2000-136 TOWN OF QUEENSBURY
742 Bay Road,Queensbury NY 128M902 (518)761-8201
Community Development-Building&Codes (518)761-8256
UtIXIIFICATE 01F OCCUPANCY
Permit Number 2000136 Date Issued: Tuesday,March 28, 2000
This is to certify that work requested to be done as shown by Permit Number 2000136
has been completed.
Location: 25 KILEY Ln
Tax Map Number; 523400.295-018-0001-058-000-0000
Owner, ADAM BURNETT
Applicant: BRENNAN,KEVIN&
This structure may be occupied as a:
Unknown By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Occupancy DOES NOT relieve the
property owner of the responsibility for compliance with Site Plan, 4
Variance,or other issues and conditions as a result of approvals by the Director of Building&Code-Enforcement
Planning Board or Zoning Board of Appeals,
BUILDING PERMIT
Town of Queensbury, 742 Bay Road, Queensbury,NY 12804
County of Warren (518) 761-8256
VALUE $ 0 Building Permit No. 2000136
TAX MAP NO. 80. -1-25 . 59
Permission is hereby granted to BRENNAN, KEVIN &
Owner of property located at 25 K I LEY LANE
in the Town of Queensbury,to construct or place a SEPTIC ALTERATION
at the above location in accordance to 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.
Owner's Address:
CHRISTINE 25 KILEY LANE
QUEENSBURY, NY 12804
Contractor or Builder's Name:
T .B. S. SEPTIC
Contractor or Builder's Address:'
2 LOWER WARREN STREET
QUEENSBURY, NY 12804
Electrical Inspection Agency:
Type of Construction:
SEPTIC
Plans and Specifications:
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
Proposed Use:
SEPTIC ALTERATION
$ 25 March 28 2002
PERMIT FEE PAID-THIS PERMIT EXPIRES
(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 To of Queensbury this 2 8 Day of March 2000
SIGNED BY l for the Town of Queensbury
ode Enforcement Officer
Application for SEPTIC DISPOSAI, PERMIT
Tow=of Queeasbury
Dept_'of Cornmuaity Development FFe-e-Paid
/', .
B ldEng &Codes Office
742 Bay Road Qt=- sbc_ry, NY I284S
I.ocadon of property for installation: n -, A-4 L (&j4,e__
Property Owner's Name: ;`I..7 C Al /5 r C ,✓1VaA/
P7,� CFP'- En
Property Owner's Mailing Address:
Insta—I?er's Name: Phone m xp
F3Ul DING AN) 'u��t'z
Neer of bedrooms {if residenr'al): Total daily flow: j 0
(residential -comptw @ I�0 gal./bdrm.)
T opograpny: e`y gat, rt?li a, stew slope q of slot e
Sal NaCL e: sand, Ioam, clay, other
C_otmd water: at rwi�•de-t&,?/ILA eet I roc or Iperviotis Mate at what depth?
_ _ feet
Percolacon test. not rw•trir,4, re i life: (, min.- ve:wch]
Domestic water sut:piv: "zaumcipal, We , oiler,
E donestic water s=mly is a WELL, water s`� -y =Qrn, ayy septic absomEca is feet.
P-ROPOSED, SYST +Y
Sepdc tankID-00 gancu (mirdmur s=e: ',CC<) 5,a.)
Tile field: e c:.zenca feet / To�I.system Iength: feet
Seepage pit(s): number-of _ "/ size ezch: . $by f4
Si-e of stone b be used: / dev;tfi or thickiess _�feet
OLDDTG TANK SYSTEM: (if=ui.r-c",
Number of tar: : Size cf e cz: g_ cas
Alar-n syste=nail assoc elee ical wc: to b�-_ :rsT ted by a oertiffed a, .
For Yc r-tscuea, please mta tit puzsLq..#to See'.<oa 136-29 cf t!:-_ Code of the Town of Qoe_-rsb= any pew or
ate-�v� a,: wbics is Eased �cu or is y afed i<t relia ca a�M risl nrsregzase^._c:cr`54ure"to=aI*a.
rn,m or cis stance kzc,;;n by or on behalf of a'a ao;Lic,. , &Lu be vvid
I—h :a ---ad t.;s regslsdons wi:u r-sped to this acpticahoa and
s��-� to abide by these sail all xie�y of the Town of
Saus.'3ry Sewage Dis. sal Ch-':az�as 1 1
Si�a-,Y e of responsible person: Y > Date: 3-"O'�_d_opo
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection req;ugest'li c i
Queensbury Building.&Code Enforcement Arrive: Q^-oc) a e am/pm
742 Bay Rd., Queensbury, NY 12804 Inspector's Initials:
NAME: 7Q6ti1 t At) P.RMI-r NO.: D — -%Q
LOCATION: LA .11 C� --
NSPEC71-ON: Z
RECHECK:
Comments and/or diagram
Soil Ty oam/Clay
Type of Water:�nijpsj". ell Water
Wafixiine-se—Ta—ration distance
Well separation distance ft.
Other wells: ft.
Well Casing Length 50' + --__Y_N N/A
Absorption Field: Total length
Length of each trench ft.
Depth of trenches
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box
Distribution Box to Field / Pit
Opening Sealed: Y N
End Cap Y N
Inlet/Outlet Pipes&B ffies Y
Location/ Separations
Foundation to tank
Foundation to absorption ft
Separation of Pits
Conforms as per Plot Plan Y N
Engineer Report and As-Built Y N
Location of System on Property:
Front ear Left Side Right Side Middle Front Middle Rear
Front S s�
S stem s
Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
Last revised 06/18/07 U\Building&Codes Forms-OLD\Building&Codes\jnspection Forms\Septic Inspection Report.doc
-TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMEWT
742 Bay R"caa
Qut--%-ns.bur-_V MY X2S64
C(518) 7 3,1-82:56
SEPTIC -DISPOSAL SYSTEM IMSPEC-FION
Name
Loca -t! on
Da to P a r-rn i -t #
SOIL -F-Y Sand - Cla_y-
Resul is o-F Per ola-tion Tes-t
-
( i -F applfcable Ra-tt---Mi ul---e/Inch
TYPE OF SYS-YEF4
ABSORPIrIOM FIE D Tot Length
Length of each -tr-en
Depth o n
Size of stone
SEEPAGE PI-FS : Numbat—
Size - !e>_ -F-t x: -F-t
Stone size
PIPING: Size Type
BI dg - to Tank
Tank to Dist - ox
Dis-t - Box to F - eld/Pi -t
Openings Seale Yes No Partial
t_OC.A1F1O6AZSEPA TI
ONS _
--
Foundation to Tank -feel--
Founda-tion -t Absorption _:!2n3D7-fe_et
Separa -tion 19 P "i I--s :�z�t -F e e
Con-Fomns a-s per PI of PI an Ta� No
t_OCA-rIOK OF SYSTEM ON PROPERTY :
( c- ir-cle one )
Fr -t - Rear- - Le-Ft- Side - Righ-t Side
,K--Midcfl-e F- ,r6_n- Middle Rear
SYSTEM USE APPROVED = Y 1+tO ��
Depart
d n p
"I have seen or observed,or believe i saw evidence of,
all objects such as houses,wells,trees,fences,etc;,
shown on this document I also represent that I have
personally measured the distances setforth on the diagram."
SIGNATURE DATE
TOWN
BUILDING &I.
RY
REVIE'AIED gay
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