2009-142 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20090142 Application Number. A20090142
Tax Map No: 523400-301-009-0001-023-000-0000
Permission is hereby granted to: ROBERT &CHERYL KUBILUS
For property located at: 40 BRONK Dr
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. Tyne of Construction Value
Owner Address: ROBERT&CHERYL KUBILUS
40 BRONK Dr Septic Alteration Residential
QUEENSBURY, NY 12804 Total value
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans &Specifications
2009-142
septic alteration residential
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Saturday,April 24,2010
(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 rt2)j�eeury, r' a April 24,2009
01/SIGNED BY for the Town of Queensbury.
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
CERTIFICATE '%(YF COMPLIANCE
Permit Number. P20090142 Date Issued: Wednesday, April 29, 2009
This is to certify that work requested to be done as shown by Permit Number P20090142
has been completed.
Tax Map Number. 523400-301-009-0001-023-000-0000
Location: 40 BRONK Dr
Owner. ROBERT & CHERYL KUBILUS
Applicant: ROBERT & CHERYL KUBILUS
This structure may be occupied as a:
Septic Alteration Residential
By Oder 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& E rcement
Planning Board or Zoning Board of Appeals.
%_._�__j__..--- ._.______. ._._.__ USE ONLY�.......................--------
OFFICE f.._._._..._.__...__._...
T X MAPO�J PERM 5�; C !7 V
IT NO. PERMIT FEE
APPROVALS: ZONING '
TOWN CLERK APB 242009
'_._
APPLICATION FOR SEPTIC DISPOSAL SYSTE DE RY
A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS.APPLICATION IS SUBJECT TO REVIEW BEFORE ISSUANCE OF A VALID
PERMIT.
OWNER: �r
INSTALLER:
ADDRESS: � n I r I ADDRESS: R
�� rr W D(
PHONE NOS. PHONE NOS. g l
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 --- gallon per bedroom = SPA OR HOT TUB
INSTALLED?
PARCEL INFORMATION:
✓ TOPOGRAPHY: Flat rolling Stee slo e
p P %Slope
✓ SOIL NATURE: Sand2"� Loam
Clay Other
✓ GROUNDWATER: At what depth?
✓ BEDROCK/IMPERVIOUS MATERIAL: At what depth? _
✓ DOMESTIC WATER SUPLY: Municipal p V Well (If well: Water supply from any septic
r system absorption Is__ft.)
✓ PERCOLATION TEST: Rate is \v�
minutes per inch [M ]
(Test to be complete 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: l O GALLON (MIN. SIZE IS 1,000 GAL.)Add 250 gallons to the size of
each garbage grinder, spa or whirlpool tub, the septic tank for
SY EM TYPE: nn
ABSORPTION FIELD (WITH NO. 2 STONE) Total length�;J
9 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
aree to abide by these and all requ.rements of the Town of QUESTIONS? CALL 761-8256 OR EMAIL
Ad-ueensburyitary ewa a 's al Ordinance.
codes aC�aueensburvnetVISIT OUR WEBSITE FOR MORE INFORMATION
ww .aus esponsible Date
; ry Town of Qtteensbury - Community Development Office - 742 Bay Road, Queensbury, NY 12804
B 5-LGL 6/06
(
Septic Inspection Report
Office No. (518) 761-8256 Date Ins coon u t rec ed:
Queensbury Building &Code Enforcement Arrive: am e m
742 Bay Rd., Queensbury, NY 12804 Inspector's Initials:
NAME: WJUus PE NO.:
LOCATION: I PECT ON: l
RECHECK:
Comments and/or diagram
Soil Ty am I Clay
Type of Water: Murn ell Water
Waterli ration distance ft.
Well separation distance ft.
Other wells: ft.
Well Casing Length 50' + / - Y N N A
Absorption Field: Total length C> ft.
Length of each trench ft.
Depth of trenches ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size TVpe
Building to tank
Tank to Distribution Box �t
Distribution Box to Field / Pit
Opening Sealed: N
End Cap N
Inlet/Outlet Pipes &Baffles Y N
Location/ Separations
Foundation to tank
Foundation to absorption
Separation of Pits ft.
Conforms as per Plot Plan _Y_ N
Engineer Report and As-Built Y N
Location of System on _ perty:
Front Re eft Side ight Middle Front fiddle Rear
SystemUse s
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
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