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2004-183 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: P20040183 Date Issued: Tuesday, April 20, 2004 This is to certify that work requested to be done as shown by Permit Number P20040183 has been completed. Tax Map Number: 523400-302-005-0001-014-000-0000 Location: 4 JUNE Dr Owner: ROBERT & SUE SMALLEY JR Applicant: ROBERT & SUE SMALLEY JR This structure may be occupied as a: By Order of Town Board Septic Alteration Residential TOWN OF QUEENSBURY Director of Building&Code Eme TOWN OF QUEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201 Community Development-Building&Codes (518) 761-8256 BUILDING PERMIT Permit Number: P20040183 Application Number: A20040183 Tax Map No: 523400-302-005-0001-014-000-0000 Permission is hereby granted to: ROBERT& SITE SMAT, RY TR For property located at: 4 JUNE 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 & SUE SMALLEY JR Septic Alteration Residential 4 JUNE Dr Total Value QUEENSBURY, NY 12804-0000 Contractor or Builder's Name/Address Electrical Inspection Agency Plans&Specifications 2004-183 SEPTIC ALTERATION $25.00 PERMIT FEE PAID-THIS PERMIT-EXPIRES: Friday,April 15, 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 To tz w Ot:5�_ApA115, 2004 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: �p � ��1 ��4� Office Use Location of installation: l ��hh 8-3 Tax Map No. / / Pile Permit No. v _l Owner's Name: �' N �1 7�t•/� /e�Lr ' Fee Paid Address: 2. INSTAI LER'S NAME :&", ymcLg J p' r-ear utcl PHONE NO.7ni d -7 4��'7 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 H f Bedrooras x cq=utation lotal FT w � �� 1980 or older J x . 150 gal/bdrm �� ED 1980— 1991 x 130 gal/bdrm 1991 —present x 110 gal/bdrm _ APR 1 4 2004 Garbage Grinder Installed yes_ / no -',-,, TOWN OF OUEENSBURY Spa or Plot Tub Installed. yes_ / no= SUILDIiNG AND CODE 4. PARCEL INFORMATION: (circle applicable information&indicate measurements) T o a c u d W Bedrock r I ervi a c Water Supply FI san at what depth at what depth < municipal Rolling oam feet wel Steep slope clay if'well;water supply �%slope other from any septic-system. depth: absorption is ft. other PcrcoIation Test:. (To be completed by licensed professional engineer or architecr) Rate: minute per inch 5. PROPOSED SYSTEM; For New Construction: All individual sewage disposal systems must be designed by a licensed professional anguieer 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 Ourbage Grinder,Spa or Whirlpool Tub. Septic Tank: 1 O0 7 gallon (min. size 1,000 gal,) Tile Field: each trench ft. Total System Lengt4- ft. Seepage Pit(s): number of size of each: ft, by ft. Size 9f Stone to be•used: # / depth or thickness feet Bed System Size: x / Alternative System: fr�!g e'T length and/or size /t5� 04 6. HOLDING TANK SYSTEM: (if required) Number of tanks: l 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 tbnt 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 require is of the Town ueensbury Sanitary Sewage Disposal Ordinance. i nature of responsible person Date T00/T00 xva cc:cT al-LL cool/To/Lo Septic Inspection Report Office No. (518) 761-8256 Date Inspection re re e' ed: Queensbury Building&Code Enforcement Arrive: am/pm ep '2A q) a pm 742 Bay Rd., Queensbuiy,NY 12804 hispector's Initia s: NAME: �'6� 1� '� P IT NO.: LOCATION: SPECT ON: RECHECK: Comments and/or diagram Soil Type: Sand/Loam/Clay Type of Water: Municipal/Well Water Waterline separation distance 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 Location/Separations Foundation to tank ft. Foundation to absorption ft. Separation of Pits ft. Conforms as per Plot Plan Y N Location of System on Property: Front Rear Left Side Right Side (� Middle Front Middle Rear System Use S tus: 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 L a �- Septic Inspection Report Office No. (518)761-8256 Date Inspectio n Queensbury Building&Code Enforcement Arrive: . Gr a m 742 Bay Rd., Queensbury,NY 1,2804 Inspector's I NAME: `)M t ,— LOCATION: 1- - � E _ RECHECK: Comments and/or diagram Soil T Sp;Sp4 Loam/Clay Type of ater: 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. , } S}ze- ier7e - -Seepage Pits: Number Size: x Stone Size: Piping Size Type Building to tank Tank to Distribution Box Distribution Box KFfield/Pit Opening Sealed Y/ artial Location/Separations Foundation to tank ft. Foundation to absorption Separation of Pits AVN Conforms as er Plot Plan Location of System on Property: Fron Rear Left Side Ri ide Middle Fro e Rear System Use Status: C��, 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 RECEIV ,_ �k APR 7 4 2004 TOWN UIL aF QUE�NSBURY � r�®r�rG ,s>rD CODE :* E; aZ 0 ` CI) `r N "I have seen or observed, or believe I saw evidence of, all objects such as houses, wells, treQs, fences, etc., shnlfirn on H,;, .11tuumCnt i aiso rerresent that I have p rsn;<��ly aSu;edted �� c � on the diagram." UIGNATURE DATE