2000-907 TOWN OF QUEENSBURY
742 Bay Road, Queensbury, NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761=8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20000907 Date Issued: Monday, December 04, 2000
This is to certify that work requested to be done as shown by Permit Number P20000907
has been completed.
Tax Map Number: 523400-11740-001043-000-0000
Location. 18 WESTERN AVE. SOUTH
Owner. GARRY LA MORA SR
Applicant. GARRY LA MORA SR
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 +CLUEENSB►URY
742 Bay Road, Queensbuxy, NY 12804-5902 (518) 761-8201
Ct Community Development - Building & Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20000907 Application Number. A20000907
Tax Map No: 523400-117-000-0010-003-000-0000
Permission is hereby granted to: GARRY LA MORA SR
For property located at: 18 WESTERN AVE, SOUTH
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 Qonstruction Vaa
Owner Address: GAR.RYY' LA MORA SR Septic Alteration Residential
19 LESTER Dr Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name / Address Electrical Inspection Agency
Plans & Specifications
BP 2000-907
SEPTIC ALTERATION; TWO BEDROOM HOUSE
$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 made to the code Enforcement
Officer
Dated at the To of I u ovember 28, 2000
SIGNED BY for the Town. of C2u.eensbury.
Director of Building & Code Enforcement
Application for Permit - Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury, NY 12804 (518) 761-8256
1 . OWNER INFORMATION; _..............I...4 ,_........_................................
Office Use
Location of installation: �y
File Permit No.
Tax Map No. f C ! Fee Paid zz*�
Owner's Name: t�� 40q
. . ......................._........._.........................................
...E
Address: /��' u ' e- e� T �N '
2. INSTALLER'S NAME : PHONE N 42000
V OF
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate it bedroom(s) and m Oi t JelyssuF4,1,
bedrooms with applicable gallons per bedroom to equal total daily o Cpp
Year of House: Ng of Bedrooms x Computation = Total Daily Flow
1980 or x 150 gaLbdrtn = 3ez)
1980 — 1991 x 130 gal/bdrm =
1991 - present x 110 gal/bdrm =
Garbage Grander Installed yes 1 no s
Spa or Whirlpool Installed yes 1 no
4. PARCEL INFORMATION: (circle applicable information &, indicate measurements)
T�QpgggAphv SoilNature . r and Water Bedrock or Impervious Material t r Supply
141at San at what depth at what depth mrrnici al
Rolling Caro feet feet we
Steep slope Clay if well; water supply
slope other from any septic-system
depth: absorption is ft.
other
Percolation Test: (To be completed by licensed professional engineer or architect)
Rate: minute per inch
5 . PROPOSED SYSTEM: For N Congrucfl n: An 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: leA Q P gallon ('min. size 1. 000 gal.)
Tile Field: each trench ft. Total System Length.: ft.
Seepage Pit(s): number of / size ofeach: r ft. by ft.
t
Size of Stone to be used: # / depth or thickness feet
Bed System Size: x
Alternative System: length an& 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
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.
Ngnat&lre of responsible person Date
TONN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
1oad
Queensbury MY 12804
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name d ` �r
Location
Date 1
v P erm iS. #�--r �—
SOIL TYPE: San a- Loam- Cl a .
Resul is of Perc�pl ati on T st-
( if applicable ) Rate-Min to/ Inch
TYPE OF SYSTEM:
ABSORPTION FIELD Total Lenqth
Length of each t nch
Depth of trenches
Size of stone
SEEPAGE PITS : !dumb r- f ------
Size - _ ft .
Stone size _ Size ype �
PIPING:
Bldg . to Tank
Tank to Dist . Box -----
Dist . Box to Field/Pits No art� a
Openings Sealed?
LOCATIONISEPARATIOMS : feet
Foundation to Tank on feet
Foundation to Absorp feet
Separation of Pits s No
Conforms as per Plot Plan
LOCATION OF SYSTEM PROPERTY :
( circle one )
Front - hear - Left Side - Right S e
Middle Front - Mid a Rear
COMMENTS
SYSTEM USE APPROVED : YES MO
.
Arrived:
Departed:
::Dkf
Building Inspector
TOWN[ OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
742 say Road
Queensbury NY 12804
(519) 761-8256
SEPTIC DISPOSAL TEM I PECTION
Name
Location 1 q
Date 11 .3G► Permit # � �C3
SOIL TYPE?/ S n Loam- Clay
Results o rcol ati on T st-
( if applicabl ) Rate-Mi ute/ Inch
TYPE OF SYS
ABSORPTION! FI yD: Tota Length
Length of each trench
Depth of trenc s
Size of stone
SEEPAGE PI mb
Size - � � f
Stone size
PIPING : Size Ype
Bldg . to Tank
Tank to Dist . Bax
Dist . Box to Fiel 1
Openings Sealed ? es No artsa
LOCATION/SEPARA ON5 feet
Foundation to T nk
Foundation to A sorpt n feet
feet
Separation of ' ts
Conforms as pe Plot P n e No
LOCATION OF SY M ON P PER
( circle one )
Front - Rear - 'Left Side Right Side
Middle Front - Middle Rea
COMMENTS :
ice P(
C.- c'� Ur '�e'� '�' fiG'•'Lr� 4d
SYSTEM USE APPROVED : YES NO
d
Departeeprarted
Building Inspector
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