2005-208 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLI-A-N- CE
Permit Number: P20050208 Date Issued: Monday, April 18, 2005
This is to certify that work requested to be done as shown by Permit Number P20050208
has been completed.
Tax Map Number: 523400-301-008-0001-076-000-0000
Location: 9 HEINRICK St
Owner: ROBERT & SANDRA ORBAN JR
Applicant: ROBERT & SANDRA ORBAN JR
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, a �
Variance, or other issues and conditions as a result of approvals by the Director of Building&Code En orcement
Planning Board or Zoning Board of Appeals.
Application for Permit-Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
Office Use
Location of installation: n Q
File Permit No. `s V
Tax Map No.
Fee Paid
Owner's Name: 0�
...................................................................
Address: C / � 5
^k
2. INSTALLER'S NAME S PHONE NO. 9 3 2-Z q U
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate#bedroom(s) and multi
bedrooms with applicable gallons per bedroom to equal total d' E I V E
Year of House: No. of Bedrooms x Computation = Total Daily Flow �►r'K -, 1►05
1980 or older x 150 gal/bdrm = TOWN OF QUEENSBURY
1980— 1991 _ f x 130 gal/bdrm = 5-2o BUILDING AND CODE
1991 —present x 110 gal/bdrm =
Garbage Grinder Installed yes— / no
Spa or Hot Tub Installed yes— / no x
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
ToDoeraDhv Soil Nature Ground Water Bedrock or impervious Material Domestic Water Supply
F ga Q� at whit depth at w at depth unici a
Rolling loam N(k feet A j 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: 2l 5'a , gallon (min. size 1,000gal.)
Tile Field: eachtrenchV310 ft. Total System Length: 2 S'S 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.
Signature of responsible person Date
wil of (2tle-ellsbu,ry
Srwcm and :icwsil;c Dispo al tltlat)it•r
AI)I)(ntlN C.
A-U.40MI'd'ION, F I I;i.,i)
Sli,'P 1It11TION Itl.tZl.1�III�hll�.t�1'1`;�
ol
PQNQ
� My
.=f
/�//(f • Mir' ,� `/\4�1
,{ � �' S1:1•LtG
Z } •� l Ito
t)tlt
r r
ll%tL*.t I
P tLL%>
• r
7• SIGNATURE &INFOPMATION FoF,.MrvNti i-r-rw%o•,s• \,LVW •."..v
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20050208 Application Number: A20050208
Tax Map No: 523400-301-008-0001-076-000-0000
Permission is hereby granted to: R011F,RT & SANDRA ORBAN IR
For property located at: 9 HEINRICK St
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 & SANDRA ORBAN JR
9 HElNRICK St Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name / Address Electrical Inspection Agency
MORNING STAR SEPTIC;
Plans&Specifications
2005-208
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 T o ueens da April 14, 2005
SIGNED BY ``�-'` 1 � for the Town of Queensbury.
Director of Building&Code Enforcement
Septic Inspection Report
Office No.(518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/ �/� epart: am/ m
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials: Zrr—-''
NAME: RrD. (' PERMITNO.: ") ®SF c)
LOCATION: INSPECT ON:
RECHECK:
Comments and/or diagram
Soil Type&Sa Clay
Type of Water:QMunicipal Well Water
Waterline separat-15—n—tniance ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenches �,Z ft.
Size of Stone N D
Seepage Pits: Number
Size: x
Stone Size:
Pi in Siz9 — Type
Building to tank c Q
Tank to Distribu ' Box // 5-PR-
Distribution
B o ield/Pit u �`
Opening Seale YJ N/Partial
End Ca s
Location/Separations
Foundation to tank
Foundation to absorption
Separation of Pits ft.
Conforms as per Plot Plan N ��� 41 -6wcr-
LE4neer Report and As-Built Y N
Location of Sy ste on Property:
Front ea , Left Side Right Side
Middle Front Middle Rear
System Use Use Stat�.
Approved
Partial Approved and needs to be re-inspected, please call the Building&Codes Office
Disapproved
Last revised 1/6/05
MORNING STAR EXCAVATING, INC.
& SEPTIC SERVICE
107 Jewel Road 518-793-2290
Frank Shaw, Pres. Gansevoort, NY 12831-2154 518-695-5505
Fax#518-793-2115
Date: D
TO: - �t1 Z L 4A) We 13689
05-�-2-012)
INVOICE: Terms: Payment Due Upon Receipt of Invoice
1 1/2% Interest After 30 Days
i A
6
If
1
i
i
I
�J
h
0�
LC
r \�
-1-0
?o/ 4- o/
BUILDING O Epp',
REVIEWED BY
Q MATE
A'dn8SN33nO 40 NMOI
soot �