2007-209TOWN OF QUEENSBURY
742 Bay Road, Queensbury, NY 12804-5902 (518) 761-8201
Community Development -Building & Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20070209
Application Number. A20070209
Tax Map No: 523400-288-008-0001-025-000-0000
Permission is herebygranted to: ANDRZEJ BENGSZ
For progeny located at: 73 STATE ROUTE 149
in the Town of Queensbury, to consttuct or place
at the above location in accot~dance 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
Owner Address: ANDRZEJ BENGSZ
73 STATE ROUTE 149 Septic Alteration Residential
LAKE GEORGE, NY 12845 Total value
Contractor or Builders Name /Address
STONE INSTALLATIONS
4305 ROUTE 50
SARATOGA SPRINGS, NY 12866-0000
V lue
Electrical Inspection Agency
Plans & Specifications
2007-209
SEPTIC ALTERATION RESIDENTIAL
$25.00 PERMIT FEE PAID -THIS PERMIT EXPIRES: Saturday, May 17, 2008
(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 Que b Th ~ 17 2007
Y
SIGNED BY for the Town of Queensbury.
Director of Building & Code Enforcement
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~g~ ~ OFFICE USE ONLY ...................... . ~ % ...... _.... .._..~
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~ TAX MAP N0. ' bv,v ~,; '
PERMIT N0._S~~_pERMIT FEE ' ~ ~ - . ~.~..~RY
~BUILafI~V ,:i~U CODE
APPROVALS: ZONING '
TOWN CLERK ~ ,
' ~, ,
APPLICATION FOR S£PTI C DI SPO SAL SYSTEII~ PE.RMIT• "' ........... ,
A PERMIT MUST BE OBTAINED BEFORE WORK BE(iIN3. APPLICATION IS SUBJECT TO REVIEW BEFORE ISSUANCE OF A VALID
PERMIT.
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OWNER: ~ r y /b ~ ~~~1~~.,~
~ INSTALLER:
PHONE N~~~~'~.
LOCATION OF INSTALLATION: _
~.-YEAR BUILT... .........•NO...OF...
....... .....• ....... .... ... BEDROOM;
1980 or older
..».1981 •1991. ..... ..................................
..-1992 -.present . .................~...............,
PARCEL INFORMATION:
X } COMPUTATION:
150 flailon per bedroom
130 ~eallon per bedroom
110 gallon per bedroom
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ADDRESS• ,, //
PHONE NOS.~~f' ' le~
~ . i Al
^ I TOTAL DAILY FLOW
RESIDENCE INFORMATION:
QARBAQE QRINDER
INSTALLED?
SPA OR HOT TUB
INSTALLED?
/ .TOPOGRAPHY: FLAT ROLLING STEEP SLOPE %SLOPE
/ SOIL NATURE: SAND LOAM CLAY OTHER~~ J
/ T AT WHAT DEPTH?
WHAT DEPTH? BEDROCK/IMPERVIOUR MaTERIAI : AT
/ DOMESTIC WATER SUPLY: MUNICIPAL WELL '~
(IF WELL: WATER SUPPLY FROM ANY SEPTIC-SYSTEM ABSORPTION IS FT ~
/ PERCOLATION TEST: RATE IS PER MIINUTE PER INCH (TEST TO BE
COMPLETED BY A LICENSED PROFESSIONAL ENGINEER OR ARCHITECT) ;
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 slze of the septic tank and leach field for each garbage grinder, spa or whirlpool tub..
/ SEPTIC TANK:, t ~ GALLON (MIN. SIZE IS 1,000 GAL.) I 1
TT L--E F.~2: EACH TRENCH _~FT,
/ TOTAL SYSTEM L~NGTH:~_~, SEEPAGE PIT(S): HOW MANY
/ SIZE OF EACH~~ FT. X FT. '
/ IZE OF STONE TO BE I~Fn; # /DEPTH OR THICKNESS FT.
/ BED SYSTEM RvF• X
/ ALTERNATIVE SYSTEM: LENGTHANO/OR SIZE
/ HOLDING TANK SYSTEM: (If required) NO.OF TANKS: /SIZE OF EACH
/ GALLONS. /TOTAL CAPAC/TY.• GAL.
i NOTE; ALARM SYSTEM AND ASSOCIATED ELECTRICAL WORK MUST BE INSPECTED BY'lA TOWN
APPROVED ELECTRICAL INSPECTION AGENCY. PLEASE REVIEW LIST PROVIDED. '
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For your protection, please note that pursuant to Section 136-29 of the Code of the Town of Queensbury, an
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 QUESTIONS ? CALL 781.15256 OR EMAIL
Queensbury Sanitary Sewage isposal Ordinance. fides®aueens ry,,~pj
VISIT OUR WEBSITE FOR MORE• INFORMATION
Siq ture of Per ponsibie Date
Town of Queensbury • Community Development Office • 742 Bay Road, Queensbury, NY 12804
j~~ od0 1a -- I Z.. ~i ~~/ O
Septic Inspection Report
Office No. (518) 761-8256 Dade Inspection i
Queensbury Building & Code Enforcement Amve: -~=~-
742 Bay Rd., Queensbury, NY 12804 Inspecdor's Initia
NAME: z ~ 1, ~ I
LOCATION: ~/
RECHECK:
/`l ~ ~-~.
Soil T .San m C
T o W . °' Munici I Well Water
Waterii se ratbn dista ft.
Well separation distance
Oder wells: ~_ ft.
ft.
Abso tlon Field: Total len ft.
of each trench Zft.
of trenches - ft.
Size of Stone ../
See a Pits: Number
Size• x
Stone Slze:
PI in Size
Bulidi to tank
Tank to Distribution Box < <
Distribution Box t'o d Pit ~~
o i sealed: artiai
End Ca
Inl Outlet Pi & Baffles Y N
Location Se rations
Foundation to tank ft.
Foundation to abso tion ft.
Se ration of Pits ft.
Co of Pian Y
ineer Re rt a As-Built Y N
~--~--
Location of System on Property:
Front ear Left Sid Right Si
Middle Front Middle Rear
system U
Approved
Partial Approved and
Disapproved
Last revised 021006
1`~~
call
_ am~
'ON: -i-D~
~a~~- m
~~~-,6,~
~~0`7
~-~7 -S ~~ ~~~~~~
Last revised 1/6/05
Septic Inspection Report
Ofi~ce No. (518) 761-8256 Date Inspection i
Queensbury Building & Code Enforcement Arrive:
742 Bay Rd., Queensbury, NY 12804 Inspector's Initia
NAME:
LOCATION:
RECHECK:
Soil T :Sand Loam Cla
T of Water: Munici I Weil Water
Waterline se ration distance ft.
Well separation distance
Other wells: ft.
ft.
Abso n Field: Total len ft.
Le of each trench ft.
De of trenches ft.
Size of Stone
See Pits: Number
Size: x
Stone Size:
Pi in Size T
Buildi to tank
Tank to DisMbution Box
Distribution Box to Field Pit
0 nin Sealed: Y N Partial
End Ca
In Outlet Pi & Baffles Y N
Local9on Se rations
Foundation to tank ft.
Foundation to absor on ft.
Se ration of Pits ft.
Conf r Plot Ptan Y N
n ineer Re As-Built N
Location of System on Property:
Front Rear Left Side Right Side
am/pm
' ON: (~2 5-'x`7
Middle Front Middle Rear
Approved
Partial Approved and needs to be re-inspected, please call the Building & Codes Office
Disapproved
Last revised 021006
Last revised 1/6105