1999-768 CERTIFICATE OF COMPLIANCE
TOWN OF QUEENSBURY
WARREN COUP1TY; NEW YORK
December 21 99
Date 19
99768
This is to certify that wo,rk .requested to be done as shown by Permit No..
has been completed: SEPTIC ALTERATION
. This structure may be used as a
15 MANOR DR. --- _
Location
�y,3Ut:: ;.B btiUkt Y. 1�t iNiS: —
O.wner
TAX MAP NO. 78 . -1--19 .& 20 By Order of Town Board.
TOWN OF QUEENSBURY
(-:1)
Director of Building & Code Enforcement
BUILDING PERMIT
Town of Queensbury, 742 Bay Road, Queensbury,NY 12804
County of Warren (518) 761-8256
VALUE $ 0 Building Permit No. 99768
TAX MAP NO. 78 . -1-19 & 20
Permission is hereby granted to QUEENSBURY ARMS
Owner of property located at 15 MANOR DR.
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:
15 MANOR DR.
QUEENSBURY, NY 12804
Contractor or Builder's Name:
QUEENSBURY SEWER
Contractor or Builder's Address:
Electrical Inspection Agency:
Type of Construction:
SEPTIC
•
Plans and Specifications:
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
Proposed Use:
SEPTIC ALTERATION
•
$ 2 5PER ET FEE PAID—THIS PERMIT EXPIRES December 20 2 001
(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 f Queensbury this 20 Day of December 1999
1r�,
SIGNED BY 'l 1
, 1- Q,LJ`iV for the Town of Queensbury
Code Enforcement Officer
Application for Permit—Septic Disposal System
Town of Queensbuty 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
x�i `� f� Office Use
Location of installation: / , ' I4 (10 R [� d , •
File Permit No " W-R/
Tax Map No. 2t(/ m /-ZC
( • Fee Paid
Owner's Name: ' (A.0 L.-I,e ti '6 Y o •SE.
Address: ecA 13t?,p- '&hiS' , Ma Rote " i-ee
2. INSTALLER'S NAME qv , C ct i
C o_� o�u PHONE NO.1
3. RESIDENCE INFORMATION: (circle year of dwdlling, 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 older x 150 gal/bdrm =
1980— 1991 4 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)
To ography Soil Nature Ground Water Bedrock or Impervious Material Domestic Water Supply
Flaitia. at what depth cit what depth municipal
oiling yam feet feet well
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.
C
Septic Tank: /6 d (I gallon-(min. size 1;000 gal)
Tile Field: each trench 6--Z) ft. Total System Length:' ft. .
Seepage Pit(s): number of size of each: ft. by ft
Size of Stone to be used: # '�---"" / 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.
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.
C: _,,,,m, , ,C,,,,21. - � 6 I
Sig atu a of responsible person Date
1.111111r--
1
TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804 .
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name (Dbe,e/Y\-,..ja Dilf/N6
Location F., -( (4-Z____
Datel -_ ermit # 9 - 7 62
SOIL TYPE. Sandi o m- lay-
Results of Percolat o Test-
(if applicable) Ra 'e-' inute/Inch
TYPE OF SYSTEM:
ABSORPTION FIELD: To al Length .,,.. 1.
Length of each tten' h c.5'C4 C�
Depth\of trench- 71"
Size o stone 7
SEEPAGE ' Number-
Size - ft. x ft.
Stone size
PIPING: Size Ty
pe
yip
Bldg. to Tan FV-1:5T
Tank.to Dist. Box � `� �
Dist. 'Box to Field/Pit i-Ji h
Openings Staled? Yes No Partial
LOCATION/S PARATIONS:
Foundatio to Tank f5a5L.feet
Foundatio to Absorption - feet
Separati. of Pits feet
Conforms as per Plot Plan q No
LOCATION OF SYSTEM ON PROPERTY:
(circle one)
Front - ar Left Side - Right Side
Middle Front—Mid
dle Rear
COMMENTS:
•
SYSTEM USE APPROVED: 1011P 0
Arrived: °Ai -
Depart: ,Ai4*
' ildinrin , actor
"I have seen or observed,
ed, or I saw evidence of,•all objects such as houses, wells,
shown on this document e !s, trees, fences, etc., a
I also repreSent that ! have Ni,
personall measured the dis n es set fil h on the diagram."
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