2005-569 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: P20050569 Date Issued: Thursday, July 28, 2005
This is to certify that work requested to be done as shown by Permit Number P20050569
has been completed.
Tax Map Number: 523400-301-012-0003-057-000-0000
Location: 15 ZENAS Dr
Owner: GREGORY & GWEN HELWIG
Applicant: GREGORY & GWEN HELWIG
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 r:
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: P20050569 Application Number: A20050569
Tax Map No: 523400-301-012-0003-057-000-0000
Permission is hereby granted to: GRFG0RY& GWFN HFI,WIG
For property located at: 15 ZENAS Dr
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: GREGORY& GWEN HELWIG
15 ZENAS Dr Septic Alteration Residential
Total Value
QUEENSBURY, NY 12904
Contractor or Builder's Name / Address Electrical Inspection Agency
Plans&Specifications
2005-569
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday, July 27, 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 To of Q ensb n day, July 27, 2005
SIGNED BY for the Town of Queensbury.
r .3'
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:
-Z n CL 5 - .................. ......_...................... ......................
e Use
Location of installation: Z C A-,
File Permit No.
Tax Map No.
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; Fee Paid � . '. <<)i),5, .
Owner's Name:
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............................................4.. 4s .w.x..... x .............:
Address: v Sdl, - `
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2. INSTALLER'S NAME >. J . r " PHONE NO.
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 = �J`D
1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm =
Garbage Grinder Installed yes_ / no
Spa or Hot Tub Installed yes_ / no
4: PARCEL INFORMATION: (circle applicable information&indicate measurements) �
Xmo graDhy Soillqhae Ground Water Bedrock or Impervious Materi ter S 1
Fla sand at hat epth at w tliepth municipal
ling feet Meet
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: >, /9-0 gallon (min. size 1,000 gal.)
Tile Field: each trench fl. Total System Length: o O ft.
Seepage Pit(s): number of size of each: ft. by ft.
rSize Stone to be used: # � depth or thickness , feed,,
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 Queensbury Sanitary Sewage Disposal Ordinance.
112 4
Signature of responsible pe on Date
Septic Inspection Report
Office No. (518)761-8256 Date Inspection request received: �� 0
Queensbury Building&Code Enforcement Arrive: am/ epart: am/pm
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials:
NAME: PERMIT NO.: R
LOCATION:
INSPECT ON:
RECHECK:
Comments and/or diagram
Soil T nd la
Type of Water( Munidi /Well Water
Waterline se ara n istance ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenches ft.
Size of Stone ,, C
Seepage Pits: Number
Size: x
Stone Size:
Piping Si4e Type
Building to tank 4'
Tank to Distribution Box 'e
Distribution Box to Field/Pit
Opening Sealed: Y/N/Partial
End Caps
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
En ineer Report and As-Built Y N
Location of Sy on Property:
Front oe'arLeft Side Right Side
MiVFrontMiddle Rear
S stem Usroved
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 G?uEENSBUR'
BUILDING & 0 T.
REVIEWED B _ �✓
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