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2003-446 TOWN OF QUEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201 Community Development-Building&Codes (518)761-8256 CE T R IFIr ATE OF COMPLIANCE Permit Number: P20030446 Date Issued: Friday,June 20,2003 This is to certify that work requested to be done as shown by Permit Number P20030446 has been completed, Tax Map Number: 523400-302.017-0002-066-000.0000 Location: 24 CLARK St Owner: ROBERT&BARBARA ROSOFF Applicant: ROBERT&BARBARA.ROSOFF This structure may be occupied as a: By Otder of Town Boatd Septic Alteration Residential TOWN OF QUEENSBURY Director of Building&Code Enforcement TOWN OF Q UEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201 Community Development-Building&Codes (518)761-8256 BUILDING PERMIT Permit Number: P20010446 Application Number: A20030446 Tax Map No: 523400-302-017-0002-066-000-0000 Permission is hereby granted to: ROBERT&BARBARA ROSOFF For property located at: 24 CLARK St 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. T Value -_)Te of Construction Owner Address: ROBERT&BARBARA ROSOFF Septic Alteration Residential 24 CLARK St ' Total Value QUEENSBURY,NY 12804 Contractor or Builder's Name Address Electrical Inspection Agency OUEENSBURY SEWER NY 12804-0000 Plans&Specifications 2003-446 SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS $25.00 PERMIT FEE PA1115-THIS PERMIT EXPIRES: Sunday,June 20,,2004 (If a longer period is required,an application for an extension must be trade to the code Enf6rcernent Officer of the Town of Queensbury before the expiration date.) Y4Dated at the To n of QA* e 20,2003 SIGNED BY for the Town of Queensbury. Director of Building&Code Enforcement Application for Permit-Septic Disposal SyftstC. �Z Town of Queensbury 742 Bay Road Queensbury, NY 12804 (518) 761-.8236 1. OWNER INFORMATION-, A2�0 -o Location of installation: op qq�Tax Map No. Fil e 3- �" � i Fee Paid� Owner's Name: a _4 ................................................................................................ Address: - 2. INSTALLER'S NAME cpu q J R(k V-!X PHONE NO. 3. RESIDENCE INFORMATION: (circle year of dwelling, indicate 4 bedroom(s) and multiply#of bedrooms with applicable gallons per bedroom to equal total dailyflow) Year of House: No. of Bedrooms x Camputatian, = Total Daily Flow ---1:980�oroldj x 150 gal/bdrm = 9 991 x 130 gal/bdrm = 1991 -present x 110 gal/bdrm = Garbage Grinder Installed yes Spa or Hot Tub Installed yes 4. PARCEL INFORMATION: (circle applicable information&indicate measurements) Too jzral3hv Soil Nature Ground Water -Bedrock or Imi)ervious Material Domestic Water Supply CFI san at what depth at what depth nict Rolling loam —feet -feet we Steep Slope clay rif�well; water supply c from slope other from any septic-system depth: absorption is_j?. 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: 110-D-v gallon (min. size 1,000 gal) . Tile Field: each trench TD ft. Total System-Length: ft. Seepage Pit(s): number of size of each: _j?. by_ft. Size of'Stone to be used: # f depth or thickness feet Bed System Size: x Alternative System: -A- &r. length and/or size 6. HOLDING TANK SYSTEM:"(it required) Number of tanks: 1 Size of each: c _gallons TOTAL Cap"a ity: gallons Note: Alarm System-and associated electrical work must be inspected by a Town:I approved electrical inspection agency. 7. SIGNATURE &INFORMATION FOR RESPONSIBLE PERSON(please read),.;' For your protection,please note that pursuant to Section 136-*29 of thd'66.de'"e�Town of Queensbury, any permit or approval granted which is based upon or-is reliance upon, any material misrepresentation or failure to make a material iaclt'6' i circumstance kri,own by or on behalf of an applicant, shall be void. I have read the regulations with respect to this application and agree to abide'15y;these,and all requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance. Sign&twr 0 responsible person Date (-Yam Septic Inspection Report Office No. (518)761-8256 Date Inspection,,reques received: Queensbury Building&Code Enforcement Ai-rive: Depart: pm 742 Bay Rd.,Queensbury,NY 12804 inspector's Initials: NAME: S rip PERMIT NO.: 0 3 LOCATION: INSPECT ON: L-ZL-111d) RECHECK: Comments and/or diagram Soil Type: and Clay Type of Wa��x�, unici al/Well Water Waterline separaliQuAfstance Well separation distance ft. Other,wells: ft. - Absorption Field: Total length V ft. Length of each trench ft. 'q�a P11 .-Depth of trenches . Size of Stone ri L t&f Ug Seepage Pits: Number Size: X Stone Size: Piping Size Type/ Building to tank 7& Tank to DistributioA Box Distribution Bo o ie d Pit %A -Opening Sealef, Y/NI Partial Location/Separations Foundation to tank Foundation to abs22tion Separation of Pits Conforms as per Plot Plan Location of Syst n Property: Location 0' �2' "I' onP, Front Rear Left Side Right Side Middle i iddle rout fiddle Rear o S ,stem Use S Y e Stat Approved Partial Approved and needs to be re-inspected,please call the'Building&Codes Office Disapproved L:\StieHemingway\Btiilding.Codes.Inspection.FORMS\Sep tic Inspection Reportdoc January 28,2003 ' e saw evidence of, or believe� or observed, fenceS,etc., '� trees, . ►tI have seen wells, also represent that i hhe diagram" I objects such as�ousts' n t aI on this docu�the distances set forth o shown ensured ,�� ' 63 . persooal1Y m w. SIG Nigi a c, Or , co t n4 Q� © 5 . ty .� 1 I BUILDING �- EIPT. REVIEWED B ATE �r ' Q