2002-1049 '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: P20021049 Date Issued: h6day,December 31,2002
This is to certify that work requested to be done as shown by Permit Number P20021049
has been completed.
Tax Map Number; 523400-303-020-0001-032.000.0000
Location; 12 PHILLIPS Ave
Owner: JOHN&JOITH DE LISLE
Applicant; JOHN&JUDITH DE LISLE
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
Director of Building&Code Enforcement
%' fi i TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20021049 Application Number: A20021049
Tax Map No: 523400-303-020-0001-032-000-0000
Permission is hereby granted to: JOB&JUDITHDELISLE
For property located at: 12 PHILLIPS 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: JOHN & JUDITH DE LISLE Septic Alteration Residential
. 345 MOTT Rd Total Value
GANSEVOORT,NY 12831
Contractor or Builder's Name/Address Electrical Inspection Agency
I.B.S. SEPTIC
2 LOWER WARREN STREET
OUFFNSBURY.NY
Plans&Specifications
2002-1049
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday,December 31,2003
(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 of Queen bury; Tu sday,December 31,2002
SIGNED BY for the Town of Queensbury.
Director of Buildiny&Co Enforcement
Application for Permit—Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
.......................................---- -................................ ................................
Location of installation: ( ( ?� C,j� C - r Office Use
Tax Map No. / / File Permit No.. y
Owner's Name: �- Z c (c�f(C
Fee Paid
�U
Address: 211,
DF,,
2. INSTALLER'S NAME PHONQ,t_ .,Z4 Qb'
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate#bedroom(s) and mu"tzjorSgV
bedrooms with applicable gallons per bedroom to equal total daily flog CQ. ,D��
Year of House: No. of Bedrooms x Computation = Total Daily Flow
1980 or older x 150 gal/bdrm = S d
1980— 1991 x 130 galfbdrm =
1991 —present x 110 gal/bdrm =
Garbage Grinder Installed yes_ / no e5-
Spa or Hot Tub Installed yes / no
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
TapoupphyS ature Ground Water Bedrock or Im ervious Material Dgpgff&9QNater Supply
Fla sand at what depth at what depth municipal
olling am ��eet feet
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 engineer or architect)
Rate: minute per inch
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: 1IAOc> gallon (min. size 1,000 gal.)
Tile Field: each trench ft. Total System Length: ft.
Seepage Pit(s): number of size of each: ft. by ft.
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 &INFORMATION FOR RESPONSIBLE PERSON(please read)
For your protection,please 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 Queensbury Sanitary Sewage Disposal Ordinance.
ature of response le person Date
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Septic Inspection Report
Office No. (518)761-8256 Date Inspection request received: t .� i 0-, —"".
Queensbury Building&Code Enforcement Arrive: i6& am/pm Depart: am/pm
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials:
r ..- 7NAME: PERMIT NO.:
LOCATION: f — INSPECT ON: V)-r3
RECHECK:
Comments and/or dia ra
2
Soil T e• Sand Loam/Clay
Type of Wa r: Municipal/Well Water
Waterline separation distance ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenches ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size T e
Building to tank
Tank to Distribution Box s
Distribution Box to Field/Pit
Opening Sealed: Y/N/Partial f�� 404
/w l �!
Location/Separations f /�
Foundation to tank ft,
Foundation to absorption
Separation of Pits
Conforms as er Plot Plan Y N
Location of System on Property:
Front Rear Left Side Right Side
Middle Front Middle Rear
System Use Status:
_ Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
have seen or �,'-,served, or relieve I saw evidence of
FI
tall objects such as houses, v�,ells, tre-'--:�, etc,, LZ ELJ
153hown o'n this docurnefrt, 1 also'repres
!personal[ elasured the distan- eiaL L th have DEC, 3 1 2002
c's set forflh, on tlh�e diagram.?'
Tovvj�Of.
0000" QV' LENSBURy
QU G iLDIN
7� �CODE
SIGN N E DATE
VC C-A
MmECEDIVED
DEC 3 1 2002-
TOWN OF QUEENSBURY or
BUILDING guiLDING AND CODE c- -
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