2000-212 A � �
C-er f om"Pi
titicate o C la" ce
Town of Queensbury �
Warren County,New Fork
April 20 , 2000
Date
3 '20002 2
This is to certify that work requested to be done as shown by Permit No.
has been completed,
SEPTIC ALTERATION
This stricture may be used,as a.-- -�
12 HERALD DR.
Location
Owner W THERELL a DAVID &
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TAX M808 NO. 125 0 -9~:6"3
By Order Fawn Board
�O ; F Q EN
Director of,Building& Code': gorcoment
BUILDING PERMIT
Town of Queensbury, 742 Bay Road, Queensbury,NY 12804
County of Warren (518)761-8256
VALUE $ 0 Building Permit No. 2000212
TAX MAP NO. 125. -9-44
WITHERELL, DAVID &
Permission is hereby granted to
Owner of property located at 12 HERALD. DR.
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:
DEBORAH 12 HERALD DR.
QUEENSBURY, NY 12804
J
Contractor or Builder's Name:
SANITARY SEWER
Contractor or Builder's Address:
DAN DRELLOS� PO BOX 224
GLENS FALLS NY 12801
Electrical Inspection Agency:
Type of Construction:
SEPTIC
Plans and Specifications:
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
Proposed Use:
SEPTIC ALTERATION
25 Apr 1 18 . 20.02 .
PERMIT FEE PAID—TI-BS 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 Town of Queensbury this 18 Day of Ap r i 1 2000
SIGNED BY �l}C' Gl; for the Town of Queensbury
Code Enforcement Officer
-I Lt No,tb:il U411't 'UU Nrl 1e:hb i U-I UWN Ut• WUt1=NZZUK7 I-HX-*125 f 45 44d f rtiuc 1
Application for Permit—Septic Disposal ,System
1'own of Queen.v1wry 742BgYRoRd Queers.bury,Iff 1287 (51V 7GJ-R256
1. OWNER INFORMATION: _.___ ... ..............�
office Use
1' �
Location of installation: _ per, /
(�C
Tax Map No File Permit (/ !
I fee Paid _ I
Owner's Name .,, l J �eG'L.
Address:
2. INSTALLER'S NAME : j„t �1 .. PHONE NO.
3, RESIDENCE INFORMATION: (circle ye f of dwelling,indicate#6edroam(i)and multiply*of
bedrooms with applicable gallons per bedroom to equal total daily flow) /�
Yr3»r of Housg� No,Qf Bedrooms Comou�tion = Total Daily„F_ -��� —_
1980 or older x 'ISO gavbdrm A� ny Z�QQ
x 130 gatlbdrm _
1t391—pt�sent ^� x 110 gal/bdrm = .�_ _
Garbage Grinder Installed yes_ I no x i3�iL{�il�Ca P.t fly�,t tCtr_
Spa or Whirlpool Installed yes_ 1 no
d. PARCEL INFORMATION: (circle applicable information&indicate measurements)
r Soil NaWre OEQuad Water__ Bedrock or 1mgerviousMaterial m c
T' sad]), at what depth at what depth ttntGt
toldtng roam feet __....._feet w•v
5'tevpxlope clay ffwell;warer.rupply
.slope other from any septic-,system
depth; .... absorptturi is.. fl.
Percolation Test: (To he completed by licensed pmlessiunal engineer or architect) _
Rate .,-._minute per inch
5. PROPOSED SYSTEM: For New C racthe+n; All Individual sc%vago disposal systems must be desil{nedby 8 licensed
proremional enginoer or architect(unless installed in a Planning Board approved subdivision). Add 250 guilons to tie size
of the septic tank and leach field far each Garbage Grinder,Spa or Whirlpool Tub.
100 0 ts�-�.J G
Septic Tank: ,_ gallon(min.slzv 1,1KlDI;al.;l )
Tile Field: each trench_S0_._..it. Total System Length:_ dam ,jt-
Seepage Pit(s): number uf ._ size ofeach: _ .___,,fi•by...-_,._...,fh
Size of Stone to be used: It_..... !depth or thickness...,._.-,,,_ ,, ....feet
Bed System Size: _..._..__._ . ..--__-- x .......___... .. .._._ __.
Alternative Systatn _. .. ..........___. ..__ length ond'or size ...._..._. . .__ _.... __.____._....._.
6. HOLDING TANK SYSTEM: (if required)
Ntunber oftanks: 1 Size of each: gallant 1 TOTAL Capacity: gallons
,Vote. 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 fkct or
circumstance known by or on behalf of an applicant,shall be void.
I have r regulations with respect to this application and agree to abide by these and all
require jeent or e Town of Ques Sanitary wage Disposal Ordinanc .
S g ature of respon Ih�e person Date
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2000212 125. -9-44
WITHERELL, DAVID & {�„
12 HERALD DR.-
SEPTIC ALTERATION
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N •a? aJOWu TOWN OF f UIENSgURY BU''_DC�O DEPARTMENT
Base ors our limited examination,
°' P " com !ia ceti�+th our comments shall
n `b construed as indicating the
a) V) ccEVIEWED 5y and specifications are in ft111
corn liana:wb,the wde" N [)ATE;
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