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2005-207 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: P20050207 Date Issued: Tuesday, May 03, 2005 This is to certify that work requested to be done as shown by Permit Number P20050207 has been completed. Tax Map Number: 523400-290-005-0001-069-000-0000 Location: 11 BROOKWOOD Dr Owner: FRANK & ILENE BERTRAM Applicant: FRANK & ILENE BERTRAM 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, k7 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: P20050207 Application Number. A20050207 Tax Map No: 523400-290-005-0001-069-000-0000 Permission is hereby granted to: FRANK & 1LF,NF.BF,RTRAM For property located at: I 1 BROOKWOOD Dr 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: . FRANK& ILENE BERTRAM 11 BROOKWOOD Dr Septic Alteration Residential Total Value QUEENSBURY,NY 12804 Contractor or Builder's Name 1 Address Electrical Inspection Agency SICTNORFI,11 ANT14ONY Plans &Specifications 2005-207 SEPTIC ALTERATION $25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Friday,April 14,2006 (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 of Queensbury; /,, Thurs y, pril 14,2005 SIGNED BY Jfor the Town of Queensbury. Director of Building&Code nforcement Application" lication for Permit—Septic Disposal Systems Town of Queensbury 742 Bay Road Queensbury,NY 12804 (�, 18) ,61-8256 1. OWNER INFORMATION: .............................................................................. ........................ Office Use Location of installation: I File Pe�rmit No. Tax Map No. Owner's Name: Fee Paid ............. ................................ ............................................ Address: 2. INSTALLER'S NAME PHONE NO. 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 IDaily Flow 1980 or older x 150 gal/bdrm = 5 1980- 1991 x 130 gal/bdrm = 1991 —present x 110 gal/bdrm = Garbage Grinder Installed yes_ no Spa or Hot Tub Installed yes no 4.- PARCEL INFORMATION: (circle applicable information&indicate me0*qr44nts) Ground Water Bedrock or impervious Material 'Domestic Water Sup, ply .............'—Fla s�an at what depth at what depth mu al Rolling loam feet —feet mu i Steep slope clay i well; water supply %slope other from any septic-system depth: absorption is 1 ft. other Percolation Test: (To be completed by licensed professional engineer or architect) """alkez Rate: minute per inch 5. PROPOSED SYSTEM: For New Construction: An 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: gallon(min. size 1,000 gal.) Tile Field: each trench ft. Total System Length: Seepage Pit(s): number of size of each: ft b , 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 bexoi 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. Signa e of AllSponsible person Date it 'of Queeltaln:i•y Kctivt:tw :tttcl 4�tvsi);s: I)i.�1>a:::t.I t:it:titit•r • j j AI#a�UIZ��'•1'I(I�I I"31�1.►I.> •, '��I:l'I12tA'1'ItaN X�I:t,�t,Jt 1tI�h]l':l�l'1`:; 1#4M � _may.,/J•/T I ^ I Hlt*t.t_ tk tltrf•tt• w<t ►��,+»e 1buzc C t�>: ,�,�,�" 11owst G vI [h'iTttpaltIry t ' • l�yrrNtt�ttcs 1 MOND j 4 1 • III • ?. !SIONATURE &INFORMATION Fm! I F6N;S ksLr, �rxwv�• �„�.�......:; , i i Septic Inspection Report Office No. (518)761-8256 Date Inspection request received: Queensbury Building&Code Enforcement Arrive: am epa am/pm 742 Bay Rd.,Queensbury,NY 12804 Inspector's Initial \ NAME: PERMIT NO.: .J C-��) LOCATION: INSPECT ON: — L RECHECK: Comments and/or diagra Soil Type: Sand/Loam/Clay Type of Water: 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 Size: x Stone Size: Piping Si Type Building to tank Tank to DistributjQQ Box Distribution Bo ield/Pit_ Opening Sealed:(Y/N/Partial End Caps Location/Separations Foundation to tank ft. Foundation to abso lion ft. Separation of Pits ft. Conforms as per Plot Plan Y N Engineer Report and As-Built Y N Location of System on Property: Front Rear Left Side Right Side Middle Front Middle Rear S stem Use Statu . Approved _ Partial Approved and needs to be re-inspected, please call the Building&Codes Office Disapproved Last revised 1/6/05 Septic Inspection Report Office No.(518) 761-8256 Date Inspection request received: `7— �7 6 Queensbury Building&Code Enforcement Arrive: a m e art: m/pm 742 Bay Rd.,Queensbury,NY 12804 Inspector's itials �o„ ,c, ,! NAME: �-c✓/ v((�J l`C�"''A �� PERMIT NO.: 7� LOCATION: INSPECT ON: 3 O RECHECK: C7� i Comments and/or dia m Soil Type: Sand/Loam/Clay Type of Water: Municipal/Well Water ` Waterline separation distance ft. Well separation distance ft. Other wells: ft. Absorption Field: Total length ft. Length of each trenc $. Depth of trenches z/ft. Size of Stone L �D 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 End Caps Location/Separations Foundation to tank ft. Foundation to absorption ft. Separation of Pits ft. Conforms as per Plot Plan 11 Y N -Engineer Report and As-Built Y N Location of Sys on Property: Front e Left Side Right Side Middle Front iddle Rear System Use Stat Approved Partial Approved and needs to be re-inspected, please call the Building&Codes Office Disapproved Last revised 1/6/05 3 f t Septic Inspection Report Office No.(518)761-8256 Date Inspection requ st receive�e7d: Queensbury Building&Code Enforcement Arrive: a p art: am/ m 742 Bay Rd.,Queensbury,NY 12804 Inspector's Initial . NAME: '�)''( PERMIT NO.: - (') LOCATION: 2co 0 b0c) INSPECT ON: RECHECK: Comments and/or diagram Soil T e. la Type of Water: Municipal/Aell Wate Waterline separation distance ft. Well separation distance ft. nn Other wells: ft. lJ�� Absorption Field: Total length ft. Length of each trench ft. Depth of trenches ft. Size of Stone rJ L ArV> Seepage Pits: Number Size: x Stone Size: Piping Si e Type Building to tank Tank to Distribution Box ft Distribution Box to Field/Pit a• Opening Sealed: Y/N/Partial End Caps 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 Location of SbRearo n Property: FrontLeft Side Right Side Middle Front Middle Rear System Use Status: proved Partial Approved and needs to be re-inspected,please call the Building& Codes Office Disapproved Last revised 1/6/05 4i J Ilk r ,? � u II - _ BUILDING & co DEIST. REVIEWED BY ?ATE �+ f `"t 3