2005-298 TOWN OF QUEENSBURY
742 Bay Road,Queensburq,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20050298 Date Issued: Thursday, May 12, 2005
This is to certify that work requested to be done as shown by Permit Number P20050298
has been completed.
Tax Map Number: 523400-279-019-0001-004-000-0000
Location: 129 SUNNYSIDE EAST
Owner: ROBERT & COURTNEY SMITH
Applicant: ROBERT & COURTNEY SMITH
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
Director of Building&Code En cem
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: P20050298 Application Number: A20050298
Tax Map No: 523400-279-019-0001-004-000-0000
Permission is hereby granted to: ROBERT & COT 1RTNFY SMITH
For property located at: 129 SUNNYSIDE EAST
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: ROBERT & COURTNEY SMITH
129 SUNNYSIDE EAST Septic Alteration Residential
Total Value
QUEENSBURY,NY 12804-0000
Contractor or Builder's Name /Address Electrical Inspection Agency
Plans&Specifications
2005-298
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID -THIS PERMIT EXPIRES: Thursday, May 11, 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 e To ofpr%
esday, May 11, 2005
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:
...................................... ........................... ........................................................
Office Use
Location of installation:
File Permit No. .,24q
Tax Map No. J/q
Fee Pai d $c�57 CRC
Owner's Name: 5L)12 co u rwv r)"
..............................................................I.............................................. ............
Address: VC1 5urtrO 51d-t-
2. INSTALLER'S NAME PHONE No. 776-5JU
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 PtS x 150 gal/bdrm =
1980- 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm = CEIVFD
Garbage Grinder Installed yes_ no 1
Spa or Hot Tub Installed yes no MAY`
TOWN OF QUEENSBORY
4. PARCEL INFORMATION: (circle applicable information&indicate measurements) -BUILDING AND COPE_
Too graphy Soil Nature Ground Water Bedrock or impervious Material Domestic Water SW ply
CEat) sane d t at what depth at what depth municipal
Rolling 0a feet noil feet Cwe�11-
Steep slope clay if well; water supply
%slo pe other - from any septic-system
depth: o absorption is IbQfft.
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.
te--><.I -- - 1
(min. sine 1,000 gal.)
Septic Tank: ga111Cnx(f->
Tile Field: each trench SZ�>ft. Total System Length: 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 Qu ens ury
Sanitary Sewage Disposal Ordinance.
Signature of sponsi a person Date
.,I owll of Oue-ellsbui•y
App(m(lix Cl
A11.80MI''1ION VNE'Ll)
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7. SICrNATURB &INFORMATIO14 FOIL-M'l'VM ;lOLr.rrw"wL`I
Septic Inspection Report
Office No.(518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: a D art: pm
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initial
NAME: PERMIT NO.: co
LOCATION: INSPECT ON: Z
RECHECK:
Comments and/or diagram
Soil Type: Sand/Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft1Db�
Well separation distance ft.
Other wells: ft. O (�
Absorption Field: Total length ft.
Len h of each trench ft•
Depth of trenches ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type-
Building Type —
Building to tank
Tank to Distribution Box
Distribution Box to Field 7-Pit
2pening Sealed: Y/N/Partial
Location/Separations
Foundation to tank fi•
Foundation to absorption ft.
S aration of Pits ft.
Conforms as per Plot Plan Y N
Location of System on Property,
Front Rear Left Side Right Side
Middle Fron Middle Rear
System Use Stat
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:1SueHemingway\Building.Codes.Inspection.FORMS1Septic Inspection Report.doc January 28,2003
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3o ,/�
Septic Inspection Report U
Office No.(518)761-8256 Date Inspection request received: 57
Queensbury Building&Code Enforcement Arrive: am/ Depart: pm
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials;;
NAME: _ �� .. _ PERMIT NO.:
1
LOCATION: l> INSPECT ON: r'
RECHECK:
Comments and/or diagram
Soil T Sand/Lo /C
Type of Wa er: unicipal ell Wat
Waterline separation distance ft.
Well separation distance ft.
Other wells. ft.
Absorption Field: Total length ft.
Len h of each trench ft.
th of trenches ft.
Size of Stone (�
Seepage Pits: Number
Size: x
Stone Size:
piping Size Type
Building to tank
Tank to Distribution Box f' 5Z b
Distribution Box to Field/Pit
Opening Sealed: Y/N/Partial
End Caps
Location/Separations
Foundation to tank
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Engineer Report and As-Built Y N /o4e.(—
Location of System on Property: `�4� ,1dA)
Front Rear Left Side fight Side /7
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
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/ part 4��m/pm
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials: c
NAME: N "�� PERMIT NO.:
LOCATION: INSPECT ON: C
RECHECK.
Comments and/or diagram
Soil Type: Sand/Loam/Clay
Type of Water: Municipal/Well Water /
Waterline separation distance ft. Clql< �
Well separation distance ft. ✓✓l "
Other wells: ft.
Absorption Field: Total length ft. C�V G�
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
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 Middle Rear
System Use Status-
proved
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