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2004-846 1 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: P20040846 Date Issued: Thursday, October 28, 2004 This is to certify that work requested to be done as shown by Permit Number P20040846 has been completed. Tax Map Number: 523400-308-011-0001-046-000-0000 Location: 355' LUZERNE Rd Owner: KENYA LASHWAY Applicant: KENYA LASHWAY This structure may be occupied as a: Septic Alteration Residential By Order of Town Board TOWN OF QUEENSBURY Issuance of this Certificate of Compliance DOES NOT relieve the property owner of the responsibility for compliance with Site Plan, Variance, or other issues and conditions as a result of approvals by the Director of Building&Code Enforcement Planning Board or Zoning Board of-Appeals. .TOWN OF QUEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201 Community Development Building&Codes (518) 761-8256 BUILDING PERMIT Permit Number: P20040846 Application Number: A20040846 Tax Map No: 523400-308-011-0001-046-000-0000 Permission is hereby granted to: KENYA LASHWAY For property located at: 355 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. Tyne of Construction Value Owner Address: KENYA LASHWAY 3 5 5 LUZERNE Rd Septic Alteration Residential Total Value QUEENSBURY,NY 12804-0000 Contractor or Builder's Name /Address Electrical Inspection Agency OITEENSBITRY SEWER JAY SWEET Plans&Specifications 2004-846 Residential Septic Alteration $25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday, October 27, 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 Qu 'sb W die a ctober 27, 2004 SIGNED BY for the Town of Queensbury. Director of Building&Code Enforcement Application for Permit=Septic Disposal System /mil Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256 1. OWNER INFORMATION: Location of installation: �` C�2e_,2,u / Office Use Tax Map No. 3(' / Cp File Permit No. t`n / Fee Paid Owner's Name: C � G ......................................................................................................................................: Address:'5.,f Z-1., Z .`y 2. INSTALLER'S NAME : �L C.w,� PHONE NO. !2d -7,10-�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 House: No. of Bedrooms x Commutation Total Daily Flow 1980 or older x 150 gal/bdrm = � 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) To a h ture Ground Water Bedrock or Im ervious Material . Do ater Su 1 lat and at what depth at what depth < muni ' o ing oam feet feet wel 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: /�V 0 gallon (min. size 1,000 gal.) Tile Field: each trench g 3 ft. Total System Length: Seepage Pit(s): number of 74 size of each: ft. by AEC i VE LD Size of Stone to be used: # depth or thickness feetOCT 2 6 2004 i Bed System Size: x T0VV1,1 O � : ;=Ci•lSSUPY 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 requirement e Town of Qu bury Sanitary Sewage Disposal Ordinance. L 0 - o i nature of resp6 6sible person Uake °I"oW11 of (11 loci SI)tli-y Sr.�vc:1•:1 soul 5c:ws1j'.c I)isjmsal (:1121plel• AI)Ix nd-I x (I A-11,801t.VVION 1.1I FII.11.) SPA" 1 It11TIO N ItEMI.l I ltEh)HIM"S r `e -.n) PgtUn • ,-77 v �, �- j c•�av AWWAP110,1 7• SIC�NA►Ttw &INFORMATION P09U..SYViOMLZC rr,^.vL'4 W4904....w. %v: 4_ Septic Inspection Report Office No. (518) 761-8256 Date Inspection request received: Queensbury Building&Code Enforcement Arrive: a Depart: am/pm 742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials: NAME: PERMIT NO.: 260 - !J b LOCATION: _ INSPECT ON: 10--/A;00 RECHECK: Comments and/or diagram Soil Type: Sad am Clay Type of Wa er: unici 1/Well Water Waterline se ara 'on dis nce ft. Well separation diKan96ft. Other wells: ft. Absorption Field: Total length ft. Length of each trench ft. Depth of trenches 09 ft. Size of Stone Nl / -Seepage Pits: Xurnber Size: x Stone Size: Piping S i,4e T e Building to tank .J Tank to Distributio Box of i2 Distribution Box tp Neld/Pit r << Opening Sealed: / /Partial Location/Separations Foundation to tank ft. Foundation to absorption ft. Separation of Pits ft. Conforms as per Plot Plan Y N Location of Syste on Property: Front Re Left Side Right Side Middle Front fiddle Rear System Use Stat 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 PT REVIEWED M � ���.r �; � o LATE o Idoo Q 1© RECEIVED OCT 2 6 2004 1 have seen or observed, or believe 1 saw evidence of, all objects such as houses, wells,trees,fences, etc., MAN OF.QUE P�SBURY sho Ism on this document. I also represent that I have s 3=1`' �C personally measured the distan s set forth on the<�—\--, diagram: /° —It' ,o SIGNATURE DATE