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2005-206 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: P20050206 Date Issued: Friday, April 15, 2005 This is to certify that work requested to be done as shown by Permit Number P20050206 has been completed. Tax Map Number: 523400-302-017-0001-046-000-0000 Location: 38 WINTERGREEN Rd Owner: MICHAEL & CHRISTINE GRAVES Applicant: MICHAEL & CHRISTINE GRAVES 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 r 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 En 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: P20050206 Application Number. A20050206 Tax Map No: 523400-302-017-0001-046-000-0000 Permission is hereby granted to: MIC'HAF,I, & C'HRISTINF GRAVFS For property located at: 38 WINTERGREEN 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: MICHAEL & CHRISTINE GRAVES Septic Alteration Residential 38 WINTERGREEN Rd Total value QUEENSBURY,NY 12804 Contractor or Builder's Name/Address Electrical Inspection Agency SIGNORF,I,I.I_ ANTHONY Plans &Specifications 2005-206 SEPTIC ALTERATION $25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Friday,April 14, 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 Quee�bu ; T rsday,April 14, 2005 SIGNED BY for the Town of Queensbury. Director of Buildin &CA Enforcement Application for Permit=-Septic Disposal System Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) �61-8256 1. OWNER INFORMATION: .................................................................. .................. }... Office Use Location of installation: G File Pe 't N �' Tax Map No. 1� ; Fee Paid Owner's Name: f� c,,4�/�' ....................... ........................................_...._......................... Address: 3 ✓f�f �'�' <�✓' 2. INSTALLER'S NAME 0 -� cb�'�• L PHONE NO. f `l 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 IDaily Flow 1980 or older ate_ _ x 150 gaVbdrm = 1980— 1991 x 130 gal/bdrm = 1991 —present x 110 gal/bdrm = ` Garbage Grinder Installed yes_ / no Spa or Hot Tub Installed yes_ / no 1 4. PARCEL INFORMATION: (circle applicable information&indicate meaitexn�nts) Tong2raphy SggNature Ground Water Bedrock or impervious Material D ater Su 1 (—Plat and'' at what depth at what depth munici o ling loam feet feet well Steep slope clay if well; water supply �%slope other from any septic-system depth: I 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. I Septic Tank: gallon (min. size 1,000 gal.) I Tile Field: each trench ft. Total System Length: ft. Seepage Pit(s): number of size of each. _ft. b �_ft. Size of Stone to be used: # / depth or thickness feet! Bed System Size: x Alternative System: r %�� E' 'f 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 13629 ofjthe Code of the Town of Queensbury, any permit or approval granted which is based upo}}�i 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. signpiure o esponsibie person date M ' ' •�•gtV11 pt ��t1t;N11R1)tlt-Y c, Sr•.�vrlw atltl Sewilge Disposal Chapter Itz)j)ondix C. ` SP;I'/1itA'CION I NM POND l`�ELL IN 11A1A'tt• .i )LISi • •tuts t'.ItSt•IC; r.......,.� .. +•- . r� 1bvaE a �f� ' , �,�>'�'' Its.>t G . E ' .� / .�' . — tray �•.� Rohn • Z l .� I ., ,� 11�1 tY. t y 7. SlrTN ATURE &WORN TION FM rVN;sx i r.rw%wvL. \yaws.-••.••�, i J- ! i Septic Inspection Report Office No. (518)761-8256 Date Inspection request received: " Queensbury Building& Code Enforcement Arrive: am/p apart: am/pm 742 Bay Rd., Queensbury,NY 12804 Inspector's Initials: 1 �'! NAME: C.17 PERMIT NO.. le' LOCATION: o, (,k,)l is 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. O� �,�� Other wells: ft. F Absorption Field: Total length ft. Length of each trench ft. Depth of trenches Size of Stone ..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/Partial Location/Separations Foundation to tank ft. Foundation to absorption ft. Separation of Pits ft. Conforms as_per Plot Plan Y N Location of System on Property: Front Rear Left Side Right Side Middle Front dle Rear System Use Stat Approved Partial Approved and needs to be re-inspected,please call the Building&Codes Office Disapproved L:SueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003 /0—// Septic Inspection Report Office No. (518)761-8256 Date Inspection request received: _ l Queensbury Building&Code Enforcement Arrive: am/pm epart: p 742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials: NAME: PERMIT NO.: LOCATION: INSPECT ON: �_- RECHECK: Comments and/or diagram Soil TyWSan lay T e of er: unicipal Well Water IIA' Per Waterline sep nce Well separation distance ft. Other wells: $, Absorption Field: Total length ft. Length of each trench $. Depth of trenches ft. Size of Stone L� Seepage Pits: Number Size: x Stone Size: piping S' e Type Building to tank y() Tank to Distribution Box Distribution Box to Field/_Pit it Opening Sealed: Y/N/Partial End Caps Location/Separations Foundation to tank /f-ft. Foundation to absorption Separation of Pits zft . Conforms as per Plot Plan N Engineer Report and As-Built Y N Location of System n Property: Front e Left Side Right Side Middle Front Middle Rear System Use Status: pproved Partial Approved and needs to be re-inspected,please call the Building& Codes Office Disapproved Last revised 1/6/05 ti tF sg 1v9 C o's, e nres set forth on the diagram." D T Qb DIVO 3(COI) AF9 03M-:91A�364 ONimins ul _3