2000-453 BUILDING PERMIT
Town of Queensbury, 742 Say Road, Queensbury, NY 12804
County of Warren (518) 761-8256
" Building Permit No.9Q,.._ 7Cs
Permission is hereby granted to
Owner of property located at
in the Town of Queensbury, to construct or place a
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.
dtn
Co or or Builder' Nana
Contractor or Builder's Address:
Electrical Inspection Agency_
Type of Construction:
Plans and Specifications,.,,,,,,,, vtssac Vlcct�
sea use: ,
- ac�
$ 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 Queenshury�ybefore the exp wat
Dated at the Town of Queensbury 's Day of
SIGNER BY �� �� �, for the Town of Queensbury
Code Enforcement. Officer
Application for Permit - Septic Disposal System
Tvwn of Queensbury 742 Bay Road Queensbury, NY 12804 (518) 761-8256
1 . OWNER INFORMATION:
Location of installation: /a e �61 + ►'C i C� } C"Tice Use
cc �'cp.�'1
Tax Mall No.
File Permit Nosz 'CX7
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' ffdrtr� { Fee Paid ,
Owner s Name: r ..
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Address: ZO � � �t//n< f JU'41 Tt OQ t 11 Co
2. INSTALLER'S NAME �I t7d"4A F'•alr`_�42k4frtl . Qog PHONE NO?e ery L-
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate # bedroom(s) and multiply # of
bedrooms with applicable gallons per bedroom to equal total dailyflow)
Year of House: No. of BeSlrooms x Computation Total Daily Flow
1980 or older .a x 150 gal/bdrm
1980 -- 1991 x 130 gal/bdrm =
1991 - present x 110 gallbdrm
Garbage Grinder Installed yes 1 no C` "t PTNQr VC
Spa or Whirlpool Installed yes / no EED
JUN 2 6 2000
d. PARCEL INFORMATION: (circle applicable information & indicate measurements) ~
ToRogaghy SgilNature r and Water Bedijor,k or IMpervious Material Dom stic Wat r S I
!a n at what depth at what depth municipal
o ling Darn �1- feet feet well
Steep slope clay ifwell; water supply
slope other from any septic-system
depth. absorption is ft.
ether
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. t
Septic Tank: gallon (min. size 1, 000 gal.) IV Ect,/ 7 24 � K / � � Ier
Tile Field: each trench ft. Total System Length: ft.
Seepage Pit(s): number of size ofeach: ft. by ft.
Size of Stone to be used: # / depth or thickness feet
Bed System Size: x
Alternative System: length and/or size
f. HOLDING TANK SYSTEM: (if required)
Number of tanks: / Size of each: gallons / 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 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
requirementss of the Town of Queensbury Sanitary Sewage Disposal Ordinance.
Signature of responsible person Date
— TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEWAT
0742 Bay Road
Queensbury__NY 12804
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name
Loc ati o��n�
Date tCi' #c/ 0oo - A J
SOIL TYgE!:];] am-Clay-
Results of Percolation Test-
( if applicable ) flat Minute/ Inch
TYPE OF SYSTEM:
ABSORPTION FIELD : Tot 1 Length
Length of each ench
Depth of trenc s
Size of stone
SEEPAGE PITS : Numbe - ft .
Size - ft •
Stone size Size ype
PIPING :
Bldg . to Tan
Tank to C1yst _ x N �` P+Jc'_.T �. L�Si►trj ,
Dist . Box field/Pit
Openings Seal d? Yeses artza
LOCATION/SEPA TIONS : � feet
Foundation to Tank feet
Foundation to bsorption feet
Separation of its o
Conforms as pe plot Plan
LOCATION of SY TEM ON PROPER
( circle one)
Front - Rear - eft Side - Right Side
Middle Front i ddl a Rear
COMMENTS :
SYSTEM USE APPROVED : YES-- � No
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TOWN OF QUEENSBURY
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BUILDING & all such as uses,this document. I also representtlad lmre
REv1EWED BY personally measured the dismnoes sd bt Dq the dim"
DATE " P 4 . �� . 4D
SIGNATURE DAB