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2005-772
TOWN OF QUEENSBURY 742 Bay Road,Queensburv,NY 12804-5902 (518) 761-8201 41111. Community Development - Building & Codes (518) 761-8256 CERTIFICATE OF COMPLIANCE Permit Number: P20050772 Date Issued: Wednesday, September 28, 2005 This is to certify that work requested to be done as shown by Permit Number P20050772 has been completed. Tax Map Number: 523400-296-014-0001-008-000-0000 Location: 80 MONTRAY Rd Owner: BERNE KOUBA Applicant: BERNE KOUBA 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 Dire o tdi4 & 1 f�rcement Planning Board or Zoning Board of Appeals. TOWN OF QUEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201 Community Development-Building& Codes (518) 761-8256 BUILDING PERMIT Permit Number: P20050772 Application Number: A20050772 Tax Map No: 523400-296-014-0001-008-000-0000 Permission is hereby granted to: BERNE KIT TB For property located at: 80 MONTRAY 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: BERNE KOUBA 80 MONTRAY Rd Septic Alteration Residential Total Value QUEENSBURY, NY 12804-0000 Contractor or Builder's Name /Address Electrical Inspection Agency OI TEENSBI TRY SEWER JAY SWEET Plans&Specifications 2005-772 SEPTIC ALTERATION $25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Tuesday, September 26, 2006 (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 T ueen ry;g 1" j i • eptember 26, 2005 lJQ/ SIGNED BY ' for the Town of Queensbury. Director of Building&Code Enforcement Application for Permit— Septic Disposal System Town of Queensbury 742 Bay Road Queensbury, NY 12804 (518) 761-8256 1. OWNER INFORMATION: 0 hi 0 n Office Use 241 Location of installation: File Permit No. caOb5-- Tax Map No. / / & �g /aP., Fee Paid7 Owner's Name: -mot 4 Address: j�'y1 t/ g 2. INSTALLER'S NAME : ake.QFV he w ( Lz...t j PHONE NO7Pea73.4(6--- 3. RESIDENCE INFORMATION: (circle year of dwelling, indicate #bedroom(s) and multiply #of bedrooms with applicable gallons per bedroom to equal total daily flow) Year of House: No. of Bedrooms x Computation = Total Daily Flow 1980 or older � x 150 gal/bdrm = 4.6 1980— 1991 x 130 gal/bdrm = 1991 —present x 110 gal/bdrm = Garbage Grinder Installed yes / Spa or Hot Tub Installed yes / eir t SEP232005 4. PARCEL INFORMATION: (circle applicable information& indicate measurements) Topography Soil Nature Ground Water Bedrock or Im ervious Material Domestic Water ST1 1 1� a an� at what depth at what depth o ling loam feet feet well Steep slope clay if well; water supply _%slope other from any septic-system depth: absorption is ft. other Percolation Test: (To be completed by licensed professional engineer or architect) Rate: minute per inch CUP -Iq `'. 1 ''s g 5. PROPOSED SYSTEM: For New Construction: All individual sewage dis osal systems must be designed by a licensed professional engineer or architect(unless installed in a Planning Board approved subdivision). Add 250 gallons to the size of the septic tank and leach field for each Garbage Grinder, Spa or Whirlpool Tub. Septic Tank/ore,-0 gallon (min. size 1,000 gal.) EW , r-1-r : each trench ...S—e) ft. Total System Length: �-V -e ft. Seepage Pit(s): number of size of each: ft. by ft. Size of Stone to be used: # / depth or thickness feet Bed System Size: x Alternative System: length and/or size 6. HOLDING TANK SYSTEM: (if required) Number of tanks: / Size of each: gallons /TOTAL Capacity: gallons Note: Alarm System and associated electrical work must be inspected by a Town approved electrical inspection agency. 7. SIGNATURE & INFORMATION FOR RESPONSIBLE PERSON(please read) 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 Queensbury Sanitary Sewage Disposal Ordinance. Signatu''e o ponsible person Date Town of Queensbury Sewers and Sewage Disposal Chapter Appendix C ABSORPTION FIELD SEPARATION REQUIREMENTS SCAM -.__._.._..�._ .._ ..__ i OP Vir.i.,1.- OA WAT rak- ri\I 'New' c.4.5r«,1 l ou E G_• Qe •• • •,s 04.4C. l e.. licibr ' VP- it /r l +Y SC.pri, / w ,Az6ok.Pnot4 r I 'fit —. --,,__ Wu.D _. .... Appendix C ABSORPTION FIELD SEPARATION REQUIREMENTS PON 7," VV. 4,,.. .•,\. t WfA're...R. 'nel HI' N.Cre.)cs\\ ,..? 1 4 +5ts di Citsalktb 6ACIKCStt/4Y6�R, f 4 1 r I • TOWN OF QUEENSBURY BUILDING DER used on otir limited examination, compliance with our comments shall — 411/ not be construed as indicating the plans and specficatons are in full compliance with the Building Codes of t\s ,it York State. (--v ' :, I <....9 -- I TOVII7 , c....,1-' ,f,:.„ .E.E7 IS;.:4)r—c- Y BUILDING 81 S P1-. . REVIEWED BY . DA TF- A , , .., .. — I. i , ,'..k,-;d, or t:,liieve I saw evidence of, Sep 2 ,, , 0 ',,ICI'i AS houses, wells, trees, fences, etc., <ups i on this document. I also represent that I have , f ! .4 measured t 'steno set forth on the diagram." s GNAT RE -- DATE s - ; A i I . a 1 k 0 Ir... t...,1 e •••1 4...—........ 4--* 1 —.. , - - .5."-e, ' —..__ , 2-crei ' 77 -c___ 1 , ,... /17. -- • i Septic Inspection Report Office No. (518) 761-8256 Date Inspection r quest ' d: Queensbury Building&Code Enforcement Arrive: am/. ►epart: am/pm 742 Bay Rd., Queensbury,NY 12804 Inspector's Initi• NAME: Y�L L S� 'k� P' '4 IT NO.: �;© LOCATION: o tJTC'_iN �� :PECT ON: L — 2.9—�5 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. 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 Tank to Distribution Box Distribution Box to Field/Pit Opening Sealed: Y/N/Partial End Cape Location/Separations Foundation to tank ft. Foundation to absorption ft. Separation of Pits Conforms as per Plot Plan - - N Engineer Report an s-Bu. Y N Location of System on Property: Front Rear Left Side Right Side Middle Front Middle Rear S 'stem Use Sta s• Approved Partial Approved and needs to be re-inspected, please call the Building& Codes Office Disapproved Last revised 1/6/05 ii 4 1 . — \A ciJ ‘1- 4c3 4 SCY / _ , AS T BUIL t lt )c I ,- '' - • -1 1 0 0 'NV 1.71"4 Y i (o ' i 1 , .:...:[ ‘.)• 1;.) erved, or believe I saw evidence I idence of, 7e.cts such as houses, wells, trees, fences, etc., ;i that .:' on on this document. I also representhave ,.),---Tally measured th istances et forth on the diagram." i ) 1 -7;27' ----- I IGNATURE DATE „ , , ( 10; OAM Septic Inspection Report Office No. (518)761-8256 Date Inspection re- ec i d: Queensbury Building&.Code Enforcement Arrive: (� .�• epart: \a-SL> 742 Bay Rd., Queensbury,NY 12804 Inspector's Init NAME: Y\ fl ` RMIT NO.: 7005- LOCATION: ReT QR` Q.O fl'D INSPECT ON: 9- �7_Dz. RECHECK: Comments and/or diagram Soil Typ . San amJ Type of a e : Municipal Water u Waterline separa i istance u • ft. Well separation distance ft. Other wells: ft. Absorption Field: Total length ft. Length of each trench L oe,Fctd. ft• Depth of trenches ft. Size of Stone 101-W, Tpl2 Seepage Pits: Number Size: x Stone Size: Piping _ Size Type Building to tank '— /}4.-\ Tank to Distribution Box 9,3h Distribution Box t •id Pit I--\ " ch c3�- TD \cJ`r1 k=c Opening Seale• ,/Partial End Caps Location/Separations Foundation to tank _ _ft. `� Foundation to absorption i" ft. �� L.F Separation of Pits ft. A "�D \ Di ' Conforms as per Plot Plan, Y A Engineer Report a � �� Location of System on Pro • : \\// Z� Front Rear Left Sid- 'ight Side Middle Front Middle Rear S stem Use St,tus: 10, Approv .. Parti• Approved and needs to be re-inspected, please call the Building& Codes Office !'approved r Last revised 1/6/05