2014-601 01111111K 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: P20140601 Date Issued: Thursday, November 20, 2014
This is to certify that work requested to be done as shown by Permit Number P20140601
has been completed.
Tax Map Number: 523400-303-016-0001-031-000-0000
Location: 473 DIX Ave
Owner: WILLIAM & CHRISTIE A BENNETT
Applicant: SASHA MEHALICK
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 the4
414..,
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 Enforcement
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
742 Bay Road,Queensbury-,1\N 12804-5902 (518)761-8201
Community Development-Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20140601 Application Number: A20140601
Tax Map No: 523400-303-016-0001-031-000-0000
Permission is hereby granted to: SASHA MEHALICK
For property located at: 473 DIX Ave
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: WILLIAM & CHRISTIE A BENNET]
473 DIX Ave Septic Alteration Residential
QUEENSBURY,NY 12804-0000 Total Value
Contractor or Builder's Name /Address Electrical Inspection Agency
Plans& Specifications
2014-601
Res. Septic Alterations (Auto Brokers)
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday,November 18,2015
(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 Quee bury• Tu(essddr,jy,, ovember 18,2014
SIGNED BY CI t ` - for the Town of Queensbury.
Director of Building&Code Enforcement
SEPTIC DISPOSAL PERMIT
Office Use Only
/
DATE i( / i r/a-v 1 / Received
/// Tax Map ID
TAX MAP ID 30 3 ' (6. -1—3/ Permit No. • — s��M�.
4 7 3 �� 6,„ A/ tLOCATION OF INSTALLATION / NovNPermit Fee
15 Mgovals:
APPLICANT S0. h N1,6h aJ i uK PHONE/E-MAIL (SI z) 3 61 -
ADDRESS 4110 (}`)t / QJetn5bury N•( 12Q)0y
INSTALLER/BUILDER: SQ.11 PHONE/E-MAIL
ADDRESS:
OWNER S d SLV o. M-f-An i L t<., PHONE/E-MAIL
Address ty crc Dfl-v{ i v 04 el N4 i?W-
CONTACT PERSON FOR BUILDING&CODES COMPLIANCE: ,�[11c, Mt hal<U` PHONE!Ott)3G?-as?-7
RESIDENCE INFORMATION
Year Built #of bedrooms X Gallons per bedroom =Total Daily Flow
1980 or older 3 Garbage grinder installed _YN
1981-1991 Spa or Hot Tub installed _Y )N
1992-Present
PARCEL INFORMATION
Topography Flat rolling Steep slope 0 %slope
Soil Nature X Sand Loam Clay Other
Groundwater At what depth?
Bedrock/Impervious Material At what depth?
Domestic Water Supply Municipal Well(if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: per minute per inch(test to be completed by licensed engineering/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION
Tank Size t000 gallons(minimum size 1,000 gallons,add 250 gallons to size for each garbage grinder or spa or hot tub)
System Type Absorption field with#2 stone Total length ft.; Each trench x
Seepage Pit with#3 stone How many: ;size
Alternative System Bed or other type?
Holding Tank System Total required capacity? Tank size #of tanks
Notes: 1)Alarm system&associated electrical work must be inspected by a Town approved electrical inspection agency;2)We will no longer
allow systems to be covered until such time as an As-Built plan is received & approved. The installed system must match the septic system
layout on file—no exceptions.
DECLARATION: Any permit or approval granted which is based upon or is granted in reliance upon any material representation or
failure to make a material fact or circumstance know by or on behalf of an applicant, shall be void. I have read the regulations and
agree to abide by these a d all requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance.
Print Name: ter Date:
Signature: Date:
Town of Queensbury Building&Codes Septic Disposal Permit July 2014
r of Queensbury Building & Code Enforcement hurl J
office No. (518) 761-8256
Septic Inspection Report
Inspection request received:
Name: \`1Q\i\QQ e Inspected on: (DG''
Location: 1 7 A .ie_ Arrive: a_..." p.m.
Permit No.: / 44` Loc] ( Inspector's Initials: _�kOir
•
o• ments and/or dia•ram
Soil Type' Sa L•.•• C
Type of er: p Well Water
Waterline cepa . • distance ft.
Well separation distance ft.
Other wells: ft.
Well Casing Length 50' +I- Y N_NIA
[150'to well required if NO]
Absorption Field: Total length ft. c r
Length of each trench ft. `,`�v
Depth of trenches ft. �1
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank �,`LC 6::A-\ \AC)
Tank to Distribution Box 1-{"
Distribution Box to Field/Pit
Opening Sealed: Y_N
End Cap _Y N
Inlet/Outlet Pipes&Baffles N
Manholes 12"or less below grade Y N
[provide extension collar if Yes] _Y N
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
ETU Maintenance Contract provided Y_N
Location of System on Property:
Front Re " Left Side Middle Front Middle Rear
S stem Use Stat :
Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
Septic Inspection Report
cloi) ) )Serki - it, aI
NOV 17 2814
TOWN OF QUEENSBUR
BUILDING & ` rl'IIEPT,
Reviewed By: A�r
Date: fy �� L.(S l-
FA-iv&
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SEPTIC PLOT PLAN Z--- Pi
_ I HAVE SEEN OR OBSERVED ALL OBJEC .5.,r '"
t.
� SUCH AS HOUSES, WELLS, TREES, FENCES. ETC le,,1
SHOWN ON T.. 'DOCUMENT.I HAVE 'ERSONA!.L(
MEASUR DISTANCE SET FORTH ON THIS DIAGR?,iri. ,
-.Ida?, idle/,-
V/
sierKi ' 'fir DATE
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