2004-163 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development- Building &Codes (518) 761-8256
CE RTIFICATE OF7- COMPLIANCE
Permit Number. P20040163 Date Issued: Monday, April 11, 2005
This is to certify that work requested to be done as shown by Permit Number P20040163
has been completed.
Tax Map Number. 523400-301-018-0001-007-000-0000
Location: 5 AMY Ln
Owner. JEFFREY & PAMELA LAURENT
Applicant: JEFFREY & PAMELA LAURENT
This structure maybe occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
Director of Building&Code Enforcement
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20040163 Application Number: A20040163
Tax Map No: 523400-301-018-0001-007-000-0000
Permission is hereby granted to: JF.FFRF,Y&PAMFLA LAT TRENT
For property located at: 5 AM 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. Tie of Construction Value
Owner Address: JEFFREY&PAMELA LAURENT
5 AMY Ln Septic Alteration Residential
Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans&Specifications
2004-163
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Saturday,April 09, 2005
(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 Q ensb 109, 2004
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
Application for Permit--Septic Disposal System a too - �0'7,V/
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
Office Use
Location of installation: , "L^o{ �_1 f.�
Q� ` 3 s
Tax Map No. / / j_ 73 ; File Permit No.
r Fee Paid
Owner's Name: ,6-9 Zt,urx- )t
Address: A)
2. INSTALLER'S NAME :�'' �-`� �x e�'Dy'���'`� 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 72 x 150 gallbdrm =
1980- 1991 x 130 gal/bdrm = q p
ED
1991 -present x 110 gal/bdrm = C �9
Garbage Grinder Installed yes_ / no p p R 0 7 20 0 4
Spa or Hot Tub Installed yes_ ./ no
OF
OWN
4: PARCEL INFORMATION: (circle applicable information&indicate measurements)
UILDIi�G
T BOr��9D CODEY
Topography Soil Nature Ground Water Bedrock or Impervious Material Domestic Water Simlly
Flat at what depth at what depth municipal
g oam feet feet we
Steep slope clay i 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: gallon (min. size 1,000 gal)
Tile Field: each trench ft. Total System Length: -2—C)Q f1.
Seepage Pit(s): number of �-~ size of each: 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 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.
gnatur f responsible person ate
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Septic Inspection Report
Office No. (518)761-8256 Date Ins ectiqwre est r ce' d:
Queensbury Building& Code Enforcement Arrive: m/p e '.� am/pm
742 Bay Rd., Queensbury,NY 1.2804 Inspector's Initia
NAME: � j{ P IT NO.: �/
LOCATION: _ ECT ON: r 9
RECHECK: -
Comments and/or diagram
Soil Type( Sand oam/C14y
Type of Municipal/ ell Water �`-
Waterline separation distance ft.
Well separation distance �p ft. 1
1 '
Other.wells: ft. +
Absorption Field: Total length p ft. _
Length of each trench t7ft.
Depth of trenches4Lft.
Size of Stone
Seepage Pits: Number `
Size: x .b
Stone Size:
Piping Size Type J `
Building to tank �\
Tank to Distribution Box �'` " L I ��
Distribution Box field/Pit %) a�F�
Opening Sealed: Y /Partial
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Y
Location of System on Property:
Front Rear Left Side Right Side
Middle Front iddle Rear
_System Use Status: 1�
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:\SueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
RECEIVED
APR 0 7 2004
April 5, 2004 TOWN OF QUEENSBURY
BUILDING AND CODE
Mr. Jeff Laurent
5 Amy Lane
Queensbury, NY 12804
Mr. Laurent:
This is in regard to your request for a permit for a new septic system
at 5 Amy Lane. I can comfirm that the well on my property at 3 Amy Lane
is, indeed, in the front yard 'of said property. Since you did not state as
to the position of your projected new septic system, I cannot accurately
make any judgements as to whether it meets the distance standards in effect.
As I understand it, a septic system must be no less than 100 feet from a
well. If your projected septic system meets that standard then I believe
our well will not be detrimentally affected.
I hope this provides the information you requested.
1�
Harry Goldma
3 Amy Lane
Queensbury, NY 12804
March 7,2004 RECEIVED
Property owner&location: George&Linda Thompson
7 Amy Lane A PR U 7 2004
Queensbury,NY 12804 TOWN OF �-r
�UEENSBURY
BUIC�iJU�pE
Dear Building and Codes Division:
Please accept this affidavit as proof that my well is located in the front of my house, on
my property located above.
ASincly, mpso
® /mot F
wC CJ�a�r Six
a
10 0=0�
ry
/A
have e n or bserred, or believe I saw evidence of,
ca al obit such s ho ses, wells, trees, fences, etc.,
�o !� st ownon this d .cum nt. I also re®resent that I have
R ,
p rsO ally meas -red he distances set forth on the diagram."
G�1•
A URE DATE
J
I0,fi' _ b` T01iAY"N Gar QUE-EN0% URY
BUILDING 5 PT.
A REVIEWED BY
DATE
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