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2003-195 1 ' TOWN OF QUEENSBURY 742 Bay Road,Queensbury,NY.12804-5902 (518)761-8201 Community Development - Building & Codes (518) 761-8256 CERTIFICATE• OF COMPLI-ONCE Permit Number:, P20030195 Date Issued: Wednesday, April 23, 2003 This is to certify that work requested to be done as.shown by Permit Number P20030195 has been completed. Tax Map Number: 523400-308-018-0001-056-000-0000 Location: 58 NORTH CHURCH Ln Owner: ROBERT &ISABEL SHEPITKA Applicant: ROBERT &ISABEL SHEPITKA This structure may be occupied as a: By Order of Town Board Septic Alteration Residential TOWN OF QUEENSBURY r 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: P20030195 Application Number: .A20030195 Tax Map No: 523400-308-018-0001-056-000-0000 Permission is hereby granted to: ROBF,RT&TSABF,T, SHEPTTKA For property located at: 58 NORTH CHURCH Ln 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: ROBERT &ISABEL SHEPITKA 58 NORTH CHURCH Ln Septic Alteration Residential Total Value QUEENSBURY,N.Y. 12804- Contractor or Builder's Name/Address Electrical Inspection Agency MORNTNO STAR SF,PTTC Plans&Specifications 2003-195 SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS $25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday,April 23,2004 (If a longer period is required,an application for an extension must be made to the code Enforcement Officer of the Town of Queensbury before the expiration date.) Dated at ow of Q spiry; sday,April 23,2003 SIGNED BY for the Town of Queensbury. Director of Building&Code Enforcement Application foi• Permit— Septic Disposal System 76lvn of Queensbil/y 742 Daylload Quee►sbury, NJ' 12804 (518) 761-8236 1. OWNER INFORMATION: .••...•...•. ;...••........•....• ..•....•.........•••.....•.......••..•..•....••............. A\ Office Use ...... Location of installation: 1� 0 f Fite Permit Noc'��' �t Tax Map No. / / Fee Paid.- Owner's Name: Address: _ .S' �.�.� �� -��::.• � ....................•........•....•••.......................••......•.........•......•.............•.,••.••......•................... 2. INSTALLER'S NAME : ��ST�L, PHONE NO. � '322-` 0 3. RESIDENCE INFORMATION. (circle'year of dwelling, indicate ll bedroom(s) and multiply i! q/ bedrooms with applicable gallons her bedroom to equal total daily flow) Year of House: No. of Bedrooms x Computation = Total Daily Flow 1980 or older `// x 150 gal/bdrnl = CRE E'VI 1980— 1991 x 130 gal/bdrin = D 1991 —present x 110 gal/bdrnt = R 2 3 2Q03 Garbage Grinder Installed yes` / rio rBUILDIN QUEENSBURY Spa or Whirlpool Installed yes / no G AND CODE 4. PARCEL INFORMATION: (circle applicable information & indicate moasurements) Btttt2l 0 tSt.CV C) C7.C9tiilSt_W....n4or o4k..or�i»pof_Y1QU.$ {t.4Qr_iell�_ om stic_W�44!'.$�q,ltly 1�%ql �0(1111 ar! al ► hot depth (rl ►t'lic,l(k1al, �,v,rlcT",uIIN►g — fuel feel ►veil Steep slope clay if well; water.supply slope other from any septic-systent depth: absorption is fl. other, Percolation Test: (To be completed by licett,red prt fessiotial enKitleer or arclillect) Rate: minute per Itch 5. PROPOSED SYSTEM: For New Construction: All individual sewage disposal systems must be designed by n licensed professional engineer or architect (unless installed in a Planning l3oard approved subdivision). Add 250 gallons to the size of lite septic lank and leach field for cacti Garbage Grinder, Spa or Whirlpool Tub. Septic Tank: /rCO gallon (nan. .size 1,000 gal.) Tile Field: each trench Total System Length: Seepage Pit(s): number of size of ecrcl►: ___fT. Gy JJ. Size of Stone to be timed: ll / cic�l,ll,or llilck„e.t.s ______ ___✓�'i'l Bed System Size: x Ahelnative System: length and/or size 6, HOLDING TANK SYSTEM: (if required) Number of tanks: / Size of each: gallons /TOTAL Capacity: gallons ti.., 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 protoction, ploase note that pursuant to Section 136-29 of the Code of the Town of Quoonsbury, any perniit or approval granted which is based upon or is granted in ralinvice upon any material misrepresentation or failure to niako n ruaterial fact or circumstance known by or on behalf of an applicant, sha11 be void. I have road the regulations with respect to this application and agree to ttbido by those and all roquiromntits_of the Towrr of Quee rsbury Sanitary Sewage Disposal Ordinance. 3 Signature of responsible person Date /V L Col.- i Septic Inspection Report Office No. (518)761-8256 Date Inspection request received. Queensbury Building&Code Enforcement Arrive: am/p epart: m/pm 742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials: NAME: 4`tC/ rf s INS ON: LOCATION: �� N: _[_tt.f ,�Gi-� 'z RECHECK: Comments and/or diagram Soil Type: Sand/Loam/Clay Type of Water: Municipal/Well Wate Waterline separation distance ft. Well separation distance ft. Other wells: ft. n _ Absorption Field: Total length Length of each trench Depth of trenches ft. Size of Stone Seepage Pits: Number Size: x Stone Size: Piping ize 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 N Location S tem on Property: Front ear Left Side Right Side dle Front Middle Rear S stem Use Sta s• Approved Partial Approved and needs to be r'e-inspected,please call the Building&Codes Office Disapproved t Septic Inspection Report Office No. (518)761-8256 Date Inspection request received: Queensbury Building&Code Enforcement Arrive: am/pepart: am/pm 742 Bay Rd., Queensbu ,NY 1,2804 Inspector's Initials: ��tl�� NAME: C, 1 PERMIT NO.: 9 m LOCATION: INSPECT ON: --0 RECHECK: �1� 1 Comments and/or diagram Soil Tyde Sail oa Clay Type of ': Mumci al/Well Water Waterline separa ' istance Well separation distance ft. ` Other wells: ft. 1 Absorption Field: Total length Length of each trench Depth of trenches Size of Stone &Ji L' See a e Pits: Number Size: x Stone Size: Piping ize T e Building to tank �,'I N Tank to Distribution Box Distribution Box to Field/Pit Opening Sealed: Y/N/Partial .tiY Location/Separations Foundation to tank ft. Foundation to absorption ft. Separation of Pits ft. Conforms as per Plot Plan 4 N �� ,. � Location of System on Property: Front Rear Left Side Right Side Middle Front Middle Rear _System Use Status: proved 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 i I E t• r � `1 Ilb-z F,/Y-q,5 11 F1 Dave seen or observed, or believe I saw evidence of, all objects such,as houses, wells, trees,fences, etc., shown on this document. !-also represent that I have l persona ll asur d the nces set forth on the diagram." SIGN RE DATE l t 1 '�rr .-7 �s k Q{ ! � 1 01 BiVO --AG (13M31A38 "1 have seen or observed, or believe I saw evidence of, all objects such'as houses, wells,trees, fences, etc., shown on this document. ) lso represent that I have personal m�asu d the nces set forth on the diagram." Z SIGN! RE �DAT--� m