2004-283 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: P20040283 Date Issued: Friday, May 07, 2004
This-is to certify that.work-requested_to be-done as shown-by Permit Number _ P20040283
has been completed:
Tax Map Number: 523400-301-019-0001-071-000-0000
Location: �' 6 FINCH Rd
Owner: KURT & ELLEN DAUBENSCHMIDT
Applicant: KURT &ELLEN DAUBENSCBAEDT
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
1
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: P20040283 Application Number: A20040283
Tax Map No: 523400-301-019-0001-071-000-0000
Permission is hereby granted to: KT TRT&F,T,T,F,N DAT TRF.NSCHMTDT
For property located at: 6 FINCH 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 in compliance with the NYS Uniform Building Codes and the Queensbury Zoning
Ordinance. Type of Construction Value
Owner Address: KURT &ELLEN DAUBENSCBMID
6 FINCH Rd Septic Alteration Residential
Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
I.B.S. SEPTIC
2.LOWER WARREN STREET
OITEENSBTTRY_ NY
Plans&Specifications
2004-283
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday, May 06,2005
(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 atffie of Vb:. Thursday,May 06, 2004
for the Town of
SIGNED BY ` Queensbury.
r .
Y
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: ............................I...............,...............,,,..,,,...........,,,....,....,,,.,.......,,,.,......................
Office Use
Location of installation. C�j
Tax Map No.
f File Permit No. v —t—�v—�
Fee Paid e�-S
Owner's Name: 6CA (z f'11/ �G1 1.....................................................................................................................................'
Address:
2. INSTALLER'S NAME Er-/9/� t 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 Flo
1980 or older x 150 gal/bdrm =
1990—1991 x 130 gallbdrm =
1991—present x 110 gal/bdrm =
Garbage Grinder Installed yes_ / no
Spa or Hot Tub Installed yes_./ no
4.' PARCEL INFORMATION: (circle applicable information&indicate measurements)
Tt1QNa1)hv SokNature Ground Water Bedrock or Impervious Material &51tes ' ter Supply
(Fhatl san at w t epth XatAhdepth municipal
vlling am eet feet l
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 Tank: Pjallon(min. size 1,000 gal)
Tile Field: each trench ft. Total System Length: 66 f i.
Seepage Pit(s): number of size of each: ft. by ft.
Size of Stone to be used: # / depth or thickness feet
i
Bed System Size: x
Alternative System: length aced/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.
.ss`' -dooms
Signature of responsible person Date
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Septic Report
Inspection Re C �
�. P p
Office No. (518)761-8256 \�-_ Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/p part: am/pm
742 Bay Rd., Queensbury,NY 12804 hispector's Initials:
NAME: � Q PERMIT NO.: 0 Ll �
LOCATION: INSPECT ON: �_
RECHECK:
Comments and/or diasram
Soil Type:Qan lay
Type of Wate : Munici /Well Water
Waterline separafimrZ istance ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length 2 ft.
Length of each trench ft.
Depth of trenches
Size of Stone IQ
Seepage Pits: Number
Size: x
Stone Size:
Piping Si e Type
Building to tank X
Tank to Distribution Box
Distribution Box field/Pit µ H
Opening Sealed: Y/N/Partial
Location/Separations
Foundation to tank .✓ '4 ft.
Foundation to absorption Z . ft.
Separation of Pits t.
Conforms as per Plot Plan N
Location of System on Property:
Front ea Left Side Right Side
Middle Front Middle Rear
S stem Usetem Use Statt
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
"I have seen or observed, or believe I saw evidence of,
all objects such as houses, wells, trees, fences, etc.,
3oj shown on this document. I also represent that I have
personally,measured the noes set forth on'the diagram."
S,
SIGNATURE DATE
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RECEIVED
2004
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