2000-244 C-er,t 1 ica e om"p f C
itd'inc"he
'.Gown of Q4eensbury
Wren County,New York
Apr11 28, 2000
.Date
2000244
This is to certify that work requested to be done as shown by Permit No,.
has been completed, I
SEPTIC ALTERATION
This stnicture may be used as a:�.9._
13 MAIN S tiQ.
Location
Owner STATE ONE INSURANCE
W
TAX MAP NO. 13@ a -3-2 2
By Order Town Board
V
Director of Building Cade Enforcement
BUILDING PERMIT
Town of Queensbury,742 Bay Road, Queensbury,NY 12804
County of Warren (518)761-8256
VALUE $ 0 Building Permit No. 2000244
TAX MAP NO. 130. -3-22,
Permission is hereby granted to STATE FARM INSURANCE
Owner of property located at 13 MAIN ST.
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:
ELYES 12 ROLLING RIDGE DR.
SARATOGA SPRINGS, NY 12866
Contractor or Builder's Name:
JOHN C. HALL INSTALLATIONS
Contractor or Builder's Address:
44 BOULEVARD
QUEENS BURY,-NY. . 12.8W4
Electrical Inspection Agency:
Type of Construction:
SEPTIC,
Plans and Specifications:
. SEPTIC. ALTERATION AS PER, PLOT, PLAN SPECIFICATIONS ,
Proposed Use:
SEPTIC ALTERATION
35 April. 27 2002 . .
$ PERMIT FEE PAIR)--:.'TMS PERMIT EXPIRES'
(if a1onger 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.)
27 - Aprij . 2000
Dated at the Town -Queensbiuy this - - Day of
SIGNED BY ::n'k���� or or Town of Queensbury
Code Enforcement Officer
Application for Permit—Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
....................................................... .....................................................
Office Use
Location of installation: /9
File Permit Noopryraqq
Tax Map No. - /—/ - - . I
�Ze Paid
Owner's Name: cc Le-v &,)'o
.......................................................... ...........................
Address:
2. INSTALLER'S NAME PHONE NO.
3. RESIDENCE INFORMATION' (circle year of dwelling, indicate#bedroom(s) and multiply# of
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/bdrm = 3oe
1980- 1991 x 130 gal/bdrm
1991 -present x 110 gal/bdrm
Garbage Grinder Installed yes no X
Spa or Whirlpool Installed yes_ l no X
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
Tgpography Soil Nature Ground Water Bedrock or Impervious Material ater Su
IT/of sand X at what depth at whqt depth (municipa 5'
.
Rolling loam —,LIA-feet tl!�- feet -Weff-1—
Steep slope clay
if well; water supply
—%slope other from any septic-system
depth: absorption is it-
other
Percolation Test: (To be completed by licensed professional engineer or architect)
Rate: minute per inch
5. PROPOSED SYSTEM: For New Construction: 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: ,00 gallon (min. size 1,000 gal.)
Tile Field: each trench A-111Z-1 Total System Length:
Seepage Pit(s): number of size ofeach: _ft. by_fl.
Size of Stone to be used: # 2 depth or thickness et X/Al&/1-1
Bed System Size: X
Alternative System: length and/or size
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: l Size of each: gallons /TOTAL Capacity: _gallons
Note. Alarm System and associated electrical work must be inspected bya'Town approved
electrical inspection agency.
T. 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.
Si pon Oure of res sf�"p rson Date
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