2001-773 . ,. TOWN OF QUEENSBURY
1 '- - 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20010773 Application Number: A20010773
Tax Map No: 523400-309-010-0001-078-000-0000
Permission is hereby granted to: BEATRICE A MANDIGO
For property located at: 50 LUZERNE 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: BEATRICE A MANDIGO Septic Alteration Residential
175 LUZERNE Rd Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name/ Address Electrical Inspection Agency
I.B.S. SEPTIC
2 LOWER WARREN STREET
OUEENSBURY,NY
Plans &Specifications
2001-773
SEPTIC ALTERATION AS PER APPLICATION
$25.00 PERMIT FEE PAID - THIS PERMIT EXPIRES: Wednesday, October 16, 2002
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at th o f Q e ns ury; /'sday, October 16,2001
,4`
SIGNED BY cf- '4'‘ for the Town of Queensbury.
Director of Building&Code Enforcement
Application for Permit—Septic Disposal System
Town of Queensbur y 742 Bay Road Queensbury, NY 12804 (518) 761-8256
1. OWNER INFORMATION:
• v 1 I Office Use
rfe
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Location of installation: / A-rc I'd
Filo Permit No. ( U-
773
Tax Map No. / /
• Fee Paid
Owner's Name: /vt Gt.Al ,:j
Address: 6-'0 C c.2 e P it/C' /-,,)
2. INSTALLER'S NAME : � , ($ I. C. f, C PHONE NO.
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate II bedroom(s) and multiply Il of
bedrooms with applicable gallons per bedroom to equal total daily flow)
•
Year of House: No. of Bedrooms x Computation = Total Daily Flow
1980 or older 3 x 150 gal/bdrm = qf-e)
1980- 1991 x 130 gal/bdrm• =
1991 -present x 110 gal/bdrin =
Garbage Grinder Installed yes / no
Spa or Whirlpool Installed yes / no
4. PARCEL INFORMATION: (circle applicable information &indicate measurements)
T...graphy So'. ature Ground Water Bedrock or Impervious Material nes ater Su 1
�1 +and a! h t epth at►I��zc epth miu7icihc
oiling own feet (t/( l 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:• MOO gallon (min. size 1,000 gal)
Tile Field: each trench 5Q f1. Total System Length: 0 0 ft.
Seepage Pit(s): number of • size of each: 11. by• ft.
Size of Stone to be used: it / depth or thickness fret.X A-'/-• C %to f P
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.
a re of responsible person Date
TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
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Name ft(
Location --)04‘), ��Q '��
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Date/O /(� Jt # Q f 773
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SOIL TYP Sand- alay-
Results of Percolation Test-
(if applicable Rate-Minute/Inch
TYPE OF SYSTE :
ABSORPTION FIE D: otal Length 7. <<�
Length of each tren•h !iI °-►t)'
Depth of trench s
Size of stone .. -.
SEEPAGE PITS: mb-, -
Size - f i x ft.
Stone size
PIPING: Size Type
Bldg. to Tank — 11;11 f __
Tank to Dist. Box fo
Dist» Box to Field/'it ...' y...T-0 ‘01E-vi�
Openings Sealed? o .Partial
LOCATION/SEPARAT : t: --
Foundation to Tank 1 .fjj feet
Foundation to Absorp' ion 2 C feet
Separation of Pits _ eet
Conforms as per Plot Plan o-
LOCATION OF SYSTEM F PROP
(circle o
Fron -. Re Sid t Side
Middle Fron. - , ear
COMMENTS:
•
SYSTEM USE APPROV : E NO
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