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2005-425
4E 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: P20050425 Date Issued: Wednesday, June 22, 2005 This is to certify that work requested to be done as shown by Permit Number P20050425 has been completed. Tax Map Number: 523400-295-019-0001-030-000-0000 Location: 12 PINEWOOD Ave Owner: FLORENCE SIMMONS LE Applicant: FLORENCE SIMMONS LE 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: P20050425 Application Number: A20050425 Tax Map No: 523400-295-019-0001-030-000-0000 Permission is hereby granted to: FLORFNC'F, SIMMONS LF, For property located at: 12 PINEWOOD Ave 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: FLORENCE SIMMONS LE KATHRYN SIMMONS Septic Alteration Residential Total Value 12 PINEWOOD Ave QUEENSBURY, NY 12804 Contractor or Builder's Name /Address Electrical Inspection Agency SANITARY SEWER DAN DRELLOS PO BOX 224 GLENS FALLS NY Plans&Specifications 2005-425 SEPTIC ALTERATION $25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Saturday, June 17, 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 70 wn o uee s u> , une 17, 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: , GL f/Ajt cw a 7 A-ut �/ File Permit No. a o ` 6 Tax Map No. Owner's Name: �(A f1 �� CC Ji AI �s + Fee Paid �5- U ....................................................................................................................................... Address:}-- J.N ta.., 2. INSTALLER'S NAME : i ; .A- PHONE NO.7 92 7,75-7 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 TV 130 gal/bdrm = E I V E 1991 -present x 1/10 gal/bdrrn = Garbage Grinder Installed yes / no,/ JUN l 3 2005 Spa or Hot Tub Installed yes_ / no TOWN OF QUEENSBURY ZONING OFFICE 4. PARCEL INFORMATION: (circle applicable information&indicate measurements) T%Rff,Rphy S e Ground Water Bedrock or Impervious Material ater Su 1 z*'F_1aL,1 san at what depth at what depth o ing loam feet feet we 1 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. ©VO Fxf J—J—I J Septic Tank: gallon(min. size 1,UOO gal.) Tile Field: each trench ft. Total System Length: ft. Seepage Pit(s): number of +� /�" size of each: ft. by ft. Size of Stone to be used: #_1_ / depth or thickness feet Bed System Size: /J It x Alternative System: length andlor size ! e A-1 f 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. Ab4 nature of r'espoKsible person I Date "I'mil of 5rwt:t•�t and Sowilge Disvosal t 011:1 Wel. App(ituli x t: " . c A-B. +t)Ii•IITION I1rI1a1.11.) Z P(0)ND 1^/Eft. tN /l�►11�'ft• r rf t<'iv! G . 5 cf,tic. i f. .1 •, • ,Atfy. • �'��tTRf'�1�S 7. SIGNATURE &WORMATION FOR-MSl'V bwLz arzr%izo"j,. w„ "w.y.w Septic Inspection Report Office No. (518) 761-8256 Date Ins ction r ues eiv d: Queensbury Building&Code Enforcement Arrive• ' U 'a epart: am/ 742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials: NAME: t ] E IT NO.: LOCATION: �JF �—�� SPECT ON: _(� _-7 7-t�h RECHECK: Comments and/o dia r Soil T e Sand ,Clay T e of WatU31 Well Water Waterline separation distance NVAft. Well separation distance ft. Other wells: ft. -Absorption Field: Total length ft. -Length of each trench ft. Depth of trenches ft. Size of Stone -Seepage Pits: Number Size: x Stone Size: -PipingSize Type Buildin to tank Tank to Distribution Box Distribution Box to Field/Pit enin Seale N/ ial �) Location/Separations Foundation to tank Foundation to abso tion ft. -Separation of Pits Z ft. Conforms as per Plot Plan Y N Location of System on Property: Fr 't :Rej:Let Si<Ri ht Sid Middle Front Middle Rear System Use State.: _Approved Partial Approved and needs to be re-inspected,please call the Building&Codes Office Disapproved L:\,SueHemingwaylSuilding.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003 C C;) fill F-- 0 0 C C-7 /0 3011-40 ONINOZ ,kan8SN33no30 NMOJ- Nnr Ic IC C13AI3038 - ;un V , 1 f n n, nn fl' I o1clument, I also represent that I hive n 0 k sured the distances set foH on the &gram SIGNATURE ' DATE 1314 DECEIVED JNN 1 3 2005 TOWN OF QUEENSBURY �h ZONING OFFICE 2 0� P r Q 10 d' J y Lr J 1 Yj t! •` � ji r r� c a