2004-845 TOWN OF QUEENSBUIRY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development- Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20040845 Date Issued: Tuesday, November 02, 2004
This is to certify that work requested to be done as shown by Permit Number P20040845
has been completed.
Tax Map Number: 523400-309-009-0002-011-000-0000
Location: 119 LUZERNE Rd
Owner: ROBERT DEYETTE
Applicant: ROBERT DEYETTE
This structure may be 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: P20040845 Application Number: A20040845
Tax Map No: 523400-309-009-0002-011-000-0000
Permission is hereby granted to: ROBERT DF,YF,TTF,
For property located at: 119 LUZERNE 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: ROBERT DEYETTE
119 LUZERNE Rd Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804-0000
Contractor or Builder's Name /Address Electrical Inspection Agency
OTJEENSBiTRY SEWER
JAY SWEET
Plans&Specifications
2004-845
1,000 gal Residential Septic Alteration
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday, November 02, 2005
(If a longer period is required,an application for an extension must be made to die code Enforcement Officer
of the Town of Queensbury before die expiration date.)
Dated at the Totivn-v ueensb ;,, Ms y,November 02, 2004
SIGNED BY C ..� ,vv � for the Town of Queensbury.
r
Director of Building& ode En orcement
/D-lam
Application for Permit..=Septic Disposal System /
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
.......................................................................................................................................
Office Use
Location of installation: L—y 2, p I,,, �i7
File Permit No.
Tax Map No.
Fee Paid 5.d
Owner's Name: 0 2
...........................................................................................................................:
Address: L v
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 x 150 gal/bdnn = '
1980— 1991 x 130 gal/bdrm =
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)
Toi3ov-raohv Soil Nature Ground Water Bedrock or Im ervious Material . Domrstic Water Su 1
lat sand at what depth at what depth al
g oam feet feet well
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: C gallon (min. size 1,000 gal.)
Tile Field: each trench ft. Total System Length: 3 -�. ft.
Seepage Pit(s): number of v size of each: ft. by ft. I� ��'fa\(ram'
Li
Size Qf Stone to be used: # A) tt / depth or thickness feet OC j 2 6 2004
Bed System Size: �f /� f-
Alternative System: length and/or size
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: 1 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
require of the Town of Qu bury Sanitary Sewage Disposal Ordinance.
CA old v
ig ature of respon able person Date
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-'!owhl of <Zticellsbu'ry
St;tivt:r:F -.111 5c:tiv;l C I>ispos:tl (:1131j)tel
' SI:P/11tA'1'1WI'd IZI�tZI•)IItI�[�Il��N'I'� '
._._, ._.. < . POND
L""S 1rl��t.. tN tr�sx•T�• .: "" .� �rt �<'r4•i .
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7. SIGN,ATURE &WORMA71ON FS�R SYv1�+9JksLC. �'��•,i� �r,oa�........:,
r.
Septic Inspection Report
Office No. (518)761-8256 Date Inspection re est r eived: t� o
Queensbury Building&Code Enforcement Arrive: am/pm' -De rt:
742 Bay Rd., Queensbury,NY 12804 Inspector's Initi Is: r
NAME: P IT NO.:
LOCATION: 1 9 ECT ON:
RECHECK:
Comments and/or diagram
Soil Type; Sand/Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft. k
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 T_ype
Building to tank I•%
Tank to Distribution Box '1
Distribution Box Kield/,Pit
Opening Sealed Y/ artial
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:
Fron Rear >LeftSide fight Side
Middle Fro t Middle Rear
System Use St us:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:wSueHemingway\Building.Codes.Inspection.FORMS1Septic Inspection Report.doc January 28,2003
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REVIEWED Y
DATE
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O oiad(
��,�����® "I have seen or observed, or believe I saw evidence of,
� all objects such as houses, wells, trees,fences, etc.,
shown on this document. I also represent that I have
.00T 2 6 2004 personally measur the distances set forth on the diagram."
TOWED OF QUEENSEU.?Y
BUILDING' A'NID CODE
SIGNATURE DATE