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2005-460 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. P20050460 Date Issued: Monday, December 11, 2006 This is to certify that work requested to be done as shown by Permit Number P20050460 has been completed. Tax Map Number: 523400-309-005-0001-017-000-0000 Location: 1 WINTERGREEN Rd Owner. DAVID SIMONS JR Applicant: DAVID K MARKS 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 nforc ent 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: P20050460 Application Number: A20050460 Tax Map No: 523400-309-005-0001-017-000-0000 Permission is hereby granted to: DAVID K MARKS For property located at: 1 WINTERGREEN Rd 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: DAVID SIMONS JR 1 WINTERGREEN Rd Septic Alteration Residential Total Value QUEENSBURY, NY 12804-0000 Contractor or Builder's Name /Address Electrical Inspection Agency iBS SEPTIC & DRAIN ATTN: IVAN BELL 2 LOWER WARREN St OUEENSBI JRY_ NY 42804 Plans&Specifications 2005-460 SEPTIC ALTERATION $25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday, July 05, 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; Tuesday, July 05, 2005 SIGNED BY 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: Office Use Location of installation: File Permit No. �`�''w—L(0 0 Tax Map No. Fee Paid Owners Name: Address: c'Y- 2. INSTALLER'S NAME • <f e � 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 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 RECEIVED Spa or Hot Tub Installed yes` / no 4. PARCEL INFORMATION: (circle applicable information& indicate measurements) TOWN OF QUEENSBURY BUI D E a h ture Ground Water Bedrock or Impervious M er SURP11, Fla and at h depth at w a depth municipal olling 9�feet feet Steep slope clay if well; water supply J%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:I&Q gallon (min. size 1,000 gal.) Tile Field: each trench �C/ ft. Total System Length: 61_f r. 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 andior 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 re'liaaice 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. I ; ? � ignature of p s&e person Date Town of Queensbury Sewers and Sewage Disposal Chapter Appendix C ABSORPTION FIELD SEPARATION REQUIREMENTS ti b Appendix C ABSORPTION FIELD SEPARATION REQUIREMENTS PON .� wax�.is.-nryr�r y 'mac � �� asr�cx ;C,�t►.�s � s } Septic Inspection Report Office No.(518)761-8256 Date Inspection re es r ceiv Queensbury Building&Code Enforcement Arrive: m!p D rt: am/pm 742 Bay Rd.,Queensbury,NY 12804 Inspector's Initi s: _/ ' 0 0C �l NAME. v i P IT NO.: LOCATION: 1 ECT ON: O RECHECK: Comments and/or diagram 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 Size Type Building to tank Tank to Distribution Box Distribution Box to Field/Pit Openin Sealed: Y/N/Partial End Ca o Location/Separations Foundation to tank ft• Foundation to absorption ft. Separation of Pits ft. Conforms as per Plot Y Engineer Report a d As-Bui 1Y IN Location of System on Property: Front Rear Left Side Right Side Middle Front Middle Rear System 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: Queensbury Building&Code Enforcement Arrive: am/pm Depart: am/pm 742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials: NAME: E�V- l6 PERMITNO.: 7 E—LAwD LOCATION: a 1 O-X-E ��F.�R(`> INSPECT ON: RECHECK: A)Ff-M bb BIN Comments and/or diagram 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 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. Location of System on Property: Front Rear Left Side Right Side Middle Front Middle Rear System Us S atus: _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 Septic Inspection Report Office No.(518)761-8256 Date Inspection 9PECT a iv Queensbury Building&Code Enforcement Arrive: ep V-t�. pm 742 Bay Rd.,Queensbury,NY 12804 Inspector's Initi NAME: A T NO.: LOCATION: — ON: RECHECK: Comments and/or diagram Soil T San Clay T e o nici al Well Water Waterline separa ' istance 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 Size Type Building to tank Tank to Distribution Box ►t Distribution Box to field/Pit Opening Seale • artial End Caps Location/Separations Foundation to tank ft Foundation to absorption ft. Separation of Pits ft. Conforms as per Plot Pl Y Engineer Report As-Built Y Location of System on Property: Front 6RL id Right Side Middle Front Middle Rear System Use Status: proved artial Approved and needs to be re-inspected,please call the Building&Codes Office Disapproved Last revised 1/6/05 a Septic Inspection Report Office No. (518) 761-8256 Date Inspection request received: Queensbury Building &Code Enforcement Arrive: am/Depart: am/pm 742 Bay Rd., Queensbury, NY 12804 Inspector's Initials: NAME: I rnnk PERMIT NO.: LOCATION: INSPECT ON: RECHECK: Comments and/or diagram Soil Type: Sand Loam/Cla -Typeof Water: Municipal/Well Water Waterline separation distance ft. Well separation distance ft. Other wells: ft. Absorption Field: Total lengthft. -Length of each trench ft. -Depth of trenches ft• Size of Stone Seeoge Pits: Number Size: x Stone Size: -PipingSize Type Building to tank Tank to Distribution Box Distribution Box to Field Pit Opening Sealed: Y I NJ Partial End Ca Inlet/Outlet Pipes&Baffles Y N Location Se rations 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 System on Property: Front Rear Left Side Right Side Middle Front Middle Rear m Use S. Approved Partial Approved and needs to be re-inspected, please call the Building &Codes Office Disapproved Last revised 021006 Last revised 1/6/05 1 �U J s v lom t Z roue 1L J i I 0-1 1 � r �� L- C (,A,oj TOW U RY BUILDING & EPT. REVIEWED BY DATE