2005-798 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: P20050798 Date Issued: Monday, October 17, 2005
This is to certify that work requested to be done as shown by Permit Number P20050798
has been completed.
Tax Map Number: 523400-302-005-0001-040-000-0000
Location: 5 CARLTON Dr
Owner: MERWIN & DONNA MAYNE
Applicant: MERWIN & DONNA MAYNE
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
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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: P20050798 Application Number: A20050798
Tax Map No: 523400-302-005-0001-040-000-0000
Permission is hereby granted to: MERWIN& DONNA MAYNE
For property located at: 5 CARLTON 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: MERWIN& DONNA MAYNE
Septic Alteration Residential
5 CARLTON Dr
QUEENSBURY, NY 12804 Total Value
Contractor or Builder's Name /Address Electrical Inspection Agency
QUEENSBURY SEWER
NY 12804-0000
Plans&Specifications
2005-798
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Tuesday, October 17, 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 T Queen ury• da October 17, 2005
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:
CDs- 79
File Permit No.
Tax Map No.30�-6-'-77-v-- o
CX3
Fee Paid ';L's ,
Owner Name.- A o <.. .... ..............................................................................................
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Address: o r v-
' 4061
2. INSTALLER'S NAME � K PHONE NO. T--
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 =
1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdn-n =
Garbage Grinder Installed yes_ /0
Spa or Hot Tub Installed yes— /(9
4. PARCEL INFORMATION: (circle applicable information& indicate measurements)
Topography Soil Nature Ground Water Bedrock or Impervious Material Domestic Water Supply
<!!79P sapid` at what depth at what depth
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 ank: gallon (min, size 1,000 gal.)
.-t4@4Wd: each trench �U ft. Total System Length: crZ
Seepage Pit(s): number of size of each: _ft. by
Size of Stone to be used: # depth or thickness feet
Bed System Size: X
Alternative System: rit r 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 b k y 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.
Sign I u re ftesponsible person Date
Town of Queensbury
Sewers and Sewage Disposal Chapter
Appendix C
ABSORPTION FIELD
SEPARATION REQUIREMENTS
POND
CA
ROAD
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Appendix C
ABSORPTION FIELD
SEPARATION REQUIREMENTS
PQ
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Septic Inspection Report
Office No. (518)761-8256 Date Inspection re est r eiv
Queensbury Building&Code Enforcement Arrive: rn/p epart: ,�F xn m_,
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials: nl"%\
NAME: `� `n _. P IT NO.: v
LOCATION: SPECT ON:
RECHECK:
Comments and/or diagram
Soil T Sand o /Clay
Type of —unicipQ Well Water
Waterlines is ance ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length ft.
Length of each trench ft.
De th 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 n
ld 1 Pit ► t F�L- �t-�b�/
Opening Seale artial
End Caps
Location/Separations
Foundation to tank ft.
Foundation to absorption
Separation of Pits ft.
Conforms as per Plo Y
-Engineer Re o As-Built
Location of System on Property: t` U')
Front Rear Left Side Right Side
Middle Fr Middle Rear
S stem Use S tus•
v
a and ne o be -i cted, please call the Building&Codes Office
s roved
Last revised 1/6/05
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