2005-368 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
42 Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20050368 Date Issued: Thursday, April 06, 2006
This is to certify that work requested to be done as shown by Permit Number P20050368
has been completed.
Tax Map Number: 523400-296-017-0001-018-000-0000
Location: 25 JUNE Dr
Owner: HOWARD & CHRISTINE GREENHOLTZ
Applicant: HOWARD & CHRISTINE GREENHOLTZ
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 Enforcement
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: P20050368 Application Number: A20050368
Tax Map No: 523400-296-017-0001-018-000-0000
Permission is hereby granted to: 140WARD & CI RISTTNE CTRF,F,NHOI,TZ
For property located at: 25 JUNE Dr
in the Town of Queensbury,to constrict 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: HOWARD & CHRISTINE GREEN
25 JUNE Dr Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804-0000
Contractor or Builder's Name / Address Electrical Inspection Agency
Plans&Specifications
2005-368
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday, June 02, 2006
(if a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queenshury before the expiration date.)
Dated at the To o ueens ry,V da June 02, 2005
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
Application for Permit- Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury, NY 12804 (518) 761-8256
1. OWNER INFORMATION:
/J5 �vAic Office Use
Location of installation: !� .1 (�
File Permit No.
Tax Map No. ! /
gy o G j Fee Paid
Owner's Name: d.Atu�
j ...................................................................................................................._
Address:
2. INSTALLER'S NAME f�t' u� (�ir'e/ PHONE NO 2-— �-57
3, RESIDENCE INFORMATION: (circle year of dwelling, indicate#bedroom(s) and multiply #of
bedrooms with applicable gallons per bedroom to equal total daily flow)
Year of House: No. of Bedrooms x Computation = Total Daily Flow
1980 or older _ x 150 gal/bdrm = "
1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm = _.
Garbage Grinder Installed yes V / no v`
Spa or Hot Tub Installed yes / no
4. PARCEL INFORMATION: (circle applicable information/ d' ate measurements)
Too a h S ure Ground Water e�crfc or Impervious Material Domestic Water Supply
Flat sand at what depth at what depth municipal
Rolling fee feet well
Steep slope clay if well; water supply
slope other from any septic-system
depth: absorption is f t.
other
Percolation Test: (To be completed by licensed professional engineer or architect}
Rate: minute per inch
5. PROPOSED SYSTEM: For New Construction: All individual sewage disposal systems must be designed by a licensed
professional engineer or architect(unless installed in a Planning Board approved subdivision). Add 250 gallons to the size
of the septic tank and leach field for each Garbage Grinder,Spa or Whirlpool Tub.
Septic Tank:�`1�� gallon (min. size 1,000 gal.) -
P$^,
Tile Field: each trench ft. Total System Length:2,`,D 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: )lkx
ly
Alternative System: . length andior 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 Qjueensbury Sanitary Sewage Disposal Ordinance.
�k7
SkjAature of resp sible person bate
Town of Queensbury
Sewers and Sewage Disposal Chapter
Appendix C
ABSORPTION FIELD
SEPARATION REQUIREMENTS
r POND
mow" CA&W s
/" tiA itt+ i
Ate.
Appendix C
ABSORPTION FIELD
SEPARATION REQUIREMENTS
PO
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a Wit ,
�RlMICMGIIY Goo*
1 43D — \ZAco
Septic Inspection Report
Office No.(518)761-8256 Date Inspection est v
Queensbury Building&Code Enforcement Arrive: 'U epart: 7 a m
742 Bay Rd., Queensbury,NY 12804 Inspector s nitia :
NAME: _ R'E �\ACGL�Z RMIT NO.:
LOCATION: Z�S TI �R1�F SPECT ON:
RECHECK:
Comments and/or diagram
Soil Type: and Loam/Clay
Type of Water. Municipal Well Water
Waterline separatImMA4ce
Well separation distance ft.
Other wells. ft•
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenches ft•
Size of Stone \00
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank " �^
Tank to Distribution Box
Distribution Box ield it
Opening Sealed Y Partial
End Caps
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Engineer Report and As-Built Y N
Location of System on Property:
Front Rear Left Side Right Side
Middle Fr t Middle Rear
System Use Sta s•
Approved
Partial Approved and needs to be re-inspected, please call the Building&Codes Office
Disapproved
Last revised 1/6/05
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TOWN OF QDEEHNS ' RY > f
BUILDING &
REVIEWED B
DATE