2005-529 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLI-A-N- CE
Permit Number: P20050529 Date Issued: Thursday, July 14, 2005
This is to certify that work requested to be done as shown by Permit Number P20050529
has been completed.
Tax Map Number: 523400-296-010-0001-010-000-0000
Location: 22 WINCREST Dr
Owner: GEORGE STARK III
Applicant: GEORGE STARK III
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.
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518)761-8256
BUILDING PERMIT
Permit Number: P20050529 Application Number: A20050529
Tax Map No: 523400-296-010-0001-010-000-0000
Permission is hereby granted to: CTF.ORCtF, STARK III
For property located at: 22 WINCREST 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. Tyne of Construction Value
Owner Address: GEORGE STARK III
KIMBERLY POTTER Septic Alteration Residential
Total Value
22 WINCREST Dr
QUEENSBURY, NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
SANITARY SEWER
DAN DRELLOS
PO BOX 224
GLENS FALLS NY
Plans&Specifications
2005-529
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday, July 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 ther7�fw
; r y,July 14,2005
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: ................ ...................................................I...........................................
Office Use
Location of installation: PX /.AJC_jL ejr.�— -/XL
0'
File Permit No. s_sc 9
Tax Map No.
Fee Paid
Owner s Name:/"
............../
...... ....
Address: ez
2. INSTALLER'S NAME -./ff All nt/1- PHONENO.79� -794'9
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 = 1-0-0
1980— 1991 ✓ x% 130 gal/bdrm =
1991 —present x 110 gal/bdrm =
L)
Garbage Grinder Installed yes no RL,
Spa or Hot Tub Installed yes no
4. PARCEL INFORMATION: (circle applicable information& indicate measurenien*'Ofl�'l DURY
i0
T a y Sa"ature Ground Water Bedrock or Impervious Material P Water Supply
Fla an at what depth at what depth nici
I Q au a ic-ig�
ing oam feet —feet well
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.
C-
Septic Tank:/ 00')
gallon (min. size 1,000 gal.)
Tile Field: each trench_ft. Total System Length:
Seepage Pit(s): number of size of each: ft. by 00' ft.
Size of Stone to be used: # 3 depth or thickness 2— 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.
VVignkat"ure of re onlsible person Date
Septic Inspection Report
d
Office No. (518) 761-8256 Date Inspection req st r c ived: —7 1 3 U
Queensbury Building&Code Enforcement Arrive: p e rt: am/
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initial
NAME: v,
�� P IT NO.:
LOCATION: c�(Q-(—J�r�L d-G' °� 7 S CT ON: cj A
RECHECK: _
Comments and/or diagram
Soil T SaW L / 1 1 -cT, h E T�Type of ater: M6nici Well Water
Waterlines is ance VLDo GE:Da-ck
Well separation distance ft. I V o"
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 x
s u ' nk,& / i �+
O ening Seale . N/Partial
End Ca s
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan VY N
-Engineer Re Port and As-Built Y N
Location of System on Property:
Fro ear eft Side Right Side
'Middle fiddle Rear
Sys em Use Stat s:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
Last revised 1/6/05
TOWN OF QUEENSB _ RY
BUILDING t°°ry
O p
REVIEWED ' la
DATE �R
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