2000-442 BUILDING PERMIT
Town of Queensbury, 742 Bay Road, Queensbury. NY 12804
�•-ry, County of Warren (518) 761-8256
Building Permit No. o -Li q
4Y _ I
1
Permission is hereby granted to
�
Owner of property located at _���= �F=�t�` ��}y� M ♦,.�
in the Town of Queensbury, to construe or place a
at the above location in accordance to application together with plot plans and other information hereto flied and
approved and in compliance with the NYS Uniform Building Codes and the Queensbury Zoning Ordinance.
UV'['rlt'.r'S Address: . 1 .
\..•ice'
Contractor or Builder's Name:
.1.
Contractor or Builder's Address;
����
� �� Fir L �� Uu r
Electrical Inspection Agency:
Type of Construction-
Plans and Specifications:
Proposed Use:
SDI €L- fOtum(Aks
"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 Queensbury before the expiration date.)
Dated at the T of Queensbury thiscs`3 4 y Day ofW- V1,k
r --
SIGNET] BY / �^ for the Town of Queensbury
Code Enforcement Officer
' Application for Permit — septic Disposal System
Town Of Q'ueeltsbury 742 Bay Roar.! Queensbury, NY 12804 (518) 761-8.256
1 . OWNER INFORMATION:
_................._...._...................._........................ - .
Ir Location of installation: " �l �" Office Use
Tax Map No, / ! v� File Permit No. Ly� C�
Owner's Name; fJ _ l _ Flee Paid
e
�� - ....._ . _ m. . .
Address: P ... ��..Z . ..............................................
24 INSTALLER'S NAME : -^ - iJ/'L'L�fe� ,= �
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate #'# bedroom(s) and multiply # of
bedrooms with applicable gallons per bedroom to equal total dailyflow)
Ywr -of HouseL No. of Bedrooms x Computation Total QaslyFlow
1980 or older _ x 150 ,gaUb+drm
i980 - 1991 x 130 gaVbdrm
1991 - present x 1 10 galfbdrm
Garbage Grinder Installed yes ! no
Spa or Whirlpool installed yes f no
4. PARCEL INFORMATION: (circle applicable information & indicate measurements)
1 r r n at r B drock- Qr 1rrepervious Material poln-9 do Water Su 1
r'?
a at what depth at wh a rth ppY
!clay �' '''" �ee1 --feet well
other rf well; water supply
depth. from any septic-system
absorption is f?.
Percolation Test; other
(T o be completed by licensed professional engineer or architect)
Rate; minute per Inch
5. PROPOSED SYSTEM: For 1V m CsnatructiQn: All individual sewage disposal systems must be designed by a licensed
proressional engineer or architect (unless installed in a Planning Board approved subdivision). Add 250 gallons to the sire
of the septic tank and leach Geld for each Garbage Griixter, Spa or Whirlpool Tub.
Septic Tank: IZ-Ia per, gallon ('min. size 1, 000 gal) T
Tile Field: each trench fl. Total System Length:
Seepage Pit(s): number of_ _ size o each: - �[
f ,,/l. by
Size of Stone to be used; # / depth or thickness 1r feet
Bed System Size:
x
Alternative System: length and/or size
6, HOLDING TANK SYSTEM: (if required)
Number of tanks: 1 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
ofQueensbury, 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 behal£of an applicant, shall be void.
I have road the regulations with respect to this application and agree to abide by these and all
requirements of the ofQueensbury Sanitary Sewage Disposal Ordinance.
�j A
ignature of res onsible person Date
IL
TOWN OF QUEENSBURY
BUILDIN &_ CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804
~(5is) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name
Location
Date 7 — Permit c►�- f ---
SOIL Sand- am- Clay-
Result of Per lation Test-
( if apple a Rate-Minutellnch
TYPE OF SY
ABSORPTION FI LD . al Length
Length of eac trench
Depth of tren hes
Size of stun
SEEPAGE PITS : Number-
Size - ft , x ft .
Stone size '
PIPING: S ze ype
Bldg . to Tan
Tank to Dist . Box EG
Dist . Box to iel i �' x
Openings Seal ? Yes No- artia
LOCATIONfSEP
Foundation to Ta . feet
Foundation to Absorption ` feet
Separation of Pits feet
Conforms as per Plot Plan a H0
LOCATION OF SYSTEM ON PROPERr
( circle
one
Front Rea eft 5- Right Side
- �Rea ~ d �,
Middle F'PSnt -' °C3Rear
COMMENTS :
SYSTEM USE APPROVED: YES 0
Arrived : : ' or,
Depa
uilding In c r -
THIS PLAN TO13 E ONCr- PROJECT SITE AT �
THE {
Q R TIaN OF
C�`�ri';T ticTIa
i �V
—s
4`...
0
TOWN 0 QUEEN8B RY BUILDING DEPARTMENT �
; ,. Based on our Hmited examination, -
comphancevith our comments shall i
not be construed as indicating the
_.
�0O plans and spacif�cations are in full
compliance with the code.
Dr observed, or believe l saw evidence of,
,jch as houses, wells, trees, fences, etc.,
this document I also represent that I he.ve
�„ measured the distances set forth cr tnt C ;c c;
SIGNATURE
TOWN OF QUEENS U Y
BUILDING & 0 PT.
REVIEWED BY � 'TE
. V�