2005-601 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: P20050601 Date Issued: Monday, August 08, 2005
This is to certify that work requested to be done as shown by Permit Number P20050601
has been completed.
Tax Map Number: 523400-227-009-0001-010-000-0000
Location: 112 ROCKHURST Rd
Owner: RICHARD & CYNTHIA SMITH
Applicant: RICHARD & CYNTHIA SMITH
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: P20050601 Application Number: A20050601
Tax Map No: 523400-227-009-000 1-0 10-000-0000
Permission is hereby granted to: RICHARD & CYNTHIA SMITH
For property located at: 112 ROCKMRST 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: RICHARD & CYNTHIA SMITH
PO BOX 142 Septic Alteration Residential
Total Value
CLEVERDALE, NY 12820-0000
Contractor or Builder's Name / Address Electrical Inspection Agency
Plans&Specifications
2005-601
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Tuesday, August 08, 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 4uee2n ury; on �y, t 08, 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 Queensbun-, ATY 12804 (518) 761-8256
l. OWNER INFORMATION:
....................I..........................
...
/ Office Use
Location of installation: t _ O
File Perrrtlo. ~(
Tax Map No.
p��
Owner's Name: tC G�t�,� yyr t�-`•(�
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Address:
2. INSTALLER'S NAME : W° PHONE NO. 3 ��
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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
x 150 gal/bdrm
1980- 1991 x 130 gal/bdrm =
1991 -present x 110 gal/bdrm =
Garbage Grinder Installed yes _ / n
Spa or Hot Tub Installed yes— /(:!n
4. PARCEL INFORMATION: (circle applicable information& indicate measurements)
Topog_raphy Soil Nature Ground Water Bedrock or Impervious Material Domestic Water Supply
FI sand at what depth at what depth municipal
Rolling loa feet feet well
Steep slope clay if well; water supply
_%slope other from any septic-system
depth: absor do is/d-V 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. U
Septic Tank: 1�gallon (min. size 1,000gal.)
Tile Field: each trench ft. Total System Length: ft.
Seepage Pit(s):4-L-,-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 gran
te 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.
V "'t K , -z -
Signatu of r s onsible person Date
Town of Queensbury
Sewers and Sewage Disposal Chapter
Appendix C
ABSORPTION FIELD
SEPARATION REQUIREMENTS
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Appendix C
ABSORPTION FIELD
SEPARATION REQUIREMENTS
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Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received: _
Queensbury Building&Code Enforcement Arrive: am/ Depart: 16 'pzm/pm i
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials: `�
,47
NAME: PERMIT NO.: �v
LOCATION: INSPECT ON: d
RECHECK:
Comments and/or diagram
Soil Type: Sand/Loam/Cla
Type of Water: Municipal/Well Water 14
NV- QC—PC 4'CGU1Z-eL)7-
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
-Seepage Pits: Number
Size: x
Stone Size: `�PA6& P(T- F4UA—
Pi in Si T _ n �L
-Building to tank f L L { 1 A)
Tank to Distribution Box _
Distribution Box to Field/Pit
Opening Sealed: Y/N/Partial
Location/Separations
Foundation to tank 0 ft.
Foundation to absorption ft.
-Separation of Pits z ft.
Conforms as_per Plot Plan Y N
Location of System on Property:
Front Rear Left Side Right Side
Middle Front fiddle Rear
System Use Stat
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:1SueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
1
Septic Inspection Report
Office No.(518)761-8256 Date Inspection request `received: .3 0-5
Queensbury Building&Code Enforcement Arrive: am/^��L,C�"rt: ��`_ am/pp
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials:
NAME: _ i'c.�°�' �-� � PERMIT NO.; q-P6V, ;—
LOCATION: INSPECT ON: G
RECHECK: _
Comments and/or diagram
Soil T e: Sand/Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft.
Well separation distance ft.
Other wells: ft. 1
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
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 System on Property:
Front Rear Left Side Right Side
Middle Front Middle Rear
System Use Status:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
Last revised 1/6/05
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SIGNATURE DATA
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