2005-667 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: P20050667 Date Issued: Monday, August 22, 2005
This is to certify that work requested to be done as shown by Permit Number P20050667
has been completed.
Tax Map Number: 523400-301-018-0001-073-000-0000
Location: 33 FAWN Ln
Owner: JEFFREY & JENNIFER GOODWIN
Applicant: JEFFREY & JENNIFER GOODWIN
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: P20050667 Application Number: A20050667
Tax Xtap No: 523400-301-018-0001-073-000-0000
Permission is hereby granted to: TF,FFRFV& TFNNTFF,R C,f?OT)WTN
For property located at: 33 FAWN Ln
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: JEFFREY& JENNIFER GOODWIN
Septic Alteration Residential
33 FAWN Ln
QUEENSBURY, NY 12804 Total Value
Contractor or Builder's Name /Address Electrical Inspection Agency
Plans&Specifications
2005-667
SEPTIC ALTERATION (TANK REPLACEMENT)
$25.00 PERMIT FEE PAID -THIS PERMIT EXPIRES: Wednesday,August 23, 2006
(If a longer period is required,an application for an extension must he made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the own o uee s ury� day, August 22, 2005
SIGNED BY �q/ for the Town of Queensbury.
Director of Building&Co e Enforcement
AppMation 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: 51.A.4y�Aa+-z
File Permit Nq20a-� 7
Tax Map No.
ou
1 Fee Paid
Owner's Name:
.......................................................................................................................................
Address: Ae e
2. INSTALLER'S NAME PHONE NO. 2,5'
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 gallbdrm =
1980- 1991 x 130 gal/bdrm =
1991 —present x 110 galibdrrn =
Garbage Grinder Installed yes_ no
Spa or Hot Tub Installed yes_ no
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
Tppoaa - 1u�
phy Soil Nature Ground Water Bedrock or Impervious Material Domestic Water 3I
Flat sand at what depth at what depth municipal
Rolling loam —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: /d-0 gallon(min. size 1,000 gal)
Tile Field: each trench ft. Total System Length:
Seepage Pit(s): number of size of each: _ft. by_ft.
Size q,,f 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 of the Town of Queensbury Sanitary Sewage Disposal Ordinance.
55040
Signature of responsible person Date
' '1 ow-1% of (2ticellsbury
srwrt•a ar/tl Sc:wARI C Disposal ("Im pter
Appendix C, -
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Septic Inspection Report
Office No.(518)761-8256 Date Inspection request received: i
Queensbury Building&Code Enforcement Arrive: an/pm Depart: ILA - 7 �
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials:
NAME: )tJ0 �-\ PERMIT NO.:
LOCATION: Y��w.� INSPECT ON:
RECHECK:
Comments and/or diagram
Soil T e: aW Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft.
Well separation distance ft.
Other wells: ft.
Abso tion Field: Total length ft.
Length of each trench ft.
Depth of trenches ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping ize T e
Building to tank
Tank to Distribution Box l
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
_Engineer Report and As-Built Y N
Location of System on Property:
Front Rear Left Side Right Side
Middle Front iddle Rear
S stem 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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