2001-774 trite/ /
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: P20010774 Date Issued: Tuesday, October 16, 2001
This is to certify that work requested to be done as shown by Permit Number P20010774
has been completed.
Tax Map Number: 523400-309-009-0003-084-000-0000
Location: 127 LUZERNE Rd
Owner: ANDREW &ADAM JOHNSON
Applicant: ANDREW &ADAM JOHNSON
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
(-34(iP /.
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: P20010774 Application Number: A20010774
Tax Map No: 523400-309-009-0003-084-000-0000
Permission is hereby granted to: ANDREW&ADAM JOHNSON
For property located at: 127 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: ANDREW&ADAM JOHNSON Septic Alteration Residential
127 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
2001-774
SEPTIC ALTERATION AS PER APPLICATION
$25.00 PERMIT FEE PAID - THIS PERMIT EXPIRES: Wednesday, October 16,2002
(If a longer period is requited,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at of Q ensbury; Tuesday, October 16,2001
SIGNED BY for the Town of Queensbury.
Director of B g ode Enforcement
Application for.Permit—Septic Disposal System •
Town of Queensbury 742 Bay Road Queensbury, NY 12804 (518) 761-8256
1. OWNER INFORMATION: ii
/0 7 (..a is Z C t' c Ptijc�Usc
Location of installation; � `—�B`gt/CJ
File Permit No. / 77
Tax Map No. _ �J ov
Owner's Name: Fee Paid '
�`a� 4ti �o � •
• Address: l , C t/ z l' 1 e r
2. INSTALLER'S NAME : r � cr C PHONE NO. 7,9a — S /
3. RESIDENCE INFORMATION: (circle year of dwelling,/ indicate l/bedroom(%) and multiply I/ (y•
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 x 150 gal/bdrin = I c oRECENE1
1980— 1991 x 130 gal/bdrttt =
1991 —present • x 110 gal/bdrm = OCT 1 6 2001
Garbage Grinder Installed yes / no TOWN OF QUEENSBURY
Spa or Whirlpool Installed yes / no BUILDING AND CODE
4. PARCEL INFORMATION: (circle applicable information &indicate measurements)
• ►ra h S uro Ground Water Bedrock or Impervious Material _.o'"±" L ater Stipp
Mat s lu at what depth al who! iepth ' nun1icipal
�lliltg omit //4,jeer / feet
Sleep 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: , /A, minute per inch
5. PROPOSED SYSTEM: For New Constntction: 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 sin
of the septic lank and leach field for each Garbage Grinder, Spa or Whirlpool Tub.
Septic Tank: l D 0D gallon (mitt. size 1,000 gal) � S
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: It` / depth or thickness fret
Bed Systetii 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.
646,„( — a_)„,/
Signature of responsible
9 p le person Date
TOWN OF QUEENSBURY
BUILDING &.CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name
Location )61 7 LUr W -,P
:5-
Date ' 0/ ermi t #i_(xY} f-77
SOIL TYPE• y-
Results of Percolation Test-
(if applicable) Rate-Minute/Inch
TYPE OF SYSTEM:
ABSORPTION FIELD. Toial Length
Length of each t enc
Depth of trenches
Size of stone
SEEPAGE PITS: Ntmbe, -
Size - ft. ft.
Stone size
PIPING: V Size Type
Bldg. to Tank 4" i,
Tank to >; 4' p
�P1"0
Di s x d/P iamb. .
Openings Sealed? INIPIN0Partial
LOCATION/SEPARATION
Foundation to Tank \ Q_ feet
Foundation to Absorption ,y-,, feet
Separation of Pits ., -et
Conforms as per Plot Plan Ye i o
LOCATION OF SYSTEM ON PROP:'T :
(circle one)
Front - Rear - eft Side Right Side
Middle Fro - Middle Rear
COMMENTS:
•
SYSTEM USE APPROVED: YES NO
Arrived: ,a•
Depart- ; .r oy
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