2001-810 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: P20010810 Date Issued: Wednesday, October 31, 2001
This is to certify that work requested to be done as shown by Permit Number P20010810
has been completed.
Tax Map Number: 523400-308-011-0001-058-000-0000
Location: 415 LUZERNE Rd
Owner: JO ANNE K. HUNT
Applicant: JO ANNE K. HUNT
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
Director of Building&Code Enforcement
-1r , TOWN OF QUEENSBURY
s 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20010810 Application Number: A20010810
Tax Map No: 523400-308-011-0001-058-000-0000
Permission is hereby granted to: JO ANNE K. HUNT
For property located at: 415 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: JO ANNE K. HUNT Septic Alteration Residential
415 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
2001-810
SEPTIC ALTERATION AS PER APPLICATION
•
$25.00 PERMIT FEE PAID - THIS PERMIT EXPIRES: Thursday, October 31,2002
(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 the of Qu nsbury; ednesday, October 31,2001
SIGNED BY f " ' for the Town of Queensbury.
Director of Buis g& N1Ade Enforcement
Application for Permit—Septic Disposal System
Town of Queensbury 742 hay Road Queensbury; NY 12804 (518) 761-8256
1. OWNER INFORMATION:
•
/ Office Use
Location of installation: ((../2- ("/'Nc. /`zv
Filo Permit No.0 if-S 1 l
Tax Map No. / /
Fee Paid C9-`j •Q5
Owner's Name: TO A A, A, fll t1 t2(
Address: (. t;/ ,^tir r
2. INSTALLER'S NAME : )
l iS . .1. Jo < i e PHONE NO. )4*--PIn V
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate II bedroom(~) and multiply II of
bedrooms with applicable gallons per bedroom to equal total daily flow)
Year of House: No. of Bedrooms x Computation = Total Daily Flow
198g or older x 150 gal/bdrm = I"C
_tile& D
— 1991 x 130 gal/bdrm = V G
1991 —present x 110 gal/bdrm =
OCT ;i D 2001
Garbage Grinder Installed yes— / no
Spa or Whirlpool Installed yes / no TOWN BU OF QUEENSBURY
ILDING AND CODE
4. PARCEL INFORMATION: (circle applicable information & indicate measurements)
a� 'raph a uro GrQund Water Bedrock or Impervious Material ),.,mcraq* Sqpply
run at whn!cleplh al wl fit cpdr ' municipalling own �/�feel /9tfeet
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 Constnmction: 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: 650 ,gallon (min. size 1,000 gal.)
Tile Field: each trench 5 d it. Total System Length: a_Fa fT.
Seepage Pit(s): number of size of each: ft. by fl.
Size of Stone to be used: it_ ) / depth or thickness I _pet
Bed System Size: x
Alternative Systein: 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 au 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.
V 9. — 7— o r
gnature of responsible person Date
M.
TOWN OF QUEENSBURY .
BUILDING & CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804
(518)761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name k-k0t3-----
Location \--v Ztta-P,11•X7- RoC
Date 1C c3\—D1 Permit #ice!-- Ill
SOIL TyPEraTA717C ay-
Results of Percolation Test-
(if applicable) Rate-Mi ute/ Inch
TYPE OF SYSTEM:
ABSORPTION FIELD: Total Length 1
Length of each trench � `� -
Depth of trenches 7-4 � V_d
Size of stone / r 2_
SEEPAGE PITS: Numbey
Size - ftik ft.
Stone size
PIPING: ►ize Type
Bldg. to Tank A' ` 30.. -9,
Tank to Dist. Box rr ��� 35—
Dist. Box to Field/Pit rr�D�__
Openings Sealed? / o Partial
LOCATION/SEPARA th
Foundation to Tank 151 il
01 feet
p
Foundation to Absorption, �/ feet
Separation of Pits 76` J et
Conforms as per Plot Plan Yes o
LOCATION OF SYSTEM ON PROP •
(circle one)
Front - Rear - Lef - Right Side
Middle Fron fiddle Rear
COMMENTS: -
•
SYSTEM USE APPROVE, , YES
Arrive . r - / )11,r -.. `N.
Depa ed: NOW
fff Itile_
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u ding Insp• or
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— -- I a►b seen'or observed, or believe Isa'r� evidence of,
1 I I 1� 1 I I I_ I�-
- all-oblects-such-as-houses,wells,--trees,-fences;etC.,
t• ! I i -.shown_oni this ument�Ialso-relpresent-that_l_have..-i „I
_ V personally measured the distances set forth on the d�iaagrahm. 1_
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