2000-190 L . M 1 r f r ♦ ./ f L r ,
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Town of Queensbury
Warren County,New York
April 14 , 2000
.date...
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This is to c i"y th t wor requested o be done as shown by Permit No.
has been completed,
SEPTIC ALTERATION
This structure may be used as a ..
239 FIFTH ST. EXT.
Location
Owner GIJA TO, RICHARD & JCELLEN
TAX MAP NO. 131 a —7-1
By Order Town hoard
O OF Q EN
Director of Building & Codo hiforcernent
BUILDING PERMIT
Town of Queensbury, 742 Bay Road, Queensbury,NY 12804
County of Warren (518)761-8256
VALUE $ 0 Building Permit No. 2000190
TAX MAP NO. 131 . -7-12
Permission is hereby granted to GIJANTO, RICHARD & JOELLEN
Owner of property located at 239 FIFTH ST. EXT.
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-
239 FIFTH ST. EXT.
QUEENSBURY, NY 12804
Contractor or Builder's Name:
CLUTE ENTERPRISES, INC.
Contractor or Builder's Address:
13 DAWN ROAD
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 April 13 . 2002.
$ PERMIT FEE PAID-TIHS 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 13 Day of April 2000
SIGNED BY for the Town of Queensbury
Co&Enforcement Officer
Application for.fernlit—Septic Disposal Systelu
Tgsvii of Queens illy 74213a),RomiQueeusbui.g N)" 1280.1 (.518) 761-82.56
1. OWNER INFORMATION:
......................._....................................,....,..............................................................
Location of installation: , �� office Use
Tax Map No. 17j 1 / `? / t a rile POrtllit No. t%U 9or
Owuor's Naufo: '
Fee Paid
.....................................................................................................
Address:
2. INSTALLER'S NAME :_�.� �, � -` PHONE NO. �Zct ?�7 7
3. RESIDENCE INFORMATION: (circle year of dwelling, lilclicate 11 be(11•00n7(t)and multiply/I o/'
bech-MMlS with applicable 1;allons per berb-ovin to equal total ciclily flow)
Yoar ofI-louse' No of I3edroollls x Com tltatiotl = 'Total Daily 11ow
1980 or older x 150 gal/bdrm = G
1980— I991 -� x 130 gal/bdrnt = �� '' k_—D
1991 —present x 110 gal/b(irin = APR 12 2QDQ
Garbage Grinder Installed yes l no PC)FII': OF Gild
Spa or Whirlpool Installed yes 1 no EU-ILQiNQ,4PJD CODE
4. PARCEL INFORMATION: (circle applicable iul'orulation &i11diente rlleasUrcallclits)
Top U•a 1•iy_, Soil Na tiro Grou�rd Water _ I3cd1_ack ot_II))hel:viotis Material Don,c4tic Water Stlfflp
T7nf a!tvhcrt depth crt w/art depth unriciLal'
Ito lttg loam feet fief lvel%
Steep slope ckly ifwell; lvcrter supply
,slope Otherfront any sep►ic-s)Isteln
depth: absorption is ft.
Porcolatiott'Test: (7`n Ge ctvmpleted Uy liceltsed pr<fe.ssioiut! other
etrgitteer or architect) .�.____+. -
Rate: millllte per inch
5, PROPOSED SYSTEM: Tor New Construction: All individual sewage disposal systems must be designed by a licensed
171-ofessiollal cllghlcer or architect(lanless illstalled in a Thinning Board illl)rovcd subdivision). Add 250 gallons to the size
of the septic lank and Icach field 1101•each Gmbagc Grinder, Spa or Whirlpool Tub.
Septic Tank: 'Doo galloll(nthl. size 1,000 gclt.)
'file Field: each ireltclr jt. 'Total System Length:
Seepage Pit(s): number size c!l'each: Jt. by_ •/l.
Size of Stone to be used: 11 / depth or thickiiess
Ded System Size: x
AItemative System: length and/or size
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: 1 Size of each: gallons /TOTAL Capacity: gallons
Nate: 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 dote Ill.-It pursuant to Section 136-29 of the Code of the'Town
of Queeusbury, any permit or approval 1,>,rallted which is based upon or is granted in
reliance t1poll any material misrepresentation or lailltl'o to nlake.a material fact or
circutlistance known by or on betlalforau applicant, shall be void.
I have road the raFgttI ti rrs with ros leer.to this nplllicat.iort and nwoo to nbitlo by these and all
requiremosits of owil of Que sbtrry Sanitary Sewage Disposal Ordinance.
Signature of r slble arson Date
TOWN OF QUEENSBURY
BUILDING & CODE EPA FORC EMEN-F
742 Bay R®a€f
Queensbear-V MY X2SO4
(5 18) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name CL
Locationo
Date P e r-rn i t #
SOIL. IFYPE: Sand- Lo 6T—cva y-:
Resin is of Perco7 at ' on Test-
--(if" applicable ) Ra -t Minute/ I ch
TYPE OF SYSTEM= CK
ABSORPTION FIELD: Total Lengt
Length of each trench
Depth of tronches
Size of stone
SEEPAGE PIS ; Number--
Size - �_ ft _ x ft _
Stone size
PIPING: _ Size Type
Bl dg _ to Tanis
Tank to Dist _ Box
Di 5-t _ Box to Fi el d/Pit _
Openings Sealed ? Yes No Parti a7
LOCA-IFIOR,/SEPARA-FIORS
Founda ,ti on to Tank feet
Foundation to Absorpt-i o feet
Soparati on o-i= Pits -Feet
con-Fomns as per P1 of P1 n Yes No
I OCATaON OF SYS`TEN ON P OPERTY
( ci rcl e cane )
Front - Rear - Left Si e - Right Side
Middle Front -- Middl a ear
COMMENTS
SYSTEM USE APPROVED: YES No
A zr-r-i a►ed
Dep a r itecf : --� ,, .
Bul I d i rig I respector-
OWN OF Q EENSBURY
BUIUDING --& CODE ENFORCEMENT
`742- Say R"acj
NY X2B64
SEP-rZC DISPOSAE SYSTEM INSPECTION
Namt---
VA,
Location
Date f 31 e r-rn i
SOX L TYPE: San>- Loam , c rc
Rasul 7is oCe al a-ti C)FT Test-
{
( 1 -f appli cabs a ) Rate- in -ta/ I c: h
-TYPE OV SYSTEM
ABSOP.P-VION FIEUD : Tc)7t' I L4--ngt;h
Length o-F each --tre_n4-_ h
Depth oT it-r46Qches
Size o-Fstone
SEEPAGE PT-r-"-- : 'I
Size F -F-t_t x
:��r - _J__CL�
1--tone SIZ41:31 Z���
PIPING : Size T-ype
Bl dg . to Tank
Tank to Dist _ Boix
Dist_ Box to F 1 ie-11 d
Openings Sea-fad? y e s, JfNo . . Part ia,
t_OCA-FIOffZSEPARA-rIO
Founda-tion to -rank _f 7t
Foundation f_-o -Abso p -ti on L-_a-t-
Se-pay-a-tion o-V -- P1t_-s ca*---t
Con-ForTns as per_,p I -t PI an A; No
F M- 5
L-OCA"TION OF -SYS -14 ON PROPERTY':
L e--F 7t Side
t 'Cav -
Front Rea
Middle Fi-on -t - M i d d I t--- 'Rea
COMMENTS
�� � �G--mac - �c� � C ��
SYSTEM . RISE APPROVED-- YES RO
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