - B
Dist-- . Box to Ff I d/ i
Openings Seal s No Partial
]LOCA-FIOMZSEPA IONS :
F
B
0-1
s S
z N
FI S -
Foundation to' Tank -Feet
o
Foundation to Absonp -tio, -Feet
-7 o
Separation of Pits Feet
;J_
Con-Forms as per Plot Plan Yes No
C) t
LOCATION OF SYSTEM ON PROPS T-Y:
( cir-cle one )
Front. - Rear - Le-ft, Side - Right Side
Middle Front - Middle Rea -r-
COM TENTS
:
SYSTEM USE APPROVED= YES no
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� � „� all objects such as houses,wells,��eLs,fences,etc,
m shown c this docuc e�lt, I also repre; ot i.I.�i P have NOU Not
m - persondily r?easure ri v{jistances set forth on the diagram."
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all objects such as houses, wells,trees,fences,etc., RECEIVED
shown on this document. I also f have
personally msnrad 11, distances set forth o!1 the diagram." NOV r 9 NZ
e TOWN OF QUEENSBURY
SIGN URE DATE B IIDING AND CODS
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