2012-305 40111111K, TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
411111
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20120305 Date Issued: Wednesday, June 27, 2012
This is to certify that work requested to be done as shown by Permit Number P20120305
has been completed.
Tax Map Number: 523400-301-009-0001-058-000-0000
Location: 725 WEST MOUNTAIN Rd
Owner: THEODORE & KATHY ANN RAWSON
Applicant: THEODORE & KATHY ANN RAWSON
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
propertyowner of the responsibility for compliance with Site Plan,
Variance, or other issues and conditions as a result of approvals by the Dire or of '1din &‘/, /
E• •rcement
Planning Board or Zoning Board of Appeals. �'
01.h4 TOWN OF QUEENSBURY
F 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20120305 Application Number: A20120305
Tax Map No: 523400-301-009-0001-058-000-0000
Permission is hereby granted to: THEODORE& KATHY ANN RAWSON
For property located at: 725 WEST MOUNTAIN Rd
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: THEODORE&KATHY ANN RAWS
725 WEST MOUNTAIN Rd Septic Alteration Residential
QUEENSBURY,NY 12804-0000 Total Value
Contractor or Builder's Name /Address Electrical Inspection Agency
IBS SEPTIC
IVAN BELL
2 LOWER WARREN STREET
OUEENSBURY.NEW YORK
Plans&Specifications
BP 2012-305 Septic Alteration
former address: 725 West Mt. Road
New Address: # Mandi Lane
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday,June 26,2013
(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 ex iration date.)
Dated at the Tow of Qu sb , /1 T /. , une 26, 2012
4
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
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✓/�` Revised 4/14/2010
OFFICE USE ON '3Q I ( ! '
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TAX MAP NO. -36• ''''.2t v�N PERMIT NO6O/oS•3O5PERMIT FEE 4r -
.1 t? % 5 2012 .3
APPROVALS: ZONING TOWN CLERK '
APPLICATION FOR SEPTIC DISPOSAL SYSTEM PERMIT: I TO,i:.. Li, „:,ch,4-, t,; Y
A PERMIT MUST BE OBTAINED BEFORE WORKr pI*RINS. APPLICATION IS SUBJECT TO REVIEW BEFORE"
ISSUANCE OFA VALID PERMIT. pe„marEh ��,dG��I nr.q
OWNER: I eta kU S `
or J Yell t�
W INSTALLER: J E��i-\I C
ADDRESS: #.1-. V�`,r IV(I• RV , ADDRESS: I UJW e/' NGV (e r+ Si'' .
PHONE NOS. 19.\ `J 17 q �PHONE NOS.'I1c t)` T '1
LOCATION OF INSTALLATION: 'i --iL C) We d � n-\- kJ '
RESIDENCE INFORMATION:
NO.OF COMPUTATION
YEAR BUILT X = TOTAL DAILY FLOW
BEDROOMS (Gallons per bedroom) GARBAGE GRIWIlp R
1980 or older ' ) X 150 = it;C) INSTALLED? lV
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1981-1991 X 130 = SPA OR HOT T�� I�
1992-present X 110 = INSTALLED? l J
PARCEL INFORMATION:
✓ TOPOGRAPHY: FLAT ROLL G STEEPS,LIONPE %SLOPE
✓ SOIL NATURE: SAND LOAM_ \V ti CLAY Iv NOTHER `Y�r
1-\-
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✓ GROUNDWATER: AT WHAT DEPTH? 1 V 11 r
✓ BEDROCK/IMPERVIOUS MATERIAL: AT WHAT EPTH? ��'
✓ DOMESTIC WATER SUPLY: MUNICIPAL WELL X11 1 I\I if well:water supply from any septic system absorption is:IV
V IT ft)
✓ PERCOLATION TEST: RATE IS PER MINUTE PER INCH[mpi]
(Test to be completed by a licensed professional engineer or architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION: All individual sewage disposal systems must be designed by a licensed professional engineer
or architect(unless installeds� in a Planning Board approved subdivision).
TANK SIZE: '( j \ GALLON(MIN.SIZE IS 1,000 GAL.)Add 250 gallons to the size of the septic tank for
each garbage grinder,spa or whirlpool tub.
SYSTEM E: — \
ABSORPTION FIELD(WITH NO.2 STONE) Total length l.0, rft. Each trench X Q
❑SEEPAGE PIT(S)(WITH NO.3 STONE) How many? \\1 1 Size? , A,
o ALTERNATIVE SYSTEM Bed or other type?
o HOLDING TANK SYSTEM Total required capacity? Iv ' ,I
.\ Tank size? Number of tanks? 1\1 K
NOTE: ALARM SYSTEM AND ASSOCIATED ELECTRICAL WORK MUST BE INSPECTED BY A TOWN
APPROVED ELECTRICAL INSPECTION AGENCY. PLEASE REVIEW LIST PROVIDED.
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 QUESTIONS? CALL 761-8256 OR EMAIL
Sanita wane Disposal Ordinance_ L f codes(a?queensburv.net
vi
i�iX�W _L- 1`�I VISIT OUR WEBSITE FOR MORE INFORMATION
Signature of Pelson Responsible Date w •pueensbury.net
Town of Queensbury* Community Development Office*742 Bay Road, Queensbury NY 12804
Septic Inspection Report
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Office No. (518) 761-8256 Date Insl =coon r- —iv-.: 4 Z , Z
Queensbury Building &Code Enforcement Arrive: D-►.rt: EMIrffiro
742 Bay Rd., Queensbury, NY 12804 Inspector's Initials: _
NAME: I/ A w -G'Y1 r ,RMI-NO.: - 3r S
LOCATION: / -2 S kir'CT V'Y C • IZOI C INSPECT ON: FI Z
RECHECK:
Comments and/or diagram
Soil Ty.-fSan--1,44...,:: LM. -
Type of Water: • . 1 Water
Water i - -paration distance ft.
Well separation distance ft.
Other wells: ft.
Well Casing Length 50' +/ - Y N N/A
[150'to well required if NO]
Absorption Field: Total length ft.
Length of each trench 1-1 6-57D ft.
Depth of trenches ,
Size of Stone ,
Seepage Pits: Number _
Size: _ x
Stone Size:
Piping Size Type
Building to tank Lb's CA-11-CL:
Tank to Distribution Box LI WC
Distribution Box to Field Pit t` - - ` ?Er
Opening Sealed: _ N
End Cap N
Inlet/Outlet Pipes &Baffles N
Manholes 12"or less below grade _Y_lye
[provide extension collar if Yes] Y N
Location/ Separations
Foundation to tank t 3 ft.
Foundation to absorption /-QCT ft.
Separation of Pits - ft.
Conforms as per PI n. _,.Y N
Engineer Report an As-Buil Y�__._N
ETU Maintenance ct _Y N
provided
Location of System on Property:
Front Rear Left Side Right Side Middle Front Middle Rear
System Use Stat :
Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
L:\Pam Whiting\2010\Building Codes Forms\Inspectlon Fonms\Septic Inspection Repo►L03 2910.doc
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"I have seen or observed, or believe I saw evidence of, 1/,
NOII3f MISN08 all r "'''' IS ` ``s (Rses, wells, trees, fences, etc.,
�o No1ld�na 3H1 sp),,vii `',1 i w:, .,._..w .ni, I also represent that I have
,�� n J� personally mExai.:ed the distances set forth on the diagram."
god S2WI1lib yr . 6--).,..,- .
IV 311S 183108d - DATE
NO 38 01 NV1d SIHI ___. ___