1999-742 CERTIFICAI O.
COMPLIANCE
- TOWN. OF QUEENSBURY
WARREN.COUNTY, NEW YORK
December '6 99
Date ;19
® r� ✓ p 99742"
This s to certify hat `work requested to be done as shown by Permit No.
has been completed.
SEPTIC ALTERATION
This structure may be used as a
68. MASS. AVE.
Location
WILLARD, 331RNt x tt. —
Owner
TAx MAP: NO. 128. -3_1 By Order. of Town Board •
. TOWN ,OF iUE NSBURY
(--2,,_,/
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• Director of Building 8 Code Enforcement s ,
BUILDING PERMIT
Town of Queensbury, 742 Bay Road, Queensbury,NY 12804
County of Warren (518) 761-8256
VALUE $ 0 Building Permit No. 99742
TAX MAP NO. 128 . -3-1
Permission is hereby granted to W I L LARD, B I RNEY R.
Owner of property located at 6 8 MA S S
in the Town of Queensbury,to construct or place a SEPTIC ALTERATION
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.
Owner's Address:
68 MASSACHUSETTS AVE.
QUEENSBURY, NY 12804
Contractor or Builder's Name:
• - SMITH, FRED
Contractor or Builder's Address:
23 VERMONT AVENUE
QUEENSBURY, NY 12804
Electrical Inspection Agency:
Type of Construction:
SEPTIC
Plans and Specifications:
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
Proposed Use:
SEPTIC ALTERATION
•
$ 25 PERMIT FEE PAID-THIS PERMIT EXPIRES December 6 2001
(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 Town of Queensbury this 6 Day of December 1999
SIGNE for the Town of Queensbury
Code Enforcement Officer
- g(2q
Application for Permit-Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
p Office Use
Location of installation: 110 /0,4,S.S ',�j/c
Tax Map No. / / R 171vdFee Paid 0 SG
cue
Owner's Name: 6/(4/6 y r(/I����� P'cG - . 1999
Address: Co 7 /17 Ass ig( U SeftS ,All/L4' 1 TOWN OF C JtE NS U 8Y
BU LD NG AND CODE
2. INSTALLER'S NAME : ) SE'I/7/ PHONE NO.' / ?/?g‘
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate#bedroom(s) and multiply# of
bedrooms with applicable gallons per bedroom to equal total daily flow)
Year of House: No. of Bedrooms x Computation = Total Daily Flow
. 1980 or olde 40i�4 x 150 gal/bdrm
1980—1991 _ x 130 gal/bdrm =
1991 —present x 110 gal/bdrm
Garbage Grinder Installed yes / no
Spa or Whirlpool Installed yes. / no
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
rah Soil Nature Ground Water Bedrock or Impervious Material Domestic Water Supply
son, at what depth at what depth �nicip
Rolling loam 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 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: jdUrJ , gallon (min. size 1,000 gal)
Tile Field: each trench • ft. Total System Length: ft.
Seepage Pit(s): number of I size of each: ft. by /, ft
Size of Stone to be used: # 3 / depth or thickness • 'feet
Bed System Size: x
•
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. 0
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.
AW ' /039
Signature of responsible person ! Dat
TOWN OP--: SBURY ' ,!' /
LDING & CODE ENFORCEMENT
742 Bay Road
Queensbury NY 128 K Ce r
�
(518) 761-8256 Y�..J" _
SEPTIC DISPOSAL SYSTEM INSPECTIONCf2
z
Name
LJ' C
Location (O"Y •
Date b/ Permit # -/7'77g-----
SOIL TYP : Sand- oam-Clay-
Results of Percolati Test-
(if applicable) Rat -Mi to/Inch
TYPE OF SYSTEM:
ABSORPTION FIELD: T tal Le th
Length of each trenc
Depth of trenches
Size of sto e
SEEPAGE PITS: -
Size - 9. ft. x ft.
Stone size + ,, )
PIPING: Size Type
Bldg. to Tank "---1 " c_A- )-1C7
Tank t 'vx:— mw
Openings Sealed? Apar . 1 Partial
LOCATION/SEPARATI'
Foundation to Tank [°� feet
Foundation to Absoro ti on -z:7 V feet
Separation of Pits" feet
Conforms as per Plot Plan es No
LOCATION OF SYST M ON PROPER
(circle one) C `CflQ CE-
Front - Rear - L ft Side - Right Side
Middle Fron - Middle Rear
COMMENTS:
•
SYSTEM USE APPROV . ES NO
Arr.' d: °.
D arted
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A u z 'Ka
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__DE -. 3 1999
TCYliv7\' fl CLi2Y
BUILDAG AtA) CODE
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"I have seen-orobserved-,-orhelleve I saw evti\ncel--of,
all objects such as houses, wells, trees, fences, etc.,
shown on, ocument. I also represent that I have
person astured he distances set forth on the diagram."
AO:f /0/17
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SI NATURE DATE
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