98-107 +CLI ,TIFIC 1'�' C►1 + COMPLIANCE
TOWN Of QUEENSBURY
WARREN coliN1'Y , NEW YORK
Da to April 16 19
98107
This is to certify that work requested to be done as shown by Permit No ,
has been completed .
SEPTIC AL''TERATIC7N
This structure may be used as a F
Location 165 L,UZERNE RDM —�
� Owner PQNL1 . MAR$'f-iALL III & --.----.---
By Order of Town Board
TAX MAP" N04 128 . - 2 - 1 TOWN UE QUEENSBURY
Director of Building & Code Enforcement
BUILDING PERMIT
VALUE S fa TOWN OF QUEENSBURY
TALL MAP NO . 128 . — 2 - 1 WARREN COUNTY, NEW YORK
POND , MARSHALL III &
PERMISSION is hereby granted to
OWNER of property located at
165 LU2ERNE RD - Street, Road or Ave.
at the Town of Oation in y.a
To Construct or place a _ SEPTIC A.LT I
at the above location in accordance to application togexher with plat plans and other information hereto filed a
nd
approved and in compliance with the Town of Oueensbury Building and Zoning Ordinance.
t. ownlEN'ANETTE 165 LUZERNE RD ,
QUEENSBURY , NY 12804
2. CONTRACTOR or BUILDERS Name
SMIT�HH I, FARED
34 CDFtTZ3VElRC7� AVENUE
QUEENSBURY . NY 12804
4. ARCH#TECT'S Name
6, ARCHITECT'S Address
5. TYPE of Construction — (Please indicate by X1 SEPTIC
1 1 Wood Frame ( 1 masonry ( I Steel ( 1
7. PLANS and SPecifitatiotn
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
No.
a. Proposed use
SEPTIC ALTERATION
25 April 6 2000
19
$ PERMIT FEE PAID — THIS PERMIT EXPIRES spector of the
(if a longer period is required an application for an extension must be msda go tha Building end Zoning in
town of Ousensbury before tM expiration deta.l 19
g April
Dated at the Town of Queensbury this
Day of 19
for the Town of Oueensbury
SIGNED BY
'Huiidirq and ionr irq ifnpeetOr
.�-- ,Appiication for SEPTIC DISPOSAL PERMIT
Town of Queensbury Permit No. f =��/
Dept. of Community Development
Building & Codes Office Fee Paid $
742 Bay Road
Queensbury, NY 12804
Location of property for instaRation: u
/ APR
Owner's1998
Property Owner's Name: !�/r1 rc f'" . � 7 <'�✓.fir! ' r . .. ,,. - � 1
Property Owner's Mailing Address:
Installer' s Name: 1`�'�17 ram" Phone #
Number of bedrooms (if residential):
v� Total daily flow: 460
(residential - compute ? 150 gal,lbdrm.)
Topography: flat, rolling, steep slope % of slope
Soil Nature: sand, loam, clay, other ! depth:
Ground water; at what
/depth? feet ! Bedrock or Impervious Material: at what depth? feet
Percolation test: " not required, required [ rate min. per inch ]
Domestic water supply: municipal, well, offer
if domestic water supply is a WELL, water supply from any septic absorption is feet.
PROPOSED SYSTEM (Z;rIS71iAl, a)
Septic tank: / Cf �gallon {minimum size: I ,G{�0 gal.)
Tile field: each trench feet ! Total system length: feet
Seepage pit(s): number of f size each: ft. by ft.
Size of stone to be used: # .�-
! depth or thickness feet
HOLDING TANK SYSTEM: (if required)
Number of tanks: Size of each: gallons
Alarms system and associated electrical Aork to be inspected by a certified agency.
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 m reliance upon anv material misrepresentation or failure to make a
material fact or circumstance known by or on behalf of an applicant, shall be void.
I bane read the regulations with respect to this application and aalree to abide by these and all requirements of the Town. of
(2ueensbury Sanitary Sewage Disposal CTdivanc
Date:
5ia11ature of responsible person:
yr
TOWN OF QUEENSBURY
BUILDING A CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804 Af /
-% f
(519) 761-82
SEPTIC DI POSAL SYSTEM INSPECTION
Names V tJr
Loc`a" ti on` ^
Date "I +3 Permit #
SOIL TYP rid- oam-Cl a
Results of ercolation Test
( if applica 1e) Rate-Minute/ nch—`7
TYPE OF SYS �7y
ABSORPTIOII IELD : Total L gt a
Length of e h trencht
Depth of tre ches
Size of ston
SEEPAGE 'PITS : Humber- ft. ..
Size - �� ft . x
Stone size Si a ype
PIPING:
Bldg . to Tank
Tank. to Dist . Box Dist . Box to Fiel P
Openings Sealed ? Yes o artza
LOCATIOn/SEPARATION y , feet
Foundation to Tank feet
Foundation to Absorpt� n feet
Separation of Pits — * es No
Conforms as per Plat PR ERT
LOCATION OF SYSTEM
( circle ht Side
Front - ear Lef Side - i9
Middle Fro - Mi le Rear
CpMMENTS :
f
SYSTEM USE APPROVED : YE NO
Arrived :. tJ
Departed : '
Bui ding nspector
t
i
R t C 171VED
APR 06 IM
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1
3
1 /
{
1
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�, . "i have seen or observed, or believe l saw evidence Ot
`y
all +baects such as houses, welts. trees, fences, etc.M
�own on rUr►leR#. I also represent that f have
I dsonat° aasc;red dista ces set forth an the 'agr
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