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2004-966 i TOWN OF QUEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201 . Community Development-Building & Codes (518) 761-8256 i CERTIFICATE OF COMPLIANCE Permit Number: P20040966 ' Date Issued: Tuesday, December 21, 2004 This is to certify that work requested to be done as shown by Permit Number P20040966 has been completed. Taxi Map Number: 523400-308-011-0001-032-000-0000 Location: 456 LUZERNE .Rd Owner: PATRICIA LA BELLE L.E. Applicant: PATRICIA LA BELLE L.E. 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: P20040966 Application Number: A20040966 Tax Map No: 523400-308-011-0001-032-000-0000 Permission is hereby granted to: PATRTC;TA T,A BF.T,T,F,T,.F.. For property located at: 456 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 Ordnance. Type of Construction Value Owner Address: , PATRICIA LA BELLE L.E. Septic Alteration Residential COLBY LA BELLE Total Value 456 LUZERNE Rd QUEENSBURY, NY 12804-0000 i Contractor or Builder's Name /Address - ! Electrical Inspection Agency FRED SMITH 23 VERMONT Ave OTTEENSBTTRY. NY 12804 i i: Plans&Specifications 2004-966 SEPTIC ALTERATION $25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Tuesday, December 20, 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 Tq o ueens ry; nday, December 20, 2004 i SIGNED BY for the Town of Queensbury. Director of Building K Code nforcement Application for Permit—Septic Disposal System 2)0 Town of Qtteensbuly 742 Bay Road Queensbury,NY 12804 (518) 761-8236 1. OWNER.INFORMATION: ..............................:.........:..................................................................................... 1 Q A Office Use Location of installation: r2IJ-11 '1}v�� �9 (LFile Permit No Tax Map No. / / R Owner's Name r a Il Fee Paid � Address: . "�� Alt)7 )Fd 2. INSTALLER'S NAME ; fil—V PHONE NO. 3. RESIDENCE INFORMATION: (circle year of dwelling, indicate #bedroom(s) and multiply I bedrooms with applicable gallons per bedroom to equal total daily flow) Year of House' No. of Bedrooms x Computation = Total Daily FPR 80 older x 150 aUbdnn = ��� Q�F ����Q 19 or g 4,04��S 1980— 1991 x 130 gal/bdrm = _ 6' 1991 -present x 110 gal/bdrin = o0�'QY "Garbage Grinder Installed yes / no Spa or Whirlpool Installed yes / no 4/ 4. PARCEL INFORMATION: (circle applicable information & indicate measurements) kong, raphy _ til_[9 Si.[outtd V�nt.Or. _a9sl.roGk_:or�mpotYi4l!4.�P1.Q.;tl__17ot»pstic Watgr_Supl�ly at what depth cat what de/)Ih nualthtpal oant feet feet well Steep slope clay if well; water.supply slope other from any septic-system depth: absorption is f1. 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 it licensed professional engineer or archilcct (unless installed in a Planning Board approved subdivision). Add 250 gallons to Ibe size of the septic tank and leach field for each Garbage Grinder, Spa or Whidpool Tub. Septic Tank: gallon (min. size 1,000 gal.) Tile Field: each trench (5—d fl. Total System Length: s fl. Seepage Pit(s): number of size ofeaclt: fl. by fl. Size of Stone to be used: 11 _ / alepth or!lalcktte.►s ________ _fire! 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 Quoensbury, any permit or approval granted which is based upon or is granted in roliance 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 ueensbury Sanitary Sewage Disposal Ordinance. _e q Z///ZW S gnature of responsible person Date Septic Inspection Report / Office No. (518)761-8256 Date Inspection re:r st e i id: Queensbury Building&Code Enforcement Arrive: p epart: ', C> am/pm 742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials L NAME: n P IT NO.: 1 LOCATION: , ECT ON: RECHECK: Comments and/or diagram Soil T Lr San Loam_/Clay Type of Water: auniciga Well Water Waterline separation distance Well separation distance ft. Other wells: ft. Absorption Field: Total length Length of each trench ft. Depth of trenches ft. 'Size of Stone Seepage Pits: Number Size: x Stone Size: Piping Size Type Building to tank 'U. �N , Tank to Distribution Box l Distribution Box to ield/Pit Opening Sealed: /Partial Location/Separations Foundation to tank ft. Foundation to absorption it. Separation of Pits ft. Conforms as per Plot Plan N Location of System on Property: Front Rear Left Side Right Side 1Vliddle Fro—no iddle Rear System Use Sta s• _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 Septic Inspection Report Office No. (518)761-8256 Date Inspection reques r ei Queensbury Building&Code Enforcement Arrive: p art: o ( pm 742 Bay Rd., Queensbury,NY 12804 Inspector's Initia r NAME: Q'(}1�L\C\�� C3�LLF RMIT NO.: ZO-OLA -q' (oig t-1��_ l �� \ -2 F INSPECT ON: \Z LOCATION: � RECHECK: Comments and/or diagram Soil T apj, m/Clay Type of unici al/Well Water Waterline se aration distance Well separation distance ft. Other wells: ft. � � Absorption Field: Total length ft. Length of each trench ft. Depth of trenches •z-- ft. Size of Stoner Seepage Pits: Number Size: x Stone Size: Piping Size -Type Building to tank Tank to Distribution Box wl Distribution Box to Field/Pit -17 Opening Sealed• Y/ /Partial Location/Separations Foundation to tank ft. Foundation to absorption ft.`t- Se aration of Pits ft. nn � \ Conforms as per Plot Plan Y Location of System on Property: Front Rear eft�e Right Side Cfiddle Front fiddle Rear System Use Status: Approved iartial 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 saw eviden,.e c , lects such as houses, wells, tree , Iersces, etc., shown on this docu,``��--r!t. i also reares nt that I have person-llyj 3easurdcl�fhe distances set forth on the diagram" SIGNATURE DA r= a c O c�a POCK V � � vow ED BY r RRv ZE t 18 f 4--S