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2009-090 TOWN OF QUEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201 Community Development- Building&Codes (518) 761-8256 BUILDING PERMIT Permit Number: P20090090 Application Number. A20090090 Tax Map No: 523400-309-015-0001-030-000-0000 Permission is hereby granted to: ANDREA CLARK For property located at: 200 FIFTH St EXT 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: ANDREA CLARK 3 HENRY WESTCOTT Rd Septic Alteration Residential WARRENSBURG,NY 12885-0000 Total value Contractor or Builder's Name/Address Electrical Inspection Agency Plans &Specifications 2009-090 septic alteration residential $25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Saturday,March 27,2010 (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 of Que buy; F iday, March 27, 2009 SIGNED BY for the Town of Queensbury. Director of Building&Cole Enforcement TOWN OF QUEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201 Community Development- Building &Codes (518) 761-8256 CERTIFICATE OF COMPLIANCE Permit Number. P20090090 Date Issued: Thursday, April 02, 2009 This is to certify that work requested to be done as shown by Permit Number P20090090 has been completed. Tax Map Number. 523400-309-015-0001-030-000-0000 Location: 200 FIFTH St EXT Owner. ANDREA CLARK Applicant: ANDREA CLARK This structure maybe occupied as a: Septic Alteration Residential By Order of Town Board TOWN OF QUEENSBURY Issuance of this Certificate of Compliance DOES NOT relieve the , 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 Enforcement Planning Board or Zoning Board of Appeals. - .. _1_.__. - OFFICE USE ONLY - �_.____ ,- ---, C f ' I ----_ r 00 TAX MAP NO. ; � ' " 0 PERMIT N0. PERMIT FEE 'r ; APPROVALS: ZONING TOWN CLERK 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: rCv` r INSTALLER: ADDRESS:�7� �� S/ ADDRESS:�� PHONE NOS._... j- �d PHONE NOS.___ LOCATION OF INSTALLATION: YEAR BUILT NO.OF X COMPUTATION= RESIDENCE INFORMATION: BEDROOMS TOTAL DAILY FLOW 1980 or older X 150 gallon per bedroom = GARBAGE GRINDER 1981 -1991 ©� INSTALLED? X 130 gallon per bedroom = 1992-present X 110 gallon per bedroom = SPA OR HOT TUB INSTALLED? PARCEL INFORMATION: ✓ TOPOGRAPHY: Flat rolling Steepslo e P %Slope ✓ SOIL NATURE: Sand Loam Clay Other ✓ GROUNDWATER: At what depth?—A4 ✓ BEDROCK/IMPERVIOUS MATERIAL: At what depth? /4 ✓ DOMESTIC WATER SUPLY: Municipal Well (If well: Water supply fro ray septic br— system absorption isPERCOLATION TEST: Rate is per minute per inch. (Test to be completed by a licensed professional engineer or architect.) PROPOSED SYSTEM FOR NEW CONSTRUCTION: All individual sewage disposal systems must be designed b a licensed professional engineer or architect (unless installed in a Planning Board approved subdivision), g y TAN—E GALLON (MIN. SIZE IS 1,000 GAL.) Add 250 gallons to the size of the septic tank f each garbage grinder, spa or whirlpool tub. P or SYSTEM TYPE: ABSORPTION FIELD (WITH NO. 2 STONE) Total length 9 ft. Each trench=X n-c/ ❑ SEEPAGE PIT(S) (WITH NO. 3 STONE) How many? �1 erJ Size ❑ ALTERNATIVE SYSTEM Bed or other type? r � ❑ 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 Queensbur an. permit or approval granted which is based upon or is granted in reliance upon an material y' Y failure to make a material fact or circumstance known by or on behalf of an applicant, shall be void_ Y misrepresentation or L- .- --- . .. Septic Inspection Report c2 Office No. (518) 761-8256 Date Inspection request received: Queensbury Building &Code Enforcement Arrive: am/pm Depart: 16 am/pm 742 Bay Rd., Queensbury, NY 12804 . Inspector's Initials: 1 v NAME: PERMIT NO.: LOCATION: INSPECT ON: /5�' 3 AL2YO� RECHECK: Comments and/or di ram Soil T Loam/ Clay Type of Water: n-i jcjpk Well Water Waterline aration distance ft. Well separation distance V I I L.- Other wells: t ft. Well Casing Length 50' + / - Y N N/A Absorption Field: Total length ft. Length of each trench ft. Depth of trenches Size of Stone Seepage Pits: Number Size: Ix L Ea Stone Size: Piping Size Type Building to tank i Tank to Distribution Box Distribution Box to Field Pit Lr Opening Sealed: Y N End Ca Y_N Inlet/Outlet Pipes&Baffles N Location Separations Foundation to tank ft. Foundation to absorption ' ft. Separation of Pits Conforms as per Plot Plan N Engineer Report and As-Built Y N Location of System on rty: Front Rear Left Side Right Side Middle Front Middle Rear System Use t . 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