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2012-241 011111b./ TOWN OF QUEENSBURY Bay Road, 742 Queensbury,y Q ,NY 12804-5902 (518)761-8201 Community Development - Building & Codes (518) 761-8256 CERTIFICATE OF COMPLIANCE Permit Number: P20120241 Date Issued: Friday, May 25, 2012 This is to certify that work requested to be done as shown by Permit Number P20120241 has been completed. Tax Map Number: 523400-308-010-0002-005-000-0000 Location: 469 LUZERNE Rd Owner: GORDON & KATEE BREAULT Applicant: GORDON & KATEE BREAULT 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 (- J property owner of the responsibility for compliance with Site Plan, Variance, or other issues and conditions as a result of approvals by the Director of Building& Code force``ent Planning Board or Zoning Board of Appeals. 4P111 Ivo TOWN OF QUEENSBURY 742 Bay Road,`uccnsbury,NY 12804-5902 (518)761-8201 Community Development- Building& Codes (518) 761-8256 BUILDING PERMIT Permit Number: P20120241 Application Number: A20120241 Tax Map No: 523400-308-010-0002-005-000-0000 Permission is hereby granted to: GORDON &KATEE BREAULT For property located at: 469 LUZERNE Rd 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: GORDON&KATEE BREAULT Septic Alteration Residential 469 LUZERNE Rd Total Value QUEENSBURY,NY 12804-0000 Contractor or Builder's Name/Address Electrical Inspection Agency Plans&Specifications 2012-241 Septic Alteration $40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday, May 16,2013 (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 ofltiueen�tsury; s , s ►i :y 16, 2012 `` 4Ve SIGNED BY ' ` for the Town of Queensbury. Director of Building&Code Enforcement P. 9 .-,,b7„1-.E..1-.34, OFFICE USE /ONLYc�V s !' TAX MAP N0,30 g .0-.3;4. PERMIT NO. ! �Ot y 1 PERMIT FEE !�00�i, y'i'.1 2012 APPROVALS: ZONING TOWN CLERK • ,ODES APPLICATION FOR SEPTIC DISPOSAL SYSTEM PERMIT: A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS.APPLICATION IS SUBJECT TO REVIEW BEFORE ISSUANCE OF A VALID PERMIT. OWNER: �^ (YhC`ham Yy(JCAu.\\--- INSTALLER: 5e` //II ((�� JJ nsbu-c� ADDRESS:`t( R (�}, )i\ � \1P RI) ` l r�KY-1 ADDRESS: Klee Q (� PHONE NOS. 1aS 2j - ((f1)` )(� PHONE NOS. a5 3 -6,3 p / LOCATION OF INSTALLATION: F.-.)ea (-1\0,1-1(3 NO.OF RESIDENCE INFORMATION: YEAR BUILT BEDROOMS X COMPUTATION= = TOTAL DAILY FLOW _ GARBAGE GRINDER 1980 or older X 150 gallon per bedroom - 3D0 INSTALLED? 1L 0 1981 -1991 X 130 gallon per bedroom = SPA OR HOT TUB 1992-present X 110 gallon per bedroom = INSTALLED? t� PARCEL INFORMATION: 1 ✓ TOPOGRAPHY: Flat rolling Steep slope %Slope ✓ SOIL NATURE: Sand V Loam Clay Other ✓ GROUNDWATER: At what depth? ✓ BEDROCK/IMPERVIOUS MATERIAL: At what depth? ✓ DOMESTIC WATER SUPLY: Municipal / Well (If well: Water supply from any septic system absorption is ft.) ✓ PERCOLATION TEST: Rate is minutes per inch [MPI] (Test to be completed by a licensed professional engineer or architect.) 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). TANK SIZE: \ ,bOO GALLON (MIN. SIZE IS 1,000 GAL.)Add 250 gallons to the size of the septic tank for each garbage grinder, spa or whirlpool tub. SYSTEM TYPE: ❑ ABSORPTION FIELD (WITH NO. 2 STONE) Total length ft. Each trench X ❑ SEEPAGE PIT(S) (WITH NO. 3 STONE) How many? Size? ❑ ALTERNATIVE SYSTEM Bed or other type? ❑ HOLDING TANK SYSTEM Total required capacity? Tank size? Number of tanks? NOTE: ALARM SYSTEM AND ASSOCIATED ELECTRICAL WORK MUST BE INSPECTED BY A TOWN APPROVED ELECTRICAL INSPECTION AGENCY. PLEASE REVIEW LIST PROVIDED. 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 QUESTIONS? CALL 761-8256 OR EMAIL Queensbury Sanitary Sewage Disposal Ordinance. coaes(aqueensburv.net VISIT OUR WEBSITE FOR MORE INFORMATION www.queensbury.net Signpture o Person Responsible Date 57171 ZdI 2 Town of Queensbury • Community Development Office • 742 Bay Road, Queensbury, NY 12804 B 5-LGL 6/06 (D AV Septic Inspection Report Office No. (518) 761-8256 Date Inspe ion request received: 5 Ja3)ir .. Queensbury Building &Code Enforcement Arrive: "'j3L am/pm Depart: am/pm 742 Bay Rd., Queensbury, NY 12804 Inspector's Initials: Wk— NAME: r eau_ t '}' PERMIT NO.: LOCATION: j i,, 1. it 2 erCt INSPECT ON: 5-.,1 41-1a. 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. Well Casing Length 50' + / - Y N N/A 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 LI lc Tank to Distribution Box Distribution Box to Field/ Pit Opening Sealed: Y N End Cap Y___N Inlet/Outlet Pipes &Baffles Y N Location/ Separations • Foundation to tankft. Foundation to absorption _ _ _ft. Separation of Pits ft. Conforms as per Plot Plan __R..Y N Engineer Report and As-Built Y N Location of System on Property: Front Rear Left Side Right Side Middle Front Middle Rear System Use tttus: Approved Partial Approved and needs to be re-inspected, please call the Building &Codes Office Disapproved Last revised 06/18/07 L:\Building&Codes Forms-OLD\Building&Codes\Inspection Forms\Septic Inspection Report.doc }• rte; ,W ice, . 1 - iL 'L/t Cl. Septic Inspection Report Office No. (518) 761-8256 Date Inspection request received: 0--3 j-- Queensbury Building&Code Enforcement Arrive: )-)/3 am/pp Depart: m/pm 742 Bay Rd., Queensbury, NY 12804 Inspector' Initials: 1A-- NAME: gUrdO)~ C-L-C J PERMIT NO.: " rc7)-' l I LOCATION: dl(� l INSPECT ON: a- j-,4) 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. Well Casing Length 50' +/ - Y N N/A [150'to well required if NO] Absorption Field: Total length I ft. Length of each trench _ ft. Depth of trenches 2-3 ft. Size of Stone JWI {- Seepage Pits: Number Size: x Stone Size: Piping Size Type )(led) / // / Building to tank ��t c /(ed) 1� 3?-4 Alas Cc: 'n eck, Tank to Distribution Box y`` Distribution Box to Field / Pit L-r/k Opening Sealed: L Y N End Cap XY N Inlet/Outlet Pipes&Baffles Y N Manholes 12"or less below grade _Y N [provide extension collar if Yes] Y N Location/ Separations Foundation to tank 1' ft. Foundation to absorption 1"5 ft. Separation of Pits ft. / Conforms as per Plot Plan ? Y j N i'a!/ (f QL4. Al' P/` Engineer Report and As-Built —Y N ETU Maintenance Contract _Y_ N provided 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 L:\Pam Whiting\2010\Building Codes Forms\Inspectlon Forms\Septic Inspection Report_03 29 10.doc . '/ ►... Community Development Office . . `#`..` Town of Queensbury • 742 Bay Rd. . Queensbury, New York •12804 PLOT PLAN ' .. Show all existing and proposed structures. 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