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2005-712 TOWN OF QUEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201 4z Community Development - Building & Codes (518) 761-8256 CERTIFICATE OF COMPLIANCE Permit Number: P20050712 Date Issued: Thursday, September 15, 2005 This is to certify that work requested to be done as shown by Permit Number P20050712 has been completed. Tax Map Number: 523400-295-019-0002-035-000-0000 Location: 12 SUNSET Dr Owner: ROBERT MEDVE Applicant: ROBERT MEDVE 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: P20050712 Application Number: A20050712 Tax Map No: 523400-295-019-0002-035-000-0000 Permission is hereby granted to: ROBERT MF,DVF, For property located at: 12 SUNSET 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: ROBERT MEDVE 12 SUNSET Dr Septic Alteration Residential Total Value QUEENSBURY, NY 12804 Contractor or Builder's Name /Address Electrical Inspection Agency SANITARY SEWER DAN DRELLOS PO BOX 224 GLENS FALLS NY Plans&Specifications 2005-712 SEPTIC ALTERATION $25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday, September 07, 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 Town of nsbury We es ay, September 07, 2005 7 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: ,�(� File Permit No`-�"K , Tax Map No. *D-5 as Fee Paid ©`- 7 Owner's Name: ..................................................................................................... _.._. Address: 2. INSTALLER'S NAME � Arl 1 V v PHONE NO. 7 P Z '72, 5 3. RESIDENCE INFORMATION: (circle yea 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 = yv D 1980— 1991 x 130 gal/bdrm = 1991 —present x 110 gal/bdrm = Garbage Grinder Installed yes_ i no a 9� Spa or Hot Tub Installed yes_ 1 no 119 / 9 4. PARCEL INFORMATION: (circle applicable information& indicate measurements) � Topggraphy Soil Nature Ground Water Bedrock or Impervious Material Water Sworly at what depth at what depth unici al Rolling feet feet we Steep slope clay if well; water supply �%slope other from any septic-system depth: absorption is fi. 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: Q0J gallon (min. size 1,000gal.) Tile Field: each trench 6 Total System Length: Seepage Pit(s): number of size of each: ft. by ft. Size of Stone to be used: # / depth or thickness �` feet Bed System Size: x S E P t1 <, L; Alternative System: length and/or size 6. HOLDING TANK SYSTEM: (if required) Number of tanks: / Size of each: gallons /TOTAL Capacity: gallons 'ti 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 Sanit Sewage Di sp sal Ordinance. i a ure of resp6dsfte person 6ate Town of Queensbury Sewers and Sewage Disposal Chapter Appendix C ABSORPTION FIELD SEPARATION REQUIREMENTS r t PoNiD .,x C.,r Appendix C ABSORPTION FIELD SEPARATION REQUIREMENTS �w W 0. WA-Mit. y COW " Talc � y Septic Inspection Report Office No.(518)761-8256 Date Inspection keque i Queensbury Building&Code Enforcement Arrive: rt: am/pm 742 Bay Rd.,Queensbury,NY 12804 Inspector's InitiNAME: ���'�� NO.: 7 LOCATION: Z D���\ SPECT ON: RECHECK: Comments and/or diagram Soil Type: Sand/Loam/Clay Type of Water: Municipal/Well Water Waterline separation distance 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 Seepage Pits: Number Size: x Stone Size: Piping Size Type Building to tank Tank to Distribution Box 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 Pla N Engineer Report an s-Built Y N Location of System on Property: Front Rear Left Side Right Side Middle Front Middle 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 Septic Inspection Report Office No. (518)761-8256 Date Inspection re est re ed: Queensbury Building&Code Enforcement Arrive: am/pm art: 742 Bay Rd., Queensbury,NY 12804 Inspector's Init o NAME: IT NO.: LOCATION: SPECT ON; RECHECK: Comments and/or diagram Soil T Sapy Type of ater: unicipal ell Water Waterline s ance Well separation distance ft. Other wells: $. Absorption Field: Total length ft. Length of each trench Depth of trenches ft. Size of Stone Seepage Pits: Number Size: x Stone Size: Piping Size Type Building to tank " "0 Tank to Distribution Box Distribution Box tw5elkl Pit -Opening Seale Y /Partial End Caps Location/Separations ` n Foundation to tank ft. C � �l Foundation to absorption ib ft. Separation of Pits ft Conforms as per Plot P Y N Engineer Report a -As-Built Y N Location of System on Property: �. Front 6e eft Side (ightSid �h Middle ont Middle Rear System Use s• Approved Partial Approved and needs to be re-inspected,please call the Building&Codes Office Disapproved Last revised 1/6/05 '��.ve seen or observed,or believe I saw evidence nof, t,,Cls such as houses,wefts,trees, fences, etc., n this document I also represent that I hnp,-- I-asured the distances set forth on the diagram." &IS1 -S 1,GNAW RE TE C CL U 01 qiw1L- 0 0 I TOWN OF QUEEN RY 7 BUILDING C D -T. REVIEWED E, - 11 DATE---