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2005-204 TOWN OF QUEENSBURY 742 Bay Road,Queensburv,NY 12804-5902 (518) 761-8201 Community Development - Building & Codes (518) 761-8256 CERTIFICATE OF COMPLIANCE Permit Number: P20050204 Date Issued: Thursday, April 14, 2005 This is to certify that work requested to be done as shown by Permit Number P20050204 has been completed. Tax Map Number: 523400-301-015-0001-023-000-0000 Location: 13 WINGS FALLS Ct Owner: ERIC & MARIANE EISENSCHMIDT Applicant: ERIC & MARIANE EISENSCHMIDT 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 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. 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: (A Mk Tax Ma No. I File Permit No. QCOS-CZo p Fee Paid Owner's Name: 4 ....................................................................................................... Address: 2. INSTALLER'S NAME PHONE NO. 3. RESIDENCE INFORMATION: (circle year oldwelling, 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 = Garbage Grinder Installed yes no Spa or Hot Tub Installed yes no Vph TO 05 4. PARCEL INFORMATION: (circle applicable information&indicate mea NN GAEN D p�tt�R IV Y 3:8w-graphy SiNature Ground Water ' Bedrock or Im ervious Material ater S ly (Flat) (sand l at,whEt depth at w t depth municipa ling AffT feet Kfeet Steep slope clay if well; water 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 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: 0 ' gallon (min. size 1,000 gal) Tile Field: each trench fl. 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. 01 oos— Signature of responsible person Date :Tow, 31 of (Illectlabut-Y So-m-1:4 s11)(1 .Sews ge Digt>omal (1,01131ple1' Api ondix C. SI;I'/11LA'1'1tJN IZI�(ZI.ItILI�[�llti(�1'It;i ' ♦aid pONp l M '� �. • Scf♦tl� -77 i .. AW+n Dct 1 x EMI 7. SIQd' &TURE &IIdFORMA710N FOR MrumswLz rr4%,ovim\YA.VO"'•••.••:,::, i Septic Inspection Report Office No. (518)761-8256 Date Inspection re uest ec ive Queensbury Building&Code Enforcement Arrive: a part: �S3Q a 742 Bay Rd., Queensbury,NY 12804 Inspector's Initial . NAME: 1�h�LL .I�i`11 r- P IT NO.: LOCATION: l ;7����(, �LL�C^T^ SPECT ON: RECHECK: Comments and/or diagram Soil T Sand oa /Cla Type of ater: unici al Well Water Waterline separation is nce ft. Well separation distance ft. Other wells: ft. Absorption Field: Total length ft. Length of each trench ft. De th of trenches Z, ft. Size of Stone Seepage Pits: Number Size: x Stone Size: Piping Size Type Building to tank LV Tank to Distribution Box Distribution Box ield/Pit Opening Seale / artial Location/Separations Foundation to tank ► ft. Foundation to absorption ✓ ft. Separation of Pits ft. Conforms as_per Plot Plan Y N Location of System on Property: Front Rear Left Side Right Side Middle Fr Middle Rear System Use S tus• Approved Partial Approved and needs to be re-inspected,please call the Building&Codes Office Disapproved L:\SueHen ingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003 1 /l Septic Inspection Report 1 Office No.(518) 761-8256 Date Inspection re st a eiv d: Queensbury Building&Code Enforcement Arrive: m/p epart: m 742 Bay Rd.,Queensbury,NY 12804 Inspector's Initia s: NAME: C� P IT NO.: _ LOCATION: ere RECHECK: Comments and/or diagram Soil Type Sa a Type of Wat unici ll Water Waterline se aration distance ft. Well separation distance ft. Other wells. ft. Absorption Field: Total length ft. Length of each trench Depth of trenches Size of Stone r, Seepage Pits: Number Size: x Stone Size: Piping Size Type Building to tank ©T G-S:> Tank to Distribution Box UA,%t Distribution Box t Field/Pit I t Opening Sealed: /,N/Partial End Caps Location/Separations Foundation to tank ft. Foundation to absorption Separation of Pits ft. Conforms as per Plot Plan N Engineer Report and As-Built N Location of System on Property: Front Rear Left Side Right Side �— G VA Middle Fyotf Middle Rear `1� i ` I ` mac- �u System Use Status: pproved � t, Partial Approved and needs to be re-inspected plea call"the Building& odes fficcee i Disapproved Last revised 1/6/05 s r &- t 5'0 - ILDI G ES _ CODS IEWED BY — � L)AIE RECEIVED a o� TOWN OF QUEENSBURY + BUILDING AND CODE 'D TO BUILDING & CODES DELI i f REVIEWED BY E DATE 13 �-J E AJ "I have seen r observed, or believi 1 saw evidence of, all objects su h as houses, weils,.tr$es,fences,etc., shown on thi document. I also represent that I.have pers ily m asured a distances Set forth on t d"sa ram." w v j