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2009-166 TOWN OF QUEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201 Community Development- Building& Codes (518) 761-8256 BUILDING PERMIT Permit Number: P20090166 Application Number: A20090166 Tax Map No: 523400-301-018-0001-008-000-0000 Permission is hereby granted to: HARRY &RUTH GOLDMAN For property located at: 3 AMY 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: HARRY &RUTH GOLDMAN Septic Alteration Residential 3 AMY Ln QUEENSBURY,NY 12804 Total value Contractor or Builder's Name /Address Electrical Inspection Agency Plans &Specifications 2009-166 SEPTIC ALTERATION RESIDENTIAL $25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Tuesday, May 04, 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 Towri o(4Quee bu rA7 , May 04, 2009 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 (E)w Community Development - Building & Codes (518) 761-8256 CERTIFICATE OF COMPLIANCE Permit Number: P20090166 Date Issued: Thursday, May 07, 2009 This is to certify that work requested to be done as shown by Permit Number P20090166 has been completed. Tax Map Number: 523400-301-018-0001-008-000-0000 Location: 3 AMY Ln Owner: HARRY & RUTH GOLDMAN Applicant: HARRY & RUTH GOLDMAN 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 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 Co e n r e Planning Board or Zoning Board of Appeals. __________6_II________- OFFICE USE ONLY---------------------- - ,_ _ ' AX MI�P N 0 PERMIT NO. - ERMIT FEE t0F]QLIEENSB]URY 1 2009 APPROVALS: ZONING TOWN CLERK ---- 13UILDING& CODES __________ _ APPLICATION FOR SEPTIC DISPOSAL SYSTEM PE BEGINS.APPLICATION IS SUBJE TO REVIEW BEFORE A PERMIT MUST BE OBTAINED BEFORE WORK B PERMIT. ISSUANCE OF A VALID OWNER: INSTALLE &� ADDRESS:3 C / ADDRESS: J� PHONE NOS._ ! PHONE NOS. - LOCATION OF INSTALLATION: LN YEAR BUILT NO.OF X COMPUTATION= RESIDENCE INFORMATION: BEDROOMS = TOTAL DAILY FLOW 1980 or older X 150 gallon per bedroom = GARBAGE GRINDER 1981 -1991 s INSTALLED? X 130 gallon per bedroom = 1992-present X 110 gallon per bedroom = SPA OR HOT TUB INSTALLED PARCEL INFORMATION: ✓ TOPOGRAPHY: Flat rolling v Steepslo e P %Slope ✓ SOIL NATURE: Sand Loam Clay Other ✓ GROUNDWATER: At what depth? ✓ BEDROCK/IMPERVIOUS MATERIAL: At what depth? ✓ DOMESTIC WATER SUP Y: Municipal Well (If well: Water supply from any septic system absorption is ft.) ✓ PERCOLATION 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 by a licensed professional engineer or architect (unless installed in a Planning Board approved subdivision). TANK SIZE: i 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 31 , ❑ 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 ;Signature sbury Sanitary Sewage Disposal Ordinance. codes@queensbury.net VISIT OUR WEBSITE FOR MORE INFORMATION `p www.gueensbury.net of P rson Responsible Date r°: - Town of Queensbury • Community Development Office• 742 Bay Road, Queensbury, NY 12804 12..a Septic Inspection Rep Office No. (518) 761-8256 Date Ins ion re ived: Queensbury Building &Code Enforcement Arrive: / m ar Jpm 742 Bay Rd., Queensbury, NY 12804 Inspector's Initial NAME: Q PE IT NO.: LOCATION: E SPECT ON: RECHECK: gEC� Q,E .�VCE�-i ►'�' Comments and/or diagram Soil Type: Sand Loam Clay Type of Water: Municipal Well Water Waterline separation distance ft. Well separation distance Other wells: Well Casing Length 50' + / - Y N N/A —J pe Absorption Field: Total length ft. t\ Length of each trench ft. Depth of trenches ft. 5 iJ Size of Stone o p Seepage Pits: Number Size: x l�►�� Stone Size: Piping Size Type Building to tank Tank to Distribution Box Distribution Box to Field/ Pit Opening Sealed: Y N End CaD Y N Inlet/Outlet Pipes&Baffles _Y_ N Location Separations Foundation to tank ft. Foundation to absorption ft. Separation of Pits ft. Conforms as per Plot Plan _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 Status: 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 .-y Septic Inspection Reportre ' Office No. (518) 761-8256 Date Ins ctio re S�6P Queensbury Building &Code Enforcement Arrive: a part: s am 742 Bay Rd., Queen ury, NY 12804 Inspector's Initials: NAME: 05 ©�u�K(�-1i. P NO.: LOCATION: I ECT ON:RECHECK: V7/0 / Comments and/or diagram Soil TY Wm/ Clay Type of Water: unici a ater zj Wa e3ZVargfion 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 Z-- ft. Size of Stone -#- See a e Pits: Number Size: x Stone Size: Piping Size Type Building to tank c I 1-A Tank to Distribution Box i... tt Distribution Box to Field Pit CAt, L Opening Sealed: N End Ca _ N � Inlet/Outlet Pipes&Baffles N Location Separations ,.�► �` r�, Foundation to tank VC> ft. Foundation to absorption ft. % ®O Separation of Pits ft. Conforms as per Plot _ N Engineer Report and -B Y N Location of System on Property: Front Rear - Left Side Right Side Middle Fro _Middle Rear SMnUse 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