2000-910 TOWN OF OUEENSBURY
742 Bay Road, Queenshury, NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761=82%
CERTIFICATE OF COMPLIANCE
Permit Number: P20000910 Date Issued: Monday, December 11, 2000
This is to certify that work requested to be done as shown by Permit Number P20000910
has been completed.
Tax Map Number: 523400-027-000-0002-017-000-0000
Location, 31 CLEMENTS Rd
Owner, DOUGLAS QUIMBY
Applicant:
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
Director of Building & Code Enforcement
TOWN OF QUEENSBURY
742 Bay Road, Queensbury, NY 12804-5942 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
19U] LDIN{G PERMIT
Permit Number: P20000910 Application Number. A20000910
Tax Map No: 5 2 3 400-027-0001 00 02-0 1 7-000-0 000
Permission is hereby granted to:
For property located at: 31 CLEMENTS Rd
in the Town of Queensbury, to construct or place
at the above location in accordance with 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. Type of Construction Value
Owner Address: VIOLA WILLS Septic Alteration Residential
31 CLEMENTS Rd Total Value
QUEENSBURY, NY 12804
Contractor or BLvlder's Name / Address Electrical Inspection Agency
CRANDALL, CFH US
Plans & Specifications
BP 2000-910
SEPTIC ALTERATION, 3 BEDROOM HOUSE
Owner Listed on application; Dennis Davis
$25.00 PERMIT FEE PAID - THIS PERMIT EXPIRES: Thursday, November 28, 2002
(If a longer period is required, an application for an extension must be rnade to the code Enforcement
C)fficer
Dated at the Town Qtte bu T,, tes , er
er 28, 2000
SIGNED BY for the Town of Queensbury.
Director of Building & Cade Enforcement
�. .� Application for Permit — Septic Disposal System
Town of Queensbury 742 Bay load Queensbury, NY 12804 (518) 761-8256
I . OWNER INFORMATION:
......................... .......................................................................................
.........._.....
„� 1�
Location of installation: Office Use� �� ' 1 'f`Y �[`�-€
File Permit o
Tax Map No.
Aff2.Ofwner s Name: Q �V�'4\c.•�_� �
Fee Paid 7 ""
.................... ............ ...............................
..._.......€
Address: (' - '\3 �{ t�-,?. 1. ,
�J
2. INSTALLER'S NAME : _ C '�`� SC cn.�%'C)n�L��,. PHONE NO.
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 Bedrooms x Cpmutation - Total Daily Flow
1980 or older x 150 gaVbdrm
1980 - 1991 _ x 130 gal/bdrm =
1991 - present x 0 gailbdrm
Garbage Grinder Installed yes _ / no �
Spa or Whirlpool Installed yes ! no NOV AS 200
1OWN OF
4. PARCEL INFORMATION: (circle applicable information & indicate measurements) SQ'WING G F?1V
- '1 N ur rand Wat r Bedrock or Im ervio s Material Domestic Water Supply
1' sand at what depth at what depth m al
Rolling lots feet � feet wel
Steep slope clay ifwell; water supply
Yo slope other from any septic-system
depth: absorption is ft.
other
Percolation Test: (To be completed by licensed professional engineer or architect)
.hate: 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: 1 ,gallon (min. size 1, 000 gal.)
Tile Field: each french ---....-410_._ft. Total System Length:
S� Pit(s): number of size of'each: ft. by ft,
11
�aif Stone to be used: # — � / depth or thickness �/ .s`feet
Bed System Size: ,z
Alternative System: length and/or size
6. 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
requirements of the Town of Quemsbury Sanitary Sewage Disposal Ordinance.
3 00
Signature of responsible person Date
TowN of QUEENISBURY
BUILDING_ A CONE ENNFORCEN�E �F a/L -L
742 Bay Rnad G� �
Qoeensbury 11 Z28O+I
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name , (�
Location
Date ► Permit �# 04LO -471C
Fix
SOIL TY Sand- Loam- lay-
Results of Percolation Test-
( if applicable ) Rate- Minute/ Inch
TYPE OF SYSTEM:
ABSORPTION FIELD : Total L th + �
Length of each trench
Depth of trenches
Size of stone
SEEPAGE PITS : Dumber-
Size - ft . x ft .
Stone size
PIPING : izf ype [ � x
Bldg . to Tank !3 `�'/
Tank to Dist . Box fir"
Dist . Box to Field/P ' r -5
Openings Sealed ? Yes No art,
LOCATIOR/SEPARATIONS .
Foundation to Tank feet
Foundation to Absorption feet
Separation of Fits eet
Conforms as per Plot Plan :e No
LOCATION OF SYSTEM ON PROPERT
{ circle
Front - Re eft S ' - Right Side
Middle rant _ Mi dl a Rear
COMMENTS:
SYSTEM USE APPROVED : YES NO
Arrived:
Departed : /
Building Inspector
RECEIVED "I have sien or observed, or believe I saw evidence of,
Ak t rs such as houses, wells, trees, fences, etc.,
per i asiJr distances set forth on the diagram "
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ILDING AND CO f
SIGNATURE DATE
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REVIEWED BY j 42�'e DATE
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