2005-737 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFI CATE OF COMPLIANCE
Permit Number: P20050737 Date Issued: Monday, September 26, 2005
This is to certify that work requested to be done as shown by Permit Number P20050737
has been completed.
Tax Map Number: 523400-295-010-0001-03 1-00 1-0000
Location: 1085 WEST MT. Rd
Owner: GEORGE & JANE LEHMANN TRUSTEES
Applicant: GEORGE & JANE LEHMANN TRUSTEES
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
17: J W k-
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: P20050737 Application Number: A20050737
Tax flap No: 523400-295-010-0001-031-001-0000
Permission is hereby granted to: GEORGE & JANE LEHMANN TRUSTEES
For property located at: 1085 WEST MT. 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 ' compliance with the NYS Uniform Building Codes and the Queensbury Zoning
Ordinance. Type of Construction Value
Owner Address: GEORGE& JANE LEIVVIANN TR Septic Alteration Residential
1085 WEST MT. Rd Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
I.B.S. SEPTIC
2 LOWER WARREN STREET
QUEENSBURY, NY
Plans&Specifications
2005-737
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday, September 15, 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 wn of Q ens ury; hursday, September 15, 2005
SIGNED dr for the Town of Queensbury.
Director of Bud ing&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:b D
File Perniit o
Tax Map No.
Fee Pai
Owner's Name:
........................ ......
I..................
..................................... ..........
Address: J—
PHONE NO. —Cq9�6
2. INSTALLER'S NAME 7 r,- 1-�
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
y Flow
1980 or older x 150 gallbdrm =
1980- 1991 x 130 gal/bdrm = �/ j
1991 —present x 110 gallbdrm =
Garbage Grinder Installed yes no
Spa or Hot Tub Installed yes no
4.' PARCEL INFORMATION: (circle applicable information&indicate measurements)
Tdooermliv A6154we Ground Water ' Bedrock or impervious Material I ater Su oply
rFlat �sand t h i depth at w a epth municipal
m et eet
MV
clay
y if well;water supply
Steep slope clay
%slope other from any septic-system
depth: absorption is
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 gallon(min. size 1,000 gal)
Tile Field: each trench ft. Total System Length: ft.
SeepagePit(s): number of size of each: ft. by ft.
Size of 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 ofthe 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 o ueensbury Sanitary Sewage Disposal Ordinance.
Signature of responsiblfi ptrison' Date
flit) vtt of Quemilsbury
5c:+vrt'v and sewstl;c: Dixj oq..t.1 Clinvier
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7. SICN A.TURE &1 opNIATION FM FuN;s j r.,�>�����,�••..,,,..:,
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Septic Inspection Rfre
Office No.(518)761-8256 Date Inspectio :
Queensbury Building&Code Enforcement Arrive: art:742 Bay Rd.,Queensbury,NY 12804 Inspector's InNAME: �F!-� 1Qt DEE
LOCATION: gyp i�F� Bj)
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 Plan N
Engineer Report a - uilt Y N
Location of System on Property:
Front Rear Left Side Right Side
Middle Fran Middle Rear
S stem Use St 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 ei d:
Queensbury Building&Code Enforcement Arrive: m/pm a rt: - in
742 Bay Rd., Queensbury,NY 12804\ Inspector's Initi ls:
NAME: P IT NO.: �S"J '
•2
LOCATION: ECT ON: _ !El=1 - cls
RECHECK:
121e-- Comments and/or diagram
Soil T e: a oam/
Type of • Municipa ell Water
Waterline sepa s ance 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 t �-
Tank to Distribution o t�
Distribution Box d Pit z
Opening Sealed /Pwrflal
End Ca
Location/Separations
Foundation to tank xb ft.
Foundation to absorption
Separation of Pits
Conforms as per Plot P n
Engineer Report and As-Built Y N
Location of System on Property:
Front Rear Left Side Right Side
iddle Fro iddle Rear
Svstem se Status:
proved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
Last revised 1/6/05
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