2003-784 TOWN'OF QU,EENSBURY
742 Bay Road,Queensbuty,NY 12804-5902 (518)761-820t
Community Development• �'
Building&Codes.(518)761-8256
UATE , F0� I,IANCE
CE'aD'.I'I F I
Permit Number. P20030784 Date Issued. Wednesday, September 241 2003
This is to certify that work requested to be done as shown by Permit Number P20030784'- `
has been completed.
Tax MagNumber: 523400-289-017-,000.1-016.000-0660
Location: 74 ASH Dr '
Owner: JAN ES&VALORIE POLUNCI
Applicant. JAMES&VALORIE POLUNCI
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN'OF QUEENSBURY
Director of Building&Code Enforcement
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
IF4,0
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20030784 Application Number: A20030784
Tax Map No: 523400-289-017-0001-016-000-0000
Permission is hereby granted to: JAMES & VAT,ORTF,POT ANCI
For property located at: 74 ASH Dr
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: JAMES & VALORIE POLUNCI
74 ASH Dr Septic Alteration Residential
Total Value
LAKE GEORGE, NY 12845-0000
Contractor or Builder's Name /Address Electrical Inspection Agency
CIJTTINCr EDGE GROI TP_ LLC
NY 12804-0000
Plans&Specifications
2003-784
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday, September 23, 2004
(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 of Que sbury; T esday, September 23, 2003
SIGNED BY for the Town of Queensbury.
Director of Building&Co e Enforcement
Application for Permit=Septic Disposal System
Town of QueensburyBay Q rY, ( ) 761-8256
1. OWNER INFORMATION;ueens u 742 Road ueensbu NY 12804 518 ° 77
3
Office Use '
Location of installation: )-/ "SA �rive - '
•�8`- l/ / / f t File Permit No. _1 R'
Tax MapNo. � / ,
J Fee Paid g
Owner's Name: JAie3- Po/U4e3 '000,
Address: ?- / /t'L /Jr:ie . ].
-getZ " i A) "`,
2. INSTALLER'S NAME : ' 1 (C4 e i7 j p L
L i C PHONE NO. 378`29 % /
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
iij JwFJe�v , 4ire� �»U �il/a/A�j.)
1980 or older a x 150 gdrm = 4 aae V
1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm =
Garbage Grinder Installed yes_ / no X
Spa or Hot Tub Installed yes / no X
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
To o aphy Soil Nature Ground Water Bedrock or Impervious Material Domestic Water Supply
lat at what depth at what depth municipal
o ing >/O feet �/� feet la"
Steep slope clay if well; water supply
_%slope other from any septic-system
depth: absorption is /6 ft.
other
Percolation Test: (To be completed by licensed professional engineer or architect)
Rate: l—< 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: % gallon(min. size 1,000 gal.)
Tile Field: each trench ft. Total System Length: ft. 6-56 D55--f GAii
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 1
Alternative System: CZ de / iee C NJ Jc y EL J�� length and/or size �n�,A� � S
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 To of Queensbury Sanitary Sewage Disposal Ordinance.
e / .,#,
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Signa ure of responsible person ate
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Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building& Code Enforcement Arrive: 332 am/gm Depart: am/pm
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials: V
CbNAME: \—1,;`(\Q l PERMIT NO.: 0 3
LOCATION: INSPECT ON:
RECHECK: r
• Comments and/or diagram
Soil Type: Sand/Loam/Clay
Type of Water: Municipal/ ell ate
Waterline separation distance ft.
Well separation distance _ 11.(0 ft.
Other wells: f j ft.
Absorption Field: Total length AS' ft.
Length of each trench /4/t- ft.
Depth of trenches i ft. w „�•�
Size of Stone
Seepage Pits: Number
Size:
Stone Size:
Piping Size T e
Building to tank yip
Tank to Distribution Box fit:
Distribution Box to _geld/Pit `/` p(L •
Opening Sealed: /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: 7�
Front Re.) Left Side Right Side
Middle Front Middle Rear
System Useus:
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