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2005-140 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: P20050140 Date Issued: Thursday, March 24, 2005 This is to certify that work requested to be done as shown by Permit Number P20050140 has been completed. Tax Map Number: 523400-295-018-0001-025-000-0000 Location: 34 PINION PINE Ln Owner: RICHARD & DONNA ROBERTSON Applicant: RICHARD & DONNA ROBERTSON This structure may be occupied as a: By Order of Town Board Septic Alteration Residential TOWN OF QUEENSBURY 1-:: JW4 - 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 BUILDING PERMIT Permit Number: P20050140 Application Number: A20050140 Tax Atap No: 523400-295-018-0001-025-000-0000 Permission is hereby granted to: RIC'HARD & DONNA ROBERTSON For property located at: 34 PINION PINE Ln in the Town of Queensbury,to constrict 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: RICHARD &DONNA ROBERTSO 34 PINION PINE Ln Septic Alteration Residential Total Value QUEENSBURY, NY 12804 Contractor or Builder's Name / Address Electrical Inspection Agency OI TEENSBI TRY SEWER JAY SWEET Plans&Specifications 2005-140 SEPTIC ALTERATION $25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday, March 22, 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 Town of Queensbury; Tuesday, March 22, 2005 SIGNED BY 0for the Town of Queensbury. irector of Buildit Enforcement Application for Permit-Septic Disposal System Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-82S6 1. OWNER INFORMATION: :.......................................................................................................... / Office Use Location of installation: °T t/'i/fiL' ' /1 e d / File Permit No. �C) Tax Map No. Fee Paid Owner's Name': r 14 & �c Address: 0 tt 9 2. INSTALLER'S NAME : -)e PHONE NO. � 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 1_5Q.gall.bdrin = 1980— 1991 x i x130 �al/bdr�� 1991 —present x 110 gal/bdrm = Garbage Grinder Installed yes / JII Spa or Hot Tub Installed yes_ /C a 4. PARCEL INFORMATION: (circle applicable information&indicate measurements) Topography Soil Nature Ground Water Bedrock or In-pervious Material Domestic Water Supply CT7�%' an_ at what depth at what depth munici a Rolling 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 5. 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). Add 250 gallons to the size of the septic tank and leach field for each Garbage Grinder, Spa or Whirlpool Tub. Septic Tank:/ZZ,3-V _gallon (min. size 1,000 gal.) Tile Field: each trench ft. Total System Length: _ Seepage Pit(s): number of size of each: ft. by ft. Size of Stone to be used: # / depth or thickness feet G,a i Bed System Size: x Alternative System:. I Je A) 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. i g n to a of responsible erson Date 1'I owll cif 011ov-11sbu*ry • App(nulix t 11-USt1li I'VION I+I IN,I.) • �I:I'nILA'I'IW�I ItI��Z1.31Itiah]I�.I�1'I`;; ' •1 paNu 1 � �•� C • �/� .fit L<'w•1 ��•�- ,•� plr..•.f.1.-ter��. `��'�/T/y� �� • ••, I R. Sc r'l Ic ,'�•!'',�~ f 1 Ut')iit11:1jfit ( ' frt0.s••b r ' 7. Sj(:INATURB &INFORMATI�?�t Ft�Rl aa'uraausL V1,�,�,,.�.r..�;:: ; ::•:;. Septic Inspection Report Office No.(518) 761-8256 Date Inspection requ t received: , Queensbury Building&.Code Enforcement Arrive: am/-part: am/pm 742 Bay Rd.,Queensbury,NY 12804 Inspector's Initial NAME: PERMIT NO.: LOCATION: INSPECT ON: RECHECK: Comments and/or diagram Soil T : Sa oa Type of Water Municipal/ ell Water Waterline separafieff4istTnke ft. Well separation distance ft. Other wells: ft. Absorption Field: Total length L ft. Length of each trench ft. Depth of trenches 2ft• Size of Stone Seepage Pits: Number Size: x Stone Size: Piping Si e T e Building to tank / Tank to Distribution Box Distribution Box to Field/Pit 1� K Opening Sealed: Y/N/Partial End Caps O Location/Se arations Foundation to tank ft. 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 Statu Approved Partial Approved and needs to be re-inspected,please call the Building&Codes Office Disapproved Last revised 1/6/05 1 /It Septic Inspection Report Office No. (518) 761-8256 Date Inspection request received: Queensbury Building&Code Enforcement Arrive: am/pW�part: am/pm 742 Bay Rd., Queensbury,NY 12804 Inspector's Initials: // �� NAME: j �� PERMIT NO.: 5'/ D LOCATION: INSPECT ON: - 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 c �b Building to tank Tank to Distribution Box Distribution Box to Field/Pit Opening Sealed: Y/N/Partial End Caps Location/Separations Foundation to tank ft. Foundation to absorption ft. Separation of Pits ft. Conforms as per Plot Plan Y N En ineer Report and As-Built Y N Location of System on Property: Front Rear Left Side Right Side Middle Fro Middle Rear System Use Statu Approved Partial Approved and needs to be re-inspected,please call the Building&Codes Office Disapproved Last revised 1/6/05 � , . � , - Nj ------� -_ --_ _-_ BUILDING-REVIEWED �Y DATE \ / U � / '---------- -- J-�