2007-747 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. P20070747 Date Issued: Tuesday, December 11, 2007
This is to certify that work requested to be done as shown by Permit Number P20070747
has been completed.
Tax Map Number. 523400-309-009-0001-086-000-0000
Location: 52 OHIO Ave
Owner. THOMAS & JENNY STAUNCHES
Applicant: THOMAS & JENNY STAUNCHES
This structure maybe occupied as a:
Septic Alteration Residential
By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the
property owner of the responsibility for compliance with Site Plan, may' X'°',
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,NY 12804-5902 (518)761-8201
Community Development- Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20070747 Application Number. A20070747
Tax Map No: 523400-309-009-0001-086-000-0000
Permission is hereby granted to: THOMAS &JENNY STAUNCHES
For properly located at: 52 OHIO 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: THOMAS &JENNY STAUNCHES Septic Alteration Residential
52 OHIO Ave Total value
QUEENSBURY,NY 12804
Contractor or Builders Name/Address Electrical Inspection Agency
Plans &Specifications
2007-747
SEPTIC ALTERATION RESIDENTIAL
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Sunday, December 07,2008
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the >own Vte4s$u ,` /IFr*day December 07,2007
yr'
SIGNED BY V for the Town of Queensbury.
Director of Building&Code Enforcement
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OFFICE USE ONLY '
O N C) 1 I
TAX MAP NO. PERMIT NO. RMIT FEE ;
APPROVALS: ZONING TOWN CLERK
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APPLICATION FOR SEPTIC DISPOSAL SYSTEM PERMIT:
A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS.APPLICATION IS SUBJECT TO REVIEW BEFORE IS UANCE OF A VALID
PERMIT.
�/�
OWNER: JeolqqU (, INSTALLER:
ADDRESS: ADDRESS: v �
PHONE NOS. ��/ C�� / PHONE NOS.
LOCATION OF INSTALLATION:
NO.OF RESIDENCE INFORMATION:
YEAR BUILT BED OOMS X COMPUTATION= TOTAL DAILY FLOW
1980 or older X 150 gallon per bedroom INSTALLED?GARBAGE RIjVp�FR
1981 -1991 X 130 gallon per bedroom T
SPA OR HOT TWi3•n
1992-present X 110 gallon per bedroom = INSTALLED? IV
PARCEL INFORMATION:
✓ TOPOGRAPHY: Flat rolling y - Steep slope %Slope
✓ SOIL NATURE: Sand V Loam Clay Other
✓ GROUNDWATER: At what depth?
✓ BEDROCK/IMPERVIOUS MATERIAL: At what depth?
✓ DOMESTIC WATER SUPLY: Municipal Well (If well: Water supply from any septic
system absorption is ft.)
✓ PERCOLATION TEST: Rate is — per minute per inch.
(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 en inee�falrrchihitect (unless installed in a Planning Board approved subdivision).
TANK SIZE: /0GALLON (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 TYPE:
tT ABSORPTION FIELD (WITH NO. 2 STONE) Total length,�W—ft. Each trench X
❑ SEEPAGE PIT(S) (WITH NO. 3 STONE) How many? Size?
❑ ALTERNATIVE SYSTEM Bed or other type?
❑ HOLDING TANK SYSTEM Total required capacity?
t
Tank size? Number of tanks?
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 t ese and all requirements of the Town of (41
S? CALL nsbur . OR EMAIL
Queens r Spn' ry Sew ge Disposal Ordinance. des®gueensburv.net
BSITE FOR MORE INFORMATION
ww.aueensburv.net
O
Signature of erson Responsible Date
Town of Queensbury - Community Development Office - 742 Bay Road, Queensbury,NY 12804
B 5-LGL 6/06
/-- 3 7
Septic Inspection Report
Office No. (518) 761-8256 Date Ins request received:
Queensbury Building&Code Enforcement Arrive: am/pm
742 Bay Rd., Queensbury, NY 12804 Inspect r'§I itials:
NAME: ' PERMIT NO.: _(l 7
LOCATION: INSPECT ON:
RECHECK:
Comments and/or diagram
Soil T Sand L4oamN Clay
_Type,of units p-aW Well Water
Waterline separ&Wukfance ft.
Well separation distance ft.
Other wells: ft,
Absorption Field: Total lengthft,
Length of each trench ft.
Depth of trenches ft,
Size of Stone ?/
.Seepage Pits: Number
Size: x
Stone Size:
--P!Ping Size Typq
Building to tank >C/
Tank to Distribution-Vox i4A pt 3-5
Distribution Box jld:2 Pit
-Opening Sealed N Partial
End Ca
Inlet/Outlet Pipes&Baffles Y N
Location/Separations
Foundation to tank ft.
Foundation to abso o ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Engineer Report and As-Built Y N
Location of System on Pro rty:
Front Rear Left Si Right Side
Middle Front Middle Rear
System UseStatus:
proved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
Last revised 021006
Last revised 1/6/05
PLOT PLAN
SEPTIC SYSTEM
Notice: The following statement must be "stamped" on your plot
plan. This sheet of paper may be used for purposes of
drawing your plot plan. After drawing such plot plan,
please 'read the statement and sign it . If you choose to
use other paper for your plot plan, the office will stamp
those plans for your signature.
i
Ho
ITAl�9 w
E ;
1 5�- OHlo AV
TOWN DF QRJEENSBURY
ReviewedABy'. ,I leave seen or observed, or believe I saw evidence of,
Date: all objects such as house wells, trees, fences, etc.,
shown on tl ' c mer also r present that 1 have
personall in ed dish es set forth on the dia rain."
SIGNAKIRE a lE