2002-121 TOWN OF QUEENSBURY
Fors742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20020121 Date Issued: Wednesday, February 27, 2002
This is to certify that work requested to be done as shown by Permit Number P20020121
has been completed.
Tax Map Number: 523400-289-007-0001-068-000-0000
Location: 583 MOON HILL Rd
Owner: CARLOS E BOMBARD
Applicant: CARLOS E BOMBARD
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
Director of Building& ode Enforcement
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development- Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20020121 Application Number: A20020121
Tax Map No: 523400-289-007-0001-068-000-0000
Permission is hereby granted to: CARLOS E BOMBARD
For property located at: 583 MOON HILL 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: CARLOS E BOMBARD Septic Alteration Residential
583 MOON HILL Rd Total Value
LAKE GEORGE,NY 12845
Contractor or Builder's Name/ Address Electrical Inspection Agency
OUEENSBURY SEWER
JAY SWEET
Plans & Specifications
2002-121
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID - THIS PERMIT EXPIRES: Thursday,February 27,2003
(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 Town of Queensbury; Wednesday,February 27,2002
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: --- Ai
/ Office Used 8� 13'lc 4 ~i1
Location of installation: J _J C x-- I
/ File Permit No. %4k
j
Tax Map No. `i / / 7
�'.._„e„r /
Fee Paid = ' C� p ,
Owner's Name: a ) c E'`'t' Lt a 4
Address:
2. INSTALLER'S NAME : l 11.,,„ k = PHONE NO. 79',1._.)Yer
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 0 r—=` x 150 gal/bdrm = 4A —7-)
1980—1991 x 130 gal/bdrm =
1991—present x 110 gal/bdrm =
Garbage Grinder Installed yes_ o_
Spa or Whirlpool Installed yes— Kiirc
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
Topography Soil Nature Ground Water Bedrock or Impervious Material Domestic Water Supply
at what depth at what depth murk' fpal
oiling loam feet feet we
Steep slope clay if well;water supply
_%slope other from any septic-system
depth: absorption is C, 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: /o de/ gallon (min. size 1,000 gal.)
Tile Field: each trench ft. Total System Length: ft
Seepage Pit(s): number of size of each: ft by f
Size of Stone to be used: # / depth or thickness feet
Bed System Size: / U x 2 e
Alternative System: /^ h /j 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 Queensbury Sanitary Sewage Disposal Ordinance.
221 -
pig to of responsible person Date
TOWN OF QUEENSBURY
BUILDING b CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name --Ck ' flunk III .4
Location E
E�� ��bYl � 1 '1t_.J�
Date OpPermi t # ()Ca- 0.
SOIL TYP(San j oam-Clay-
Results of Percolation Test-
(if applicable) Rate-M'nute/Inch
TYPE OF SYSTEM: r
ABSORPTION FIELD: Total ength ,rj _
Length of each trench ' ' a-)
Depth of trenches
Size of stone M1,,,_ h'1 -1.-Z-M
SEEPAGE PITS: Number- '
Size - ft. x ft.
Stone size
PIPING: /Size Type
Bldg. to Tank ` 4y•j 13(-
Tank to Dist. Box � 11 fil<2,_
Dist. Box to Field/PX't -N3C T
Openings Sealed? iligEnli No Partial51
LOCATION/SEPARATI" .
Foundation to Tank s. - feet
Foundation to Absorption . t)-feet
Separation of Pits feet
Conforms as per Plot Plan 4 Yes]No_.
LOCATION OF SYSTEM ON PROPER Y:
(circle • 4, .--
Front - Ream L- ' . - 'i •ht Si . -
Middle + - iddle Rear
COMMENTS:
wE� (a ` TC) 'LEA
F‘Et.
SYSTEM USE APPROVED: YES NO
Arrived: -
Depart L
u ing In a or