2000-454 Certlilcate of Compliance
Town of Queensbury
ffII 'Warren County, New York
I June 29, 20OU
Date
off+rsI40�c7"��� !V r J{1 I1 S 2000454
This i o zfy t a wr�r cquested to e o shown by Permit No.
has been completed,
SEPTIC ALTERATION
'Phis structure may be used as a
2 MANOR
Location .__Owner �
BRYAN , J . BUCKLEY , JR .
r
TAX MAP NO , �
,,�
y Order wn Board
+ 'f if 'lC� f . T+DW'hT CIF uF l�cl5f )_R. Y- ._
K �
Director of Building & Code Enforcement
BUILDING PERMIT
Town of Queensbury, 742 Bay Road, Queensbury, NY 12804
County of Warren (S 18) 761 -8256
Building Permit No. lV '> >4BL4
Permission is hereby grantee#. to
JJ or Owner of property located at
in the Town of Queensbury, to construct or place a t Y .' ' Tom- I oy�'+
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.
Ss-
tom' 1
Contractor or Builder's Name:
Ar
Contractor or Builder's Address_
J
Electrical Inspection Agency;
Type of Construction-
Plans and. Specifications- Sp
Proposed Use:
$ PERMIT FEE PAD — THIS PERMIT EXPIRES `-1� C � t�
(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 dame.)
Dated at the T of Queensbury this 3LL""e'40
SIGNED BY A::: for the Town of Queensbury
Code nforoernent Officer
Application for Perruit — Septic Disposal System
Town of Queenshury 742 Bay Road Queenshury, NY 12804 (518) 761-8256
L OWNER INFORMATION:
_.._..._..__......................................................................................................._......A..AA
Location of installation: `� / �— y � ,�a F
File Permit No.
Tax Map No. I I I
! pc�
Owner's Name: t Fee Paid F
Address:
2. INSTALLER'S NAME J ,� ,,. �h PHONE NO.
3 , RESIDENCE INFORMATION: (circle year of dwelling, indicate 0 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
,� '. 80 or alders x 150 gallbdrin = qa-
L lytiU ^Cg9T"� x 130 gal/bdrm — 7 " ' . Ad-
1991 — present x 1 10 gallbdrtn = '-
_.. s.v.
Garbage Grinder Installed yes � !
JUN 2 6 2000
Spa or Whirlpool Installed yes I T'r Ali.. , �^ ;
4. PARCEL INFORMATION: (circle applicable information & indicate measurements)
A.To ra 1t Soil Nature round Water I3cdrack or lux ervious Material Dom stir Water Suuuly
1 a rclay
at what depth at what depth fmloiling fee[ ,/eel eSteep slope if well; water supply
sloper from any septic-system
pth: absorption is ft.
other _
Percolation Test: (To be completed by licensed professional engineer or architect)
Rate: ininute 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 Plaryning Board approved subdivision). Add 250 gallons to Elie sire
of the septic lank and leach field for each Garbage Grinder, Spa or Whirlpool Tub.
Septic Tank: to�4 ;-' _ ggallo—n- (min. size 1, 000 gal.) Y
Tile Field: each trench �� 7 , � ft. Total System Length :
Seepage Pit(s): number of_ size ofeach: _ ft. by ft.
Size of Stone to be used: 11 / depth or thickness feel
Bed System Size: x
Alternative System: ETC .- �_ length andlor size
6. HOLDING TANK SYSTEM: (if required)
Number of tanks : 1 Size of each: gallons f 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 Codo of the Town
of Queensbury, any permit or approval ,granted which is bused 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 ofQueensbury Sanitary Sewage Disposal Ordinance.
SI at re of responsible person Date
CC1MMONW lu LTHofrice 17 Doc Run ReadNTM aphe rn, PA1�qg VICE, INCQ:7.
rq,MUNICIPAL CERTIFICATE - ELEC TRICAL APPROVAL
67704 Cut-in Card Na. .........«,,......
.................
Panel Boa�iNo._.....,..."_....I........._Cert. N4 ....... ....... .... .....!.. ..`.,t.�y..'.�........._...
Location . CT. . ........ ....... T./1.lJ G . ' ...........
Installation Consisting af ...... G f<---" ..........
..........".............
............ ............... 'i" .,......... ....., I_ic. No, .,........,,.."..
Installed 13y....". ...
..'........ ......».................._..........
............,.. ,. .. ... ... .. certificate
Previously issued is
The conditions following governed the issuance of this certifinstal and any
ment and installation conditions as of date. upon 'he
i cancelled: - rom tl made for inspection
This certificate only covers the electrical equip licalion shall be p P y
etions at any time. and if its
introduction of additional equipm 5hn}ir leave alterations,
priaptege of makm ,e�company �, tlt care ,rry
inspectars of this P, shall have the right tu0. -'
� rules are violated, the Company' ............ ........
2 ! ......_........ 1NSPECTOFt .........,- Memher N.
Date"....... .........
TOM OF QUEENSBURY
BUILDIMG._ a2CODE
E a�RCEMENT
i
Queensbury_ NY _ 12804
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name
i
� r
Location
4t�
Date
Permit
gSan
SOIL TYPE: oam- Clay-
Results of Percolation Test-
( if applicable ) Rate-minute/ inch
TYPE OF SYSTEM: 2 ?J
ABSORPTION FIELDo Total Len,+gt,�
Length of each trench
••
Depth of trenche
Size of stone IN
SEEPAGE PITS : number- ft .
Size - ft . x
Stone size }z
PIPING:
Bldg . to Tanis/ Pu w-p
Z.e� to Dist . Box AIL 3
Dist . Box to FieldlPi o art� a
Openings Sealed? Y s
LOCATION/SEPARATI / "! feet
Foundation to Tank eet
Foundation to Absorpt an feet
Separation of Pits O
Na
Conforms as per Plot 1 an
LOCATIC0 OF SYSTEM PROPER
( circle - Left Side - Right Side
Front - e
Middle F nt - Mi dd1 Rear
COMMENTS :
SYSTEM USE APPROVED :
Arrived :
Departed:
Suiiding Inspec
J
-` _.-_- — --- _ "1 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 di ances set forth on the diagram.,
S NATURE DATE
4000454
t
f 2 c ERYAN iJ 1.7
Mr v:: i. x 7%
77MM - .� :OP r I
1 � Py�WNC" IiEVSBi�`: 3�'i' (� `� ~EPA,RIMFNT t o
Based on ourlimeu exarninatio
Cor;Zpiiance-4t our
be construed as indicat- th
plans and
1 ciFcaE+oI are ifl �i
.: 1,U ir.
� r
TOW OF Q � EENSBURY
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.. . :-- 1 BUS ING & pT
REVIEVfED RY
Ui7Jl (��' DATE
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