2005-858 TO`XN OF QUEENSBURY
742 Bay Road,Queensbury,NY,12804=5902 (518) 761-8201
Community Development- Building &Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number.; P20050858 Date Issued: Wednesday, November 02, 2005
This is to certify that work requested to.be done as shown by Permit Number . P20050858
- -has°beemcompleted� - - -
Tax Map Number. 523400-303-016-0001-070-000-0000
Location: 416-418 DIX Ave
Owner. MARJORIE M. BRUEDER
Applicant: MARJORIE M. BRUEDER
This structure may be occupied as.a:
Septic Alteration Residential
By Order of Town Board
T OF Q NSBUR
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: P20050858 Application Number. A20050858
Tax Map No: 523400-303-016-0001-070-000-0000
Permission is hereby granted to: MARJORIF.M_ RRI JFDF.R
For property located at: 416-418 DIX Ave
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: MARJORIE M. BRUEDER
2 BARBER Ave Septic Alteration Residential
Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
MORNING STAR EXCAVATING
Plans &Specifications
2005-858
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Thursday, November 02,2006
(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; Wednesday, November 02, 2005
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
Juk rr-M
► Application for Perffiit— Septic DisP
"
KEQ
Town of Queensbury 742 Bay Road Queensbury, NY 128044E(518)T1 J;Y
1, OWNER INFORMATION: 'NQ.V 0 ................................................. ................................
Office Use
Location of installation: !hBl�N!OF QUEENSBURYUIL!21DIL.?Ail q�
Tax Map No.
Fee Paid
Owner's Name:
13
tl ........................................................ .....................................................................
Address: &S&1e `����
2. INSTALLER'S NAME PHONE NO. 9 9_Y22
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 galibdrm =
1980— 1991 x 130 gal/bdnn =
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 measurements)
o o a h Soil Nature Ground Water Bedrock or Impervious Material Domestic Water Supply
sand at what depth at what depth. C u—n i—c i a
Rolling loam —feet feet well L
Steep slope clay if well; water supply
%slope other from any septic-system
depth: absorption is
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 Phnning Board approved subdivision). Ada 250 gallons to the size
of the septic tank and leach field for each Garbage Grinder, Spa or Whirlpool Tub.
Septic Tank: /Igg�(D gallon (min. size 1,000ga".)(25-0)
Tile Field: each trench ft. Total System Length:
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 and/or size
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: Size of each: gallons TOTAL Capacity: _gallons
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 know;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 Se a e Disposal Ordinance.
Signature of reYponsible person Date
Application for Permit— Septic DispR ILS l
Town of Queensbury 742 Bay Road Queensbuiy, IVY 12804 (518)P�p_
1. OWNER INFORMATION: NQ.V 0 1 2005 1.........................I.......................................................
Office Use
Location of installation: 6NOF:�4 QUEENSBURY
I Ile
Tax Map No.
Fee Paid
Owner's Name:
Address: ��6 "' ��/8 �,cy� � �` o �. 1 � G���
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 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
Spa or Hot Tub Installed yes— no
4. PARCEL INFORMATION: (circle applicable information& indicate measurements)
Too graphv Soil Nature Ground Water Bedrock or Impenvlious Material Domestic Water Supply
019� sand at what depth at what depth qu�nicipa
Rolling loam —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), Add25O 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)(2 510)
Tile Field: each trench ft. Total System Length:
Seepage Pit(s): number of size of each: ft. by
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 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 Se a e Disposal Ordinance.
g i S a of
re pnonature nssiblerperson Date
Town of Queensbury
Sewers and Sewage Disposal Chapter
Appendix C
ABSORPTION FIELD
SEPARATION REQUIREMENTS
POND
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LVr~w
'te
Appendix C
ABSORPTION FIELD
SEPARATION REQUIREMENTS
P'ON
,xw
I
N$A P P— SK�F T
4
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Septic Inspection Report
r
Office No. (518)761-8256 Date Inspection re est e eiv f� i U
Queensbury Building&Code Enforcement Arrive: p epart: , a pm
742 Bay Rd., Queensbury,NY 12804 // Inspector's Initia
NAME: Ci/`` it l tir-��C �'I— E IT NO.:
LOCATION: PELT ON:
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 $.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank % �-A t l G
Tank to Distribution Box Lk
Distribution Box to Field/Pit c
Opening Sealed: Y/N/Partial
End Caps
Location/Separations
Foundation to tank ft.
Foundation to absorption r A ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Engineer Report and As-Built Y N
Location of System onProperty:
Fro R� ear -Side- Ri ht Side
Middle Front - e
System Use S atus:
t 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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. -__._ RECEIVED
NOV 0 1 2005
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