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2011-537 4 TOWN OF QUEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201 Vi v./TO Community Development-Building& Codes (518) 761-8256 BUILDING PERMIT Permit Number: P20110537 Application Number: A20110537 Tax Map No: 523400-239-015-0001-008-000-0000 Permission is hereby granted to: PAUL KASSELMAN REVOCABLE TRUST For property located at: 25 WILD TURKEY 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: PAUL KASSELMAN REVOCABLE" Test Pit/Perc Test Review P&B KASSELMAN 237 ELM NE Total Value P.O. BOX 87 DELMAR,NY 12054 Contractor or Builder's Name /Address Electrical Inspection Agency Plans&Specifications 2011-537 deep hole/perc test $200.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Tuesday,April 01,2014 (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; Monday,April 01,2013 SIGNED BY for the Town of Queensbury. Director of Building&Code Enforcement Town of Queensbury• Building&Codes Enforcement Office•742 Bay Road• Queensbury,NY 12804 DEEP HOLE/PERC TEST Request for Town Engineer Review Property Owner: PA UL KA SS E LMA N Phone: Property Owner's 025 Wi 1-•I) -Tu 2KEy LANE Location of Test: s25 4 D 'Tj R KE y 1-4Pia Tax ID#: a 3 9 • 15 - 1 - 8 *Applicant's Engineer: G. TFEOP4kS H UTCH-INSP.E. Phone: 518) 4q5- 0304 H U-rc.H lit s Applicant's Agent: I OU G M GG*LL /ENGINEERING Phone: (51 g) -4-1-4 4 - 14 95 Additional Notes: 1. Reason for Request? New Septic System Replacement Septic System Failed Septic System Subdivision Site Plan Review 2.Are Wetlands present? YES n NO UNKNOWN *Note: Applicant is required to engage an engineer for design and testing of the system. The Town Engineer's responsibility is to witness system testing only. PLOT PLAN: Plot plan, to scale, to be submitted with application FEE SCHFEDU&E— a. $200 Flat Fee Date Paid: /©—f q-ii Check No.: 2/T7-- . b. OR Fee to be determined during To Be Determined: Site Plan/Subdivision review process SIGNATURE: In carrying out the provisions of Article IV, the Local Board of Health or the enforcement officer may engage the services of a qualified professional consultant for expert review and recommendation arising from the carrying out of the provisions of Art. IV, including but not limited to the review of plans, specifications and reports, attendance at inspections, dye tests, deep hole test pits, septic related deep hole and percolation tests, system installations, and any other aspect of any matter contained in this Art. IV, and any costs incurred in such review shall be paid to the Town by the owner of the property before any approval can be granted under this Art. IV shall become effective within 30 days of presentment of an invoice for same, whichever is sooner. Such costs shall not exceed$1,500 without prior written notice to the party to be charged with same. My signature below indicates I have thoroughly read and understand the instructions, agree to the submission requirements and have completed the application. I also fully understand that additional engineering fees may be necessary per Town of Queensbury Local Law 136-14D. SIGNATURE OF APPLICANT: Date: SIGNATURE OF AGENT: 'i Ok Date: G' .411IL\Mir Original (B&C File) Canary(Planning) Pink(Applicant) Gold (Town Clerk) ;t 0 -10 _ C•dw VM for — 0 F- r rn o a: � U � yam-• C � � � m \ a s C: �o L� E N N O LO D c U w Z L aoo .. ..N x � y U O t � � N pt N C OU 0 = W 'q- N i N O cn d , ^ �0 H r O) 00 rn z Y o m o Q r 3 N LO D c w Z v o z W:DO , ^ �0 U ^ CL W 3 rn L0 S x a U D m N Z c c o rr� W d ++ V v CL Q 0 O o 0 li.. 0 V p p 00 CL .- OM 0 U O Q y � 3 N mN w =C F- U Cm p N 0