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2004-863 P 'TOWN OF QUEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201 Community Development.-Building & Codes (518) 761-8256 CERTIFICATE-OF COMPLIANCE __ Pe niit Number _�_P20040863. : D`ate Issued ` .-; Friday, December 03, 2004 _ _ This_is ao_cerdfy.that.work requested:to.be done as shown by Permit Number P20040863 has been completed. Tax Map Number: 523400-290-005-0001-014-000-0000 - - Location: 3 WAGON Trl _ Owner: MAUREEN A BILLINGS Applicant; MAUREEN A BILLINGS 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 c 742 Bay Road,Queensbury;NY 12804-5902 (518)761-8201 Community Development-Building&Codes (518) 761-8256 BUILDING PERMIT Permit Number: P20040863 Application Number: A20040863 Tax Map No: 523400-290-005-0001-01*000-0000 Permission is hereby granted to: MAT TRFF,N A B1T,T,TNGS For property located at: 3 WAGON Trl 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. p I IType of Construction Value Owner Address: MAUREEN A BILLINGS 3 WAGON Trl Septic Alteration Residential Total Value QUEENSBURY,NY 12804 Contractor or Builder's Name /Address Electrical Inspection Agency Plans&Specifications 2004-863 SEPTIC ALTERATION $25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Saturday, October 29, 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 Toloro-f-oveens Pztober 29, 2004 SIGNED BY or the Taws�f Queensbury. Director of Building&Code Enforcement i 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: Z File Permit No. Tax MapNo /�_/ '! Fee Paid t Owner's Name:_u*_*)% x_t FRM ......................................................... ...................... Address: 3 iA�i't 'C'R R11_ 29� 1 / �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 Z x 150 gandrm = 720-l)` 1980— 1991 x 130 gandrm = 1991 —present x 110 gal/bdrm = Garbage Grinder Installed yes^ I no Spa or Hot Tub Installed yes / -no �: COVED 4. PARCEL INFORMATION: (circle applicable information&indicate measurements9CT 19 2004 �'�"�"�I To»oQranhy Soil Nature Ground Water Bedrock or Impervious Ma enal, �._Dornestic a er Supply P s-n at what depth at what depth mu ipal- Rollin feet feet wel teep 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. V_yAbn%yb Septic Tank: 10DO gallon(min. size 1,000 gal.) Tile Field: each trench ft. Total System Length: ft. Seepage Pit(s): number of size of each: ft. by r ft. Size of Stone to be used: # . / depth or thickness feet Bed System Size: x 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 requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance. t`-`Signature of responsible person _—Dote.- -- �� .'I'ow,11 of (Illoolisliui-Y 5�nvt:r;t sss:cl. 5t:wslJ;t: I)ixlsa�:t1 t:lisslsit�t• Aislsc:tulix (: • All-SORI''VION It')1'1,I.) SBA" 11tA,'i' ON llIN-11 n \� ! ) PoNp ' 't11�.1tT C!�'1►t(; •ram.., ,•- . t'PdY, Itcho ..r,. a ....��• .•+� ' r 7. SIONATLU;E &II�IFOI Z'I�J�i FQI�I YV�I 1xsLsr >✓ v�. �,a�.�......:;: `; Septic Inspection Report Office No.(518)761-8256 Date Ins ection re st rec Queensbury Building& Code Enforcement Arrive: ' " a De rt: am/ 742 Bay Rd.,Queensbury,NY 12804 Inspector's Initia s: NAME: �� \ 1`I 'S\c P IT NO.: ��— LOCATION: _ire` INSPECT ON: RECHECK: Comments and/or diagram Soil Type: Sand/Loam/Clay Type of Water: Municipal/Well Water Waterline separation distance ft. Well separation distance ft. Other wells: ft. Absorption Field: Total length ft. Length of each trench ft. De th of trenches ft. Size of Stone -Seepage Pits: Number Size: =X Stone Size: il D 1,�)ET) EV.Vbm 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 N Location of System on Property: Front Rear Left Side Right Side Middle Fr nt Middle Rear System Use St tus: NJ Approved Partial Approved and needs to be re-inspected,please call the Building&Codes Office Di8approved L:%SueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003 I� rnU.r!-,Ur W.nUmrsen I .....�. ..._.+... Appendix C Stale Environmental Quality Rev low SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I—PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT/SPONSOR 2. PROJECT NAME t dJ 3. PROJECT LOCATIO : Municipality County 4. PRECISE LOCATION(Street address and road intersecllontprominent landmarks,etc.,or pr vl a map) 5. IS PROPOSED ACTION: ❑New ❑Expansion ❑Modlllcatlon/allerallon 6. DESCRIBE PROJECT BRIEFLY: Erx tb-rt �c, x- S' r 3va0 A M t o,mUl-/► 7. AMOUNT OF LAND AFFECTED: Initially acres Ultimately c 11 acres 8. WILLYnOPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Yes ❑No It No,describe briefly 9. WHAj.1S PRESENT LAND USE IN VICINITY OF PROJECT? Residential ❑IndUSlflal ❑Commercial ❑Agriculture [],Park/Forest/Open space ❑Other Describe: 10. DOES ACTT N INVOLVE';%PERMIT APPROVAL,OR FUNDING,NOW OR ULTIMATELY FROM ANY•OTHER"GOVERNMENTAL AGENCY(FEDERAL, STATE LOCAI)? Yes ❑No If yes,list agency(s)and permitlapprovals 11. DOES ANY ASP T OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑Yes IgNo It yes;list agency name and permlUapproval 12. AS A RESULT OF ROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? ❑Yes 110 No 1 CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: Date: Signature: Ab If the action Is In the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER 1 • PAGE 5 NEIGHBOR OR TENANT RELEASE STATEMENT I, (we) do hereby relieve the Town of Queensbury from any liabilities on the plumbing and septic system located at: I, (we) realize that putting the system less than the required feet from the IL E1 LL, may increase risk of pollution. Neighbo Tenant Signature G��2ate '20 NEIGHBOR OR TENANT RELEASE STATEMENT I, (we) do hereby relieve the Town of Queensbury from an ilities on the plumbing and septic system located at: f I, (we) realize that put ' the system less than the required feet from the may increase risk of pollution. XeighborL] Tenant ❑ Signature Date NOTICE: This form may be duplicated as required for further Neighbor or Tenant Statements as required per the Town Board of Health. PA�E4,& Al L Pe B TCE c1b 2-90.5- Z� (� '00 LLJ C_ VA IVI V Pk "I have seen or observed, or bell ve I saw evidence of, all obiects such as houses, wells, tr s, fences, etc., shown on V--,is dorum.ant, 1 also represent that I have . ..... personally ineasured the dista i set for on the diagram." SIGNATU KE TE Billings September'20, 2004 6WIZP16%m m 20 30 40 Feet ro ti •i1;�''" e civ15 ey b 6 P �cim l nqp! 62 5 J. Jf 1 '40 �drr'jdr7.5.192 16�b 1`< I.PFt e deed, this 0 dnd 59 ^+s�3 Ab N � o i ote' het sSybJ lG�js/ t �� 11 � l v•,;y �llflt 4� e , 3Ae C10:10 NO K 1 a \ the ►Ea°tl oft►or o� r�',,�TEt� , _- �•„ t O.iA pCCSI c> �ta4' F co 35 Q3 pQ ES � _ SEA �6 OQ 0 , QA �j© aC'Sl ,,6 C IDE���(EC) 4. �3°p Z�AAA��s) 5E--t'�5,6 ,E5,�E 5) CP A. s i ';. As sc - I: I Lo Lp ya" m M gfl _ - G t _ C4 i y) 3) 5 F, 7 4 � 00 46 SU�at�Y S 1.DE - I SCAL,.I "- 1.30' PREPARED BY Q�ATE ITEM t r I ` VAN DUSEN McCORMACK & BRIGHT MAPPING ASSOCIATES' o GLENS FALLS, NEW ,YORK ui THIS MAP COMPILED FROM DEED DATA AND DOES NOT REPRESENT ; . A FIELD SURVEY. INTENDED FOR ASSESSMENT PURPOSES ONLY- ' r