2005-568 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: P20050568 Date Issued: Tuesday, July 26, 2005
This is to certify that work requested to be done as shown by Permit Number P20050568
has been completed.
Tax Map Number: 523400-289-008-0001-011-000-0000
Location: 13 KINGS PI
Owner: ROBERT & DEBRA LA FONTAINE
Applicant: ROBERT & DEBRA LA FONTAINE
This structure may be occupied as a:
Septic Alteration Residential
By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the �J
property owner of the responsibility for compliance with Site Plan,
Variance, or other issues and conditions as a result of approvals by the Director of Building&Code EtWorceruAt
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20050568 Application Number: A20050568
Tax Map No: 523400-289-008-0001-011-000-0000
Permission is hereby granted to: ROURT &DF,BRA LA FONTAINE
For property located at: 13 KINGS PI
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 Construction Value
Owner Address: ROBERT & DEBRA LA FONTAINE
13 KINGS Pl Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
I.B_S. SEPTIC
2 LOWER WARREN STREET
OIJEENSBURY_ NY
Plans&Specifications
2005-568
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID -THIS PERMIT EXPIRES: Tuesday, July 25, 2006
(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 eensbury; Monday, July 25, 2005
SIGNED BY for the Town of Queensbury.
Director of Building& �eli cement
Application for Permit-Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
�//� Office Use
Location of installation:J C_
File Permit No.
Tax Map No.
: Fee Pai�
Owner's Name:
C
..............................` ................... ........................ ._-..... ...... ................,.......
Address: .!�- C cep � ��1 (. ).....
2. INSTALLER'S NAME j—, 6., G - C. PHONE NO. �.QY
3. RESIDENCE INFORMATION: (circle year of dwe ing,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 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm = '-d 05
Garbage Grinder Installed yes_ / no
Spa or Hot Tub Installed yes— / no
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
zTCARImaphyoil a e Ground Water Bedrock or Im ervious Material Domestic Water SgRpl
Flat sand at t epth at what epth riwelllawater
R Ing �eet feetSteep slope clay 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 hc�nsed
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: / gallon (min. size 1,000 gal.)
Tile Field: each trench 0 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.
Signature of responsible person Date
Septic Inspection Report
Office No.(518)761-8256 Date Inspection request received: r
Queensbury Building&Code Enforcement Arrive: am/ Depart: - /
742 Bay Rd., ueensbury,NY 12804 Inspector's Initials:
NAME: PERMIT NO.:
LOCATION: 01INSPECT ON:
RECHECK:
Comments and/or diagram
Soil Type Typ<San /Loam/C
Type of er: Municipal Well Wate
Waterline se aration distan ft.
Well separation distance 4-ft.
Other wells: ft.
Absorption Field: Total length ft.
Len h of each trench ft.
Depth of trenches ft.
Size of Stone ?i
-Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank 5 T ^1600
Tank to Distribution Box Sp/�
Distribution Box to Field/Pit
Opening Sealed: Y/N/Partial Al
End Caps
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Engineer Report and As-Built Y N
Locati System on Property:
QrDontRear Left Side Right Side
MiddljFont Middle Rear
S stem Use Spproved
Partial Approved and needs to be re-inspected,please call the Building& Codes Office
Disapproved
Last revised 1/6/05
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