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2004-377 ,.. y TOWN OF QUEENSBURY icoN742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201 Community Development- Building& Codes (518) 761-8256 CERTIFICATE OF COMPLIANCE Permit Number: P20044377 Date Issued: Tuesday, June 29, 2004 This is to certify that work requested to be done as shown by Permit Number P20040377 has been completed. Tax Map Number: 523400-226-015-0001-002-000-0000 Location: 170 LAKE Pky Owner: ELEANOR LEINOFF PER. RES. TRUST Applicant: DAN JENSEN This structure may be occupied as a: By Order of Town Board Septic Alteration Residential TOWN OF QUEENSBURY Director of Building&C de E orcement TOWN OF QUEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201 10,0 Community Development-Building&Codes (518) 761-8256 BUILDING PERMIT Permit Number: P20040377 Application Number: A20040377 Tax Map No: 523400-226-015-0001-002-000-0000 Permission is hereby granted to: DAN TENSEN For property located at: 170 LAKE Pky 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: ELEANOR LEINOFF PER. RES. TR Septic Alteration Residential BOBBI KAMIL TRUSTEE 1606 HODGES Ct Total Value MARINA, CA 93993 Contractor or Builder's Name /Address Electrical Inspection Agency OI TEENSBI TRY SEWER JAY SWEET Plans&Specifications 2004-377 SEPTIC ALTERATION $25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday, June 02, 2005 (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 To of • , ,ensb :i ,.day,June 02, 2004 SIGNED BY V ` for the Town of Queensbury. Director of Building&Code Enforcement Application for Permit—Septic Disposal System Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256 1. OWNER INFORMATION: `7 L Office Use Location of installation: 0 / f0 �, ive / File Permit No.oil 7 7 Tax Map No. eg / / / 2 Owner's Name: , 19y �,°J%� .Su J•C/13. n { Fee Paid Address: 39 l& Sno to re r I�r j / e/1l 0ar4e P1 3.Z xa9 y 2. INSTALLER'S NAME : my 5 u e e r' PHONE NO. 361- 3. RESIDENCE INFORMATION: (circle year of dwelling,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 = /i 4 U ,j'',#hief ••e-yr/5-iw) ,'K rives Garbage Grinder Installed yes / no X Spa or Whirlpool Installed yes / no 4. PARCEL INFORMATION: (circle applicable information&indicate measurements) Topography Soil Nature Ground Water Bedrock or Impervious Material Domestic Water Supply • Flat sand 5:4n4, at what depth at what depth municipal Rolling loam6fivel 2 feet feet well Steep slope c Safi Gf err ;�� /�© -e 06 ved if well;water supply /f %slope (ther from any septic-system depth: ,S2" absorption is ft. other /i #e Lmpr ems,, Percolation Test: (To be completed by licensed professional engineer or architect) Rate: /Z'M0;4 c lf,(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. Septic Tank /a 5 0 gallon(min. size 1,000 gal.) RE £V ._ d : each trench ft. Total System Length: ft. Seepage Pit(s): numbe size of each: ft. byj ,,. rNS B J RY ropp �F. Size of Stone to b : # th or thickness feet ystem Size: Alternative System: 1 Jk f{1 length and/or size , 6. HOLDING TANK SYSTEM: (if required) Number of tank: / 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. 221- ignature of responsib " person ate gb;441) Septic Inspection Report Office No. (518)761-8256 Date Inspection request received: Queensbury Building&Code Enforcement Arrive: /t a2 am/pm, Depart: am/pm 742 Bay Rd., Queensbury,NY 12804 Inspector's Initials: 11 NAME: _ Y1 PERMIT NO.: 1.37. 7 LOCATION: 1-1 Ls,ver G>rk�� INSPECT ON: WW2=�1 RECHECK: Comments and/or diagram Soil Type: Sand/Loam/Clay Type of Water: Municipal/Well Water Waterline separation distance Well separation distance Other wells: Absorption Field: Total length ft. Length of each trench _ft. Depth of trenches ft. Size of Stone Seepage Pits: Number Size: x Stone Size: • Piping Size Type Building to tank Tank to Distribution Box Distribution Box to Field/Pit Opening Sealed: Y/N/Partial Location/Separations Foundation to tank ft. Foundation to absorption ft. Separation of Pits ft. Conforms as per Plot Plan Y N i :Ittft Location of System on Property: fike- Front Rear Left Side Right Side Middle Front Middle Rear System Use Status: Approved — 4 Partial Approved and needs to be re-inspected,please call the Building&Codes Office Disapproved L:\SueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003 Septic Inspection Report Office No. (518)761-8256 Date Inspectio request received: Queensbury Building&Code Enforcement Arrive: 2a3j am/pm. Depart: am/pm 742 Bay Rd., Queensbury,NY 12804 Inspector's Initials: (- NAME: T]2L J PERMIT NO.: C -`' '9'0A- 1 LOCATION: I u � ��,,.t INSPECT ON: RECHECK: 1 Comments and/or diagram Soil Type: Sand Loam/Clay Type of W. - Municipal/Well Water Waterline separation distance ft. Well separation distance ft. Other wells: ft. Absorption Field: Total length ft. Length of each trench ft. Depth of trenches ft. Size of Stone Seepage Pits: Number U Size: x Stone Size: • Piping Size Type Building to tank Zccrru fvi` Tank to Distribution Box Distribution Box , field/Pit 5-Pk- Opening Sealed: /Partial Location/Separations Foundation to tank _ 0 ft. Foundation to absorption 3') ft. Separation of Pits ft. Conforms as per Plot Plan Y N Location of System on Property: � // Wed (r � 14Cdr�`�� Fron Rear Left Side Right Side Middle Front Middle Rear ( � System Use Status: jl Approved /" Partial Approved and needs to be re-inspected,please call the Building&Codes Office Disapproved L:\SueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003 COMMONWEALTH ELECTRICAL INSPECTION SERVICE,INC. Lj Main Office 176 Doe Run Road-Manheim,PA 17545 �l MUNICIPAL CERTIFICATE - ELECTRICAL APPROVAL \ , ;rmit No. Cert. ® 76397 Cut-in Card No. .r caner P, r.c/ nation 7 0 /I4 I PK/- e9,-18" stallation Consisting of � i7! f 1 Pam- 6-3 ,'M o v� stalled By Ai- 5A-to Lic.No. The conditions following governed the issuance of this certificate,and any certificate previously issued ncelled:- This certificate only covers the electrical equipment and installation conditions as of date. Upon tl :roduction of additional equipment or alterations,application shall be promptly made for inspection. Inspectors of this Company shall have the privilege of makin .imp ections at any time, and if i les are violated,� the Company shall have the right to ev this ate _�Lf`°X INSPECTOR