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2003-436 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: P20030436 Date Issued: Friday, November 26, 2004 This is to certify that work requested to be done as shown by Permit Number P20030436 has been completed. Tax Map Number: 523400-226-012-0001-073-000-0000 Location: 336 CLEVERDALE Rd Owner: HELENE W HORN Applicant: HELENE W HORN This structure may be occupied as a: Septic Alteration Residential By Order of Town Board TOWN OF QUEENSBURY 719 = Issuance of this Certificate of Compliance DOES NOT relieve the �►} property owner of the responsibility for compliance with Site Plan, „may Q' 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 Fosy 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201 Community Development-Building& Codes (518) 761-8256 BUILDING PERMIT Permit Number: P20030436 Application Number: A20030436 Tax Map No: 523400-226-012-0001-073-000-0000 Permission is hereby granted to: HELENE W HORN For property located at: 336 CLEVERDALE 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: HELENE W HORN Septic Alteration Residential P.O. BOX 129 Total Value CLEVERDALE,NY 12820 Contractor or Builder's Name /Address Electrical Inspection Agency Plans&Specifications 2003-436 SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS $25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday,June 18,2004 (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 e To of ens ury; Wednesday,June 18,2003 SIGNED BY / 40^ for the Town of Queensbury. Director of B I . & ode Enforcement # y ' Application for Permit —Septic Disposal System Town of Queensblay 7.12 Bay Road Queeusbur�. NY 1280,1 (518) 761-8256 1. OWNER INFORMATION: • i Office Use Location of installation: 336 Cleverdale Rd. , Cleverdale,NT ...- 1-13(p Filo Permit No Tax Map No.226.12/ 1 / 73 • Fee Paid . Owner's Name: Helen Horn Address: 336 Cleverdale Rd. , Cleverdale, NY 2. INSTALLER'S NAME : Pete Carr/Crandall Excuvating PHONE NO. 3. RESIDENCE INFORMATION: (circle year of dwelling, indicate II bedroom(s) and multiply ll of bedrooms with applicable gallons per bedroom to equal total daily li ‘,<' \r). w) Year of House: • No. of Bedrooms x Computation_ = Total Daily Flow/ 1980 or older x 150 gal/bdrm = �p,�� /it 1980— 1991 x 130 gal/bdrm = /f'V,C;,, 1 1991 —present 3 x ILO gal/bdrm = 330 -- .;1; rt, H2O Garbage Grinder Installed yes / no X `�r'`s�li Spa or Whirlpool Installed yes / no X ,,_ r, �l- 4. PARCEL INFORMATION: (circle applicable information & indicate measurements) Top_omplty_AQil Na ur4 ground Water Bedrock or Impervious Material Doimmestic.Water Sul>hly Mai sand at what depth at what dc/Nh municipal Rolling oan 1 feet 37 fee! well Steep slope clay if well; water supply 5 %slope othe from any septic-system epth: absorption is ft. other Lake Percolation Test: (To be completed by licensed professional engineer or architect) Rale:see plans 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 hoard approved subdivision). Add 250 gallons to the sirs of the septic tank and leach field for each Garbage Grinder, Spa or Whirlpool Tub. Septic Tank: 1000 gallon (min. size 1,000 gal.) Existing Tile Field: each trench N/A ft. Total System Length: _-N/A __ft. Seepage Pit(s): number of N/A size of each: ft. by fi. • Sizo of Stone to be used: II N/A / depth or thickness _fret Bed System Size: 10' x 38'6" (Eljen In—Drain System) Alternative System: See Plans length and/or size 6. - HOLDING TANK SYSTEM: (if required) N/A 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 Tom • 6 tcensbury Sanitary Sewage Disposal Ordinance. re / datilM1 / 0/63 Si•n.ture of r sponsible person Date Septic Inspection Report Office No. (518)761-8256 Date Inspection request received: , Queensbury Building&Code Enforcement Arrive: arrp� part: am/pm 742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials: (( J NAME: \AC'Cp PERMIT NO.: 0Q �l 3 LOCATION: J e INSPECT ON: RECHECK: Comments d/or dia ram Soil Type: Sand/Loam/Clay I ) 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 -7/ Foundation to tank ft. Foundation to absorption ft. Separation of Pits ft. Conforms as per Plot PI Y Y N % - /1`v _Is 0 Location of System n Property: Front ear Left Side Right Side Middle Front Middle Rear System Use Stat s: 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 � ci 3 . c: u 3 ; 4r Septic Inspection Report Office No. (518) 761-8256 Date Inspection request received: Queensbury Building&Code Enforcement Arrive: am/ppl Depart: 4, m/pm 742 Bay Rd., Queensbury,NY 12804 Inspector's Initials: 4 NAME: PERMIT NO.: 03— i LOCATION: C4v61Z+Qkc 6r leo . INSPECT ON: CEP t Ze`O- RECHECK: Comments and/or diagr:m Soil Type: an /Loam/Clay 111 Type of Wate : Municipal/Well Water 45.,(ler ,44p`�j A Waterline separation distance ft. - 'r� Well separation distance ft. fm 71,J Other wells: ft. Citnv—Pa-- Absorption Field: Total length 6444...4 ft. Length of each trench ¢' ft. Depth of trenches J?2 PLC-�1� ft. Size of Stone 61_j A) 4 r4 Seepage Pits: Number Size: x Stone Size: • Piping Size Type Building to tank Act'fr7�JE Tank to Distribution Box 2- S.-, 6 Distribution Box to Field/Pit It" ZO Opening Sealed: Y/N/Partial Location/Separations Foundation to tank ft. - / Foundation to absorption �,N Separation of Pits ft. f� Conforms as per Plot Plan N /�%L-�G� /7 5 -13 U(L Location of System on Property: Front Rear Left Side Right Side Middle ront Middle Rear System Use Status: pproved 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 -JA'^RETT-MARTIoN ENGINEERS, PLLC H.Thomas Jarrett, P.E. Professional Engineering Kenneth Martin, P.E. November 23, 2004 RECEIVED NOV 2 6 2004 Town of Queensbury—Building & Codes Dept. TOWN OF QUEENSBURY Atin: Mr. Joel Clugstone BUILDING AND CODE 742 Bay Road Queensbury,NY 12804 Re: Helene Horn.Property 336 Cleverdale Road Wastewater Disposal System JM 03-033 Dear Joel: This letter is to certify that this office has witnessed construction of the wastewater disposal system to serve 336 Cleverdale Road in the Town of Queensbury. Based on our field observations we believe that the system has been constructed substantially in conformance with plans prepared by this office, and approved by the Town of Queensbury Building and Codes Department on June 18, 2003 by Dave Hatin. If you have any questions, please do not hesitate to contact us at 792-2907. Sincerely, Jarrett-Martin Engineers,__ PLLC in� Robert U. Holmes II, P.E. Project Engineer CC: Helene Horn Chris Crandall Peter Carr F:\Archived Files\2003 Projects\03-033 Horn WW\030331 12404 Horn WW Const cert letter to Qby.doc 12 East Washington St. • Glens Falls, NY 12801 518-792-2907/ 518-798-1864 Fax 0 Printed on Recycled Paper RESOLUTION APPROVING SEWAGE DISPOSAL VARIANCE APPLICATION OF HELENE HORN RESOLUTION NO.: 16,2003 BOH INTRODUCED BY: Mr.Roger Boor WHO MOVED ITS ADOPTION SECONDED BY: Mr.Theodore Turner WHEREAS, Helene Horn filed an application for a variance from provisions of the Town of Queensbury On-Site Sewage Disposal Ordinance, such application requesting that the Local Board of Health authorize Ms. Horn to install a fill system four feet (4') from the property line instead of the required ten feet (10') setback on property located at 336 Cleverdale Road, Queensbury, and WHEREAS, the Town Clerk's Office published the Notice of Public Hearing in the Town's official newspaper and the Local Board of Health conducted a public hearing concerning the variance request on June 2°a, 2003, and WHEREAS, the Town Clerk advises that property owners within 500 feet of the subject property have been duly notified, NOW,THEREFORE,BE IT RESOLVED, a) that due to the nature of the variance, it is felt that the variance would not be materially detrimental to the purposes and objectives of this Ordinance or to other adjoining properties or otherwise conflict with the purpose and objectives of any plan or policy of the Town of Queensbury; and b) that the Local Board of Health finds that the granting of the variance is necessary for the reasonable use of the land and that the variance granted is the minimum variance which would alleviate the specific unnecessary hardship found by the Local Board of Health to affect the applicant; and BE IT FURTHER, RESOLVED, that the Town of Queensbury Local Board of Health hereby approves the application of Helene Horn for a variance from the Sewage Disposal Ordinance to allow Ms. Horn to install a fill system four feet (4') from the property line instead of the required ten feet (10') setback on property located at 336 Cleverdale Road, Queensbury and bearing Tax Map No.: 226.12-1-73. Duly adopted this 2nd day of June,2003 by the following vote: AYES : Mr. Boor, Mr. Turner, Mr. Stec,Mr. Brewer, Mr. Brower NOES : None ABSENT: None