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2004-750 TOWN OF QUEENSBURY 742 Bay Road,Queensbuxy,NY 12804-5902 (518) 761-8201 Community Development- Building & Codes (518) 761-8256 CE_RIFICA'I`E _OF: .COMI'�LIAN E _ Permit'Nurriber. �p20040750 .� Date;Issued:- Friday, January 06, 2006 -This is.to'certify that work requested to be-done as shown by..Pern it Number P20040750 . has been completed. _ . Tax Map Number: 523400-266-001-0001-014-005-0000 Location: 80 OAK VALLEY Way Owner: - THOMAS & TERRI KUBRICKY _ _Applicant:..- --- _. THOMAS &TERRI KUBRICKY = 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 Gy property owner-of theresponsibility for compliance with Site Plan, Variance,or other issues and conditions as a result-of approvals-bythe -- - 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: P20040750 Application Number: A20040750 Tax Map No: 523400-266-001-0001-014-005-0000 Permission is hereby granted to: THOMAS & TF.RRT KT TRRTC;KY For property located at: 80 OAK VALLEY Way 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: THOMAS & TERRI KUBRICKY Septic Alteration Residential 80 OAK VALLEY Wav Total Value QUEENSBURY, NY 12804 Contractor or Builder's Name/Address Electrical Inspection Agency Plans&Specifications 2004-750 ADDITIONAL SEPTIC SYSTEM FOR BATHROOM IN GARAGE $25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday, September 23, 2005 (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 Queensb , T ur day, September 23, 2004 SIGNED BY J for the Town of Queensbury. Director of Building Code ' forcement Application for Permit-Septic Disposal System Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256 1. OWNER INFORMATION: .................................................................................................... n Office Use Location of installation: File Permit Ndie Tax Map No. / _/ -� L/ 00 j Fee Paid- j Owner's Name: / p M a(L1 C,LU��i Address: 2. INSTALLER'S NAME Omani ) �j?lZ,/Cl�,� PHONE NO. S/ 2.O je 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 = n �°.,. 1980— 1991 x 130 gal/bdrm = �� 1 �� 1991 —present , x 110 gal/bdrm = SEP. 2 3 2004 Garbage Grinder Installed yes— / no Spa or Hot Tub Installed yes_ / no - )WN OF QUEENSQUR' tILDING AND CQL�� 4.' PARCEL INFORMATION: (circle applicable information&indicate measurements) Topography i S -Nature Ground Water Bedrock or Im ervious Material . Domestic Water Su 1 Flat at what depth at what depth municipal Rolling tam feet feet well Steep slope 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. Septic Tank: 44d0 ' gallon (min. size 1,000 gal.) 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: # 02 / 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 Sewage Disposal Ordinance. Signature of responsible person Date . , . ''I't)ty►t t�f LZut;c:►►�I)ury Srwcrs at:cl 5rwsi�►,c: I)i�j)a�al (:I►s►j)t�`:•. 11'1 .►;t)IiI'''�'t(?�1 IN I+;ICI,) ;E-PARA'MON ItI;t,Zt.Jiltl�hlI��N'I`:� •off-> Z POND . 'ttil�liT CJ�'I�II•; ram.... �+•- . Of _ 1Loua� t� nE ' , .,z+� '• '�III:>V= G . !• E .. ✓ •fir ' 5ct•1►c, ��• �CV! �'�� U�'�lltpr�lri�•11 P R.I. > i 7, SIGNATURE &MORIdATION PO.I,Utilivrow.Lror a1Vl`I �Jivgw•v�.�y i R Vow Septic Inspection Report Office No. (518)761-8256 Date Inspection r uest r cei d: % Queensbury Building&Code Enforcement Arrive: am/p „ epart: A4,11 am/pm 742 Bay Rd., Queensbury,NY 12804 Inspector's Ini ials: NAME: tl U�( E IT NO.: T 7� LOCATION: SPECT 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 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 L Side Right Side Middle Fro Middle Rear System Use Sta s: Approved Partial Approved and needs to be re-inspected, please call the Building& Codes Office Disapproved Last revised 116105 Septic Inspection Report Office No. (518)761-8256 Date Inspection rerQueensbury Building&Code Enforcement Arrive: am/pm 742 Bay Rd., Queensbury,NY 12804 Inspector's Initi sNAME: \t) �p LOCATION: _ SPECT ON: —Z q—p RECHECK: Comments and/or diagram Soil Type: Sand/Loam/Clay -Type of Water: Munici al/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/ artial Location/Separations Foundation to tank ft. Foundation to absorption ft. Separation of Pits ft. Conforms as er Plot Plan V Y N Location of System on Property: �EC� �� 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 L:\SueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003 C L� TCrnn �-D Septic Inspection Report , Office No. (518) 761-8256 Date Inspection re est ec iv d: Queensbury Building&Code Enforcement Arrive: �/p e art: - anV/ 742 Bay Rd., Queensbury,NY 12804 Inspector's Initials NAME: c� PE IT NO.: LOCATION: D C- PECT ON: —p RECHECK: Comments and/or dialzram Soil T e Sa oa la Type of Water: . unrcipal/kell Water Waterline separation distanc 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 VS Tank to Distribution Box Distribution Box to Field/Pit Opening Sealed: Y/N/Partial Location/Separations Foundation to tank ft. Foundation to absorption ft. �J Separation of Pits ft. \ � \ Conforms as per Plot Plan N � I v Location of System on Property: Front Rear Left Side Right Side f Middle F. iddle Rear System Use Status: 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 TOE X0Oa",C�c� !4 f: "I have seen or observed, or believe I saw evidence of, o all objects such as houses, wells, trees,fences, etc., Q shown on this document. I also represent that I have personally measured the distances set forth.on the diagram." _ 3 SIGNATURE _� DAZE 5�� 1 .ram a�9viD �Ar��cA KM0CzLN1cr/ -p F�47 orNER LAA(DX OF `O T/-�oMf1.I KUBQJCky N v �--�� ' cJo \ n) UU k ?••S/OENCF \ e � 3 0 V� wwa• y ♦� In of U lq N J0AN KvQ R�CKy 0 �0 3 . 6 o Lf3,V DJ o F 3.7 '9C h M 4 /CENT TN c lfiER E M N L vk E rHoroAX V rEaei E Z F aF4o 8*.//52 1-0. 272 s 81-Sr aa•s� • V A o MO N LEA I v� M LUM LU M LLJ G112 CY CD0 LLJ Lo LU "I have seen or observed, or believe I saw evidence of, , . . . . all objects such as houses, wells, trees, fences, etc., �� ,•® I�NU Sp .® shown on this document. I also represent that I have ,'�Sti �, M� ��` • r� n e i y'�'�- I��;;',.� • �� `� COS+ 'tom • personally measured the disc th on the diagram :i }.: • �`��'` s► R � R SIGNATURE DATE �,„ � � t, f JNf S�A�� ,Svx►lEy AfWP,By AfMO OF IXX1,01' OF A s RWO T �o4vLT£.Q p/��Co eiyi�C'/e /y0 l K I r"U S R I C K T R�R Y L/CENIED LAND 1'U.2YEy0.2,!' 92 BAY ,1T.PEET RF/.vim inT ivo: -ems• jr�'V" '/ cnvr v r..a nI�i r.nw/ '�