2003-668 eak 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: P20030668 Date Issued: Thursday, January 29, 2004
This is to certify that work requested to be done as shown by Permit Number P20030668
has been completed.
Tax Map Number: 523400-289-010-0001-016-000-0000
Location: 24 JAY Rd
Owner: DEAN REALI
Applicant: DEAN REALI
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
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Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20030668 Application Number: A20030668
Tax Map No: 523400-289-010-0001-016-000-0000
Permission is hereby granted to: DEAN REALT
For property located at: 24 JAY 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: DEAN REALI
SUZANNE RAYESKI Septic Alteration Residential
Total Value
24 JAY Rd
LAKE GEORGE,NY 12845
Contractor or Builder's Name /Address Electrical Inspection Agency
I.R.S. SEPTIC
2 LOWER WARREN STREET
OI JEENSRI JRY.NY
Plans&Specifications
2003-668
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Saturday,August 14,2004
(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 T n of eens ry; , , August 14,2003
40,
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: (Je y ,;r
File Permit No. t 3- Co
2
Tax Map No. / /
Fee Paid as-
go
Owner's Name: /)tea o f /c1" ? /7
Address: ()� i f?c17 4?(/(
e-, fjpe ,/
2. INSTALLER'S NAME : Cac ,JCp /-("" PHONE NO. ie l S t' 0
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 150 gal/bdrm =
1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm =
Garbage Grinder Installed yes / no — l
Spa or Hot Tub Installed yes_ / no / `' -
AUG 1. 2003
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
T� J`'Y
Topography Soil Nature Ground Water Bedrock or Impervious Material l fie 'atci'Su p/7
FI > sand at what depth at what depth municipal
Rolling Cloak- 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: /ItsC7' gallon (min. size 1,000 gal)
.2 SG'
Tile Field: each trench S ft. Total System Length: '" ft. 2-W
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 ofkiwn of eisb r Sanitary Sewage Disposal Ordinance.
il , ..„.„‘.,,, 2,._,,,..S, .6" 7
Signature of res sible person Vi)
t-- Tu
PcM VI
Septic Inspection Report SZ 7/6;
Office No. (518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: c /O am/pm�_ Depart: am/pm
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials: �',ir—
NAME: - - L 1 PERMIT NO.: (Q�o
LOCATION: `'1 .J A •,( (z�'� aj INSPECT ON: Z '
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. r 2 keS
Absorption Field: Total len,th ft. ((de'Length of each trench ft. _ )
Depth of trenches ft. tort( (;8 �d.r ���
Size Stone
Seepage e Pits: Number /OD Scl'
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:
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
4.
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Septic Inspection Report
Office No. (518) 761-8256 Date Inspectio request received:
Queensbury Building&Code Enforcement Arrive: /t am/pm Depart: am/pm
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials: IV-
Y V
NAME: 'C`�,� i 1 `C1 PERMIT NO.: � _,-
LOCATION: ' CA - C,.,,,i INSPECT ON: 3
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 3'I Uz- ft. ``
Depth of trenches 3-. ft. ¢,//i .L 2 //'pi °
Size of Stone N�
Seepage Pits: Number ` �� 'f3aip
Size: x Co r
cife-
Stone Size: 44 /-Z r'
•
Piping Size Type L/ /` `lZ/
Building to tank _ i; PUL ri-tatit. �7 ui-Ci ( .
Tank to Distribution Box C/h ca.
Distribution Box Field/Pit E,Z
Opening Sealed Y N/Partial
Location/Separations � hmFoundation to tank ft. ()Air fi 4.'
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan ----Ty N
Location of System on Property:
Front Rea Left Side Right Side Ge,e_
Middle Front Middle Rear
System Use Status:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:\SueHemingwayU3uilding.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
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Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: 316 am/ Depart: am/pm
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials:
NAME: °s` -)C% ; 1 Y-\ PERMIT NO.: QJ- �Yj2
LOCATION: aL�j� INSPECT ON: 73---a(-)-C.
RECHECK:
Comments and/or diagram
Soil Type: Sand/Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft.
Well separation distance ft. c�- c+
Other wells: ft.
Absorption Field: Total lent h ft. 4 r �3 '—
Length of each trench ft. G�t cr�
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:
Approved
N 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
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Septic Inspection Report
Office No. (518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: ')'34, am/pm I ,Depart: am/pm
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials: sU
NAME: c-C:2Z2C2kX1 (3NN, C PERMIT NO.: —
LOCATION: INSPECT ON: j
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 len: h , ft.
Length of each trench ft. /I
Depth of trenches ft. 1�+v ,!V
U �
r ���Size of Stone �Seepage Pits: Number SJ
Size: x 1y--
Stone Size: P
Piping Size Typ
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:
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
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