2004-958 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201 .
Community Development- Building &Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Penn it Number. P2004O95,8 Date Issued: Wednesday, December 15, 2004
This is to certify that work requested to be done as shown by Permit Number P20040958
has been completed.
Tax Map Number. 523400-301-008-0002-079-000-0000
Location: 41 HILLCREST Ave
Owner. RICHARD & LINDA MACHOLD
Applicant: RICHARD & LINDA MACHOLD,
This structure maybe occupied as a:
By Order of Town Board
Septic Alteration.Residential TOWN OF QUEENSBURY
Director of Building&Code Enforcement
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20040958 Application Number: A20040958
Tax Map No: 523400-301-008-0002-079-000-0000
Permission is hereby granted to: RICHARD &I,MA MACHOLD
For property located at: 41 HILLCREST 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: RICHARD &LMA MACHOLD
41 HILLCREST Ave Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
COOKS SEPTIC
NY 12804-0000
Plans&Specifications
2004-958
Septic Alteration (moving septic system front front to back yard)
1.050 gallon tank(poly)
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday, December 14, 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 To of Queens ry; T es ay, December 14, 2004
i
SIGNED BY for the Town of Queensbury.
Director of Building Code nforcement
Septic Disposal System
Application for Permit .
Town 761-8256
i. OwNERINFORmATI Richard Machold 2004-958 .................................
Office Use
4
Location of instalJ 1 Hillcrest Drive
Septic Alteration Permit No.
T Ma
:bNo
Fee Paid e—;?,
wnet�&Naxnel ........................................................
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 = JI.ECE,VED
Garbage Grinder Installed yes no' DEC
Spa or Hot Tub Installed yes_ no 1 3 2004
TOWN OF QUEENSBURY
4.' PARCEL INFORMATION: (circle applicable information&indicate measurements) BUILDING,4ND CODE
Topography Soil Nature Ground Water Bedrock or Impervious Material Domestic Water SupplyY
Flat sand at what depth at what depth municipal
Rolling loam —feet feet well
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 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: gallon (min. size 1,600 gal,) 67
Tile Field: each trench dO 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 Z,-
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 yourprotection,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 th��ons with respect to this appl'p tlon i . d agree to abide by these and all
p
requirements
To fQueen ni Se, ge Disposal Ordinance.
V.
A of responsible perso at
1,ow"11 of (lucell.-I1)llt-Y
Sezvc.1-s and Sc;wsistc I)isj)omal C.Impfcr
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7. SIQTNATURE &INFORMA71ON FML MS1'U b=J A r>rr-AOvL, uuas►•w awu , ,,
Septic Inspection Report
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P p p
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: ,/ /-, arn/pm Depart: am/pm
742 Bay Rd., ueensbury,NY 12804 Inspector"s Initials: Q
NAME: ��Gt. PERMIT NO.: o ' Sv
LOCATION: INSPECT ON:
RECHECK:
Comments and/or diagram
Soil Type: San -Loa Clay
Type of Wa er: @unipipal/Well Water
Waterline separation distance ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length /U, ft.
Length of each trench L ft.
Depth of trenches
Size of Stone
-Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank AVL
Tank to Distribution Box
Distribution Box to Field/Pit
O ening Sealed: /N/Partial
Location/Separations
Foundation to tank / ft.
Foundation to absorption 30 ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Location of System on Property:
Front 0
Left Side Right Side
Middle Front Middle Rear
J
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
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Septic Inspection Report
Office No. (518)761-8256 Date Inspection request received:
Queensbury Building& Code Enforcement Arrive: am/pm Depart: am/pm
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials: _/
NAME: 14e, r� PERMIT NO.: DI
LOCATION: ��j n; /�p� INSPECT ON: c
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
Location/Separations
Foundation to tank ft.
Foundation to absorption ft•
Separation of Pits ft.
Conforms as per Plot Plan Y N J
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
I,AgueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
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RECEIVE®
DEC 1 5 2004
TOWN OF QUEENSBURY �
BUILDING AND CODE
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_ all objects such as houses, wells, trees, fences, etc.,
shown on this document. I aIs re pr n that ! have
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Richard Mach
J old 2004-958
41 Hillcrest Drive
Septic Alteration