2005-809 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
(zt Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20050809 Date Issued: Friday, October 14, 2005
This is to certify that work requested to be done as shown by Permit Number P20050809
has been completed.
Tax Map Number: 523400-301-008-0001-067-000-0000
Location: 63 HELEN Dr
Owner: RICHARD & MICHELLE REYNOLDS
Applicant: RICHARD & MICHELLE REYNOLDS
This structure may be occupied as a:
Septic Alteration Residential
By Order of Town Board
TOWN OF QUEENSBURY
4
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: P20050809 Application Number: A20050809
Tax Map No: 523400-301-009-0001-067-000-0000
Permission is hereby granted to: RICHARD &MICHF,I,I,E REYNOLDS
For property located at: 63 HELEN 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: RICHARD & MICHELLE REYNOL
63 HELEN Dr Septic Alteration Residential
Total Value
QUEENSBURY,NY 12804
Contractor or Builders Name /Address Electrical Inspection Agency
I.B.S. SEPTIC
2 LOWER WARREN STREET
OI TEENSBI TRY_ NY
Plans&Specifications
2005-809
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Saturday, October 14, 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 Queensbu Fri y, October 14, 2005
SIGNED BY (7for the Town of Queensbury.
Director of Building& de E rcement
Application for Permit—Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,IVY 12804 (518) 761-8256
1. OWNER INFORMATION:
......................................................................................................................................
Location of installation: Office Use
File Permit No. C) 30�
Tax Map No.
Fee Paid
Owner's Name: C,,-;
..........................................................................................................................
Address: a 6
2. INSTALLER'S NAME 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 (it- x 150 gal/bdrni =
1980- 1991 x 130 gaVbdrm =
1991 —present x 110 gaVbdrm =
Garbage Grinder Installed yes_ no �5
Spa or Hot Tub Installed yes_ no
4.* PARCEL INFORMATION: (circle applicable information&indicate measurements)
Y9&aaDhv A M�ia e Ground Water Bedrock or LmRervious Material
D45;;iK &er Sunply
Flat sand a�,�h�e th aVta��epth municipal
m —1 4 1
Wing In eet eet
Steep slope clay if well;water supply
%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 syste;ms must be designed by a licensed
professional engineer or architect(unless installed in a Planning Board approved subdivision).
ubdivision). Add 250 gallons to the'Size
of the septic tank and leach field for each Garbage Grinder,Spa or Whirlpool Tub.
Septic Tank: gallon (min. size 1,000 gal)
•
6A1Tile Field: each trench V-7-W Total System Length: ft.
Seepage Pit(s): number of size of each: t. by_f
Size of 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.
ignaturepf req@onsible pefton Date
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Septic Inspection Report
Office No.(518)761-8256 Date Inspection re est ce' e
Queensbury Building&Code Enforcement Arrive: m/p part: pm
742 Bay Rd.,Queensbury,NY 12804 Ins ector's Initi s:
�\
NAME.: � �. � R iG��q P IT NO.:
LOCATION: F PECT ON:
RECHECK:
Comments and/or diagram
Soil T e San . Loam/Clay
Type of Water: unicipa Well Water
Waterline separdfi—mr&grameft.
Well separation distance ft.
Other wells: $,
Absorption Field: Total length ft.
Length of each trench 1150.i4vto t--)l �..�
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 t eld/Pi 14
Opening Seal artial
End Caps
Location/Separations
Foundation to tank ft.
Foundation to absorption
Separation of Pits
Conforms as per of P
En ineer R o a uilt
Location of Sys Property:Front Rear Let Side Right Side
Middle Fr G
System Use St us:
proved
a . I roved and needs to be re-inspected,please call Building&Codes Office
s roved
Last revised 1/6/05
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OCT-14-2005 03:55P FROM: TO:7454437 P.1/2
IBS SEPTIC &DRAIN SERVICE, INC.
2 LOWER WARREN STREET
QUEENSBURV,NY 12804
PHONE#: (518) 798-8194
FAX#: (518) 798-3213
FAX TRANSMISSION COVER SHEET
DATE I -/y _19
NO. OF COPIES: C' j-1
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