96-149 CLRTIFICKrE OF COMPLIANCE
TOWN OF QUEENSBURY
WARREN COUNTY, NEW YORK
Date 19 ar
ri
This is. to certify that, work requested to be done as shown by Permit No. 96149
has been completed.
This structure may be used as a SEPTIC AL,T1 RATION
Location 17 01-110 AVE.
Owner NELS011 , 'ROBI;-R`1'
By Order of. Town Board
TAX 4.111P NO. 127 . -1 1-4 TOWN OF QUEENSBURY
: Director of Building & Code Enforcement
BUILDING PERMIT
VALUE S 0 TOWN OF QUEENSBURY 96149
TAX MAP NO.. 127. -11-4 No.
WARREN COUNTY, NEW YORK
PERMISSION is hereby granted to NELSON, ROBERT
OWNER of property located a 17 OHIOt AVE. Street, Road or Ave.
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 Town of Queensbury Building and Zoning Ordinance.
1. OWNER'S Address is
PATTEN -HILL RD.
GLENS FALLS, NY: . 12801
2. CONTRACTOR or BUI LDER'S Name
QUEENSBURY SEWER
3. CONTRACTOR or BUILDER'S Address
JAY SWEET. - MOBILE PHONE#744-0028
4. ARCHITECT'S Name
5. ARCHITECT'S Address
6. TYPE of Construction—(Please indicate by X)
SEPTIC
( )Wood Frame ( ) Masonry ( )Steel ( )
7. PLANS and Specifications
SEPTIA. ALTERATION AS PER PLOT PLAN SPECIFICATIONS
8. Proposed Use
SEPTIC, ALTERATION-.-,
$ PERMIT FEE PAID —THIS PERMIT EXPIRES April 25 19 98
(If a longer period is required an application for an.extension must be made to the Building and Zoning inspector of the
town of Queensbury before the expiration date.)
=25 April 96
Dated at the Town of Queensbury this Day of 19
SIGNED BY �� — for the Town of Queensbury
FBu 1ding and Zoning Inspector
Application foil SEPTIC DISPOSAL PERM171 .0
Locatimi of property Im- iimlallalimi: n�4 C-0
171
A P R 2 iQofz
Owner's Namc 11 -'s 0(_p us _4�_
S-:
Owner's Mai
ling Address: C'
FF IAIDC'L.';,
Installer's Name Q I'llolle #:
(71
Number of bedrooms (if residential): 3 1,10
Total daily flow (residenlia! -compute (d.) 150 gal. per hedroolil):
Topography: rV_1 Flat Rolling Steel) Slope 0'0' 6f Slope
Soil Nature: Sand Q Loam clay Q otilcl.
Ground Water: at what depth? .ect
Bedrock or Impervious Material: -it what (Icl)tll? reel
Pul-colatioliTest: Not Re(plilml
Required/Role 11.Required/Role —nliper inch
Domestic Water- Supply: AE-21 Municipal Well (mller
If domestic water supply is a WFIJ.: water supply from any septic absorption is reel
PIMPOSI
Septic gal. (Illillillmill size: 1,000 gal.)
.'Iilc Field: each Trench feel. total sys(eill length 02-U-0 feet.
Seepage Ilit(s): tit imber of size cacti: —ft. x — ft.'
Size of stone to be tlsc(.I: # depth or thickness -/'!p Ile, feet.
11101A)INGTANKSYSTE-M- (if required)
Number of tanks: Size of each: gal.
Aletrin sj'slem and(Issoci(Ited elecirictil work to be inspected by it certified (igeirc)'.
For your protection, please note thus 1)"I'sitt"ll to Section 136-29 of the Code ofthe 7,oll-1, of
Queensburyj tin), periptit ortipprowl grott'led which is b(tsed upon or is g1willed ill reliance i1poll
(Ilty material misrepresematiolt orfiiijill-e to make ti materi(il fire!t or circuilishince known by or on
fieh(ilfof(tit applictint, shall be void.
I have read the regulations with respect to this('1717licillioll and agree to abide by these (ind all
requirements of the Town ofQueensbitry Sanitary Sell,I�5 Disposal Ordinance.
( p
Signature ofresponsiVe person: Mile: z�
r�CO
TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
531 Bay Road
Queensbury NY 12804
518-745-4447
SEPTIC DISPOSAL SYSTEM INSPECTION
Name J/
Location
Date Permit
SOIL TYPE: an -Loam-Clay-
Results of Percolation Test-
(if applicable) -Ratk
ch
TYPE OF SYSTEM:
ABSORPTION FIELD. T ?- �
Length of each t nDepth of trenchesSize of stone
SEEPAGE PITS: Nu bSize - ft, t.
Stone size
PIPING: Size ,Type
Bldg. to Tanky,
Tank to Dist. B x
Dist. Box to ield/Pit
?Openings Se ed �res
�—
No Partial
CATION
5PARATI Foundation to Tank /J feet
Foundation to Absorption feet
Separation of Pits _ feet
Conforms as per Plot Plan a No
LOCATION OF SYSTEM ON PROPERT .
(circle
Front Rear Left Side - Right Side
Middle F - Middle Rear
COMMENTS:
SYSTEM USE APPROVED: YES NO
Arrived: 16 . M
Departed: /
�V
Building nspector
c
F_a��q�=4i`•` , � "I have seen or observed,or believe I saw evidence of,
all objects such as houses,wells,trees, fences, etc.,
shown on this document.I also represent that I have
7:Zmeasured the distances set forth on the diagram."
SIGNATURE DATE
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