2004-967 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building &Codes (518) 761-8256
CE RT I F I CAT E OF COMPLIANCE
Pemit Number. P20040967 Date Issued: Monday, December 11, 2006
This is to certify that work requested to be done as shown by Permit Number P20040967
has been completed.
Tax Map Number. 523400-301-013-0001-004-001-0000
Location: 573 WEST MT. Rd
Owner. MICHAEL & SHAREEFAH DRAHOS
Applicant: MELANIE SCHWAB
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&Co Enfo ement
Planning Board or Zoning Board of Appeals.
Application for Permit®Septic Disposes System
Town of Queensbury 742 Bay Road Queensbury,M' 12804 (518) 761-8256
1. OWNER WORMATION: .............................................................................................................
Location of installation: 7 e®1 11 �I � Office Use
J 194
_ File Permit No.oq--
Tax Map No. ,W j r as
Owner's Name:
Fee Paid
� .`f1� _ �x�` ..... ...............................-.,,...,,..,.,,,.-..,,,,......,,.................................,..............
Address:
2. INSTALLER'S NAME o,� G�MQ �c, PHONE NO. 6I;,�3l�
3. RESIDENCE INFORMATION: (circle year of dwelling,indicate#bedroo3 s) and multiply#of
bedrooms with applicable gallons per bedroom to equal total daily flow)
-Year of&use: No Bedr orn - -3:otal DLIy Flow
1980 or older' x 150 gal/bdrm =
1980—1991 x 130 gal/bdrm -
1991-present x 110 gallbdrm =
Garbage Grinder Installed yes,+ / no �~ l
Spa or Hot Tub Installed yes- 1 no
4: PARCEL INFORMATION: (circle applicable information&indicate measurements)
I-moxaphy 7 Sol Nat me. Ground a hedr-ock-or LmPervious Material D-omestig Water S 1
Flat sand at what depth at what depth municipal
Rolling loam feet feet well
Steep slope clay if well-,water supply
4 slope other from any septic-system
depth: absorption is
p ._..,q,ft.
other
Percolation Test: (To be completed by licensed professional engineer or architect)
Rate: minute per inch
S. PROPOSED SYSTEM: For Dtew 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: f-15 a gallon(min.size 1,000 gal)
Tile Field: each trench fl, Total System Length:
Seepage Pit(s): number of _ size of each: ft. by
Size/Qf Stone to be used: # / depth or thickness felt °
Bed system size: `I x ��' r0jV OF�C 2004
Alternative System: length attd/or size e�ll0�G�UFAA
F�IS
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.
Signature of responsible person Date
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TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20040967 Application Number: A20040967
Tax Map No: 523400-301-013-0001-004-001-0000
Permission is hereby granted to: WT,ANTF, SCHWAB
For property located at: 573 WEST MT. 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: MELANIE SCHWAB
175 BROAD St Suite 301 Septic Alteration Residential
Total Value
GLENS FALLS,NY 12801
Contractor or Builder's Name /Address Electrical Inspection Agency
Plans&Specifications
2004-967'
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 T Queen /Ztda December 20, 2004
SIGNED BY for the Town of Queensbury.
�.'
Director of Building&Code Enforcement
Septic Inspection Report
Office No. (518)761-8256 Date Inspection r ue t recei e
Queensbury Building&Code Enforcement Arrive: am/ m Depart:
742 Bay Rd., Queensbury NY 12804 Inspector' Initial -
i
NAME: - A P IT NO..
LOCATION:s SPECT ON: L
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.
Depth of trenches ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank Q,11 h
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 f.
Conforms as per Plot Plan Y N
6t5v kc i p\'
Location of System on Property: - ���Z
Front Rear Left Side Right Side
Middle Front Middle Rear
System Use Status:
Zi
provedrtial Approved and needs to be�e-inspected,please call theBuilding&Codes Office
sapproved
L:\SueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
Septic Inspection Report ` --�
Office N - /�e o. (518}761 8256 Date Inspection req��r ei ed:
Queensbury Building&Code Enforcement Arrive: m epart: .1 _
742 Bay Rd., Queensbury,NY 12804 Ins ,ctoT's fiiitia
NAME: U� P RMIT NO.:
LOCATION. - ASPECT ON: —
RECHECK:
Comments and/or diagram
Soil Type: an - 3rI -C
T e of r� Munici a Well Water----
Waterline se aration distance ft.
Well separation distance ft.
7+�iN+'GiJ�
Other wells: ft.
Absorption Field: Total lengt1i
Length of each trench ft. �`��� �� x 6 z'\
Depth of trenches
Size of Stone _
.-Seepage Pits: Number
Size: x �� \A,p1
Stone Size: l
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 Foundation to absorption ft. _LTT
\z_t1_\� zl v__
Separation of Pits
Conforms as per Plot Plan Y
Location of System on Property:
Fro t ea eft Side ght Side
Middle Front Middle Rear
System Use Status:
proved
artial 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 r ue rec
Queensbury Building&Code Enforcement Arrive: am/ m 1�part: amlp'm
742 Bay Rd., Queensbury,NY 12804 Inspector's Initi s.
NAME: Ou;A P IT NO.:
LOCATION: yT�M Uti �_ m' RD SPECT ON: 17--?--7-n!4
RECHECK:
Comments and/or diagram
Soil T . Sand oam/Clay
_.Type o icI ell Water
Waterline se ara on Istance ft.
Well separatrorr4istance ft.
Oth wells: ft. c�
� icy 3
Abso tion ie d: Total lengtht�
ft. (��3�L�iU 4v
Len h of each trench .ft.
Depth of trenches ft. y., u u-
Size of Stone
Seep a e Pits: NumberSiz x ��, �- \ �•� `tU� c�.\is t
Stone Size:
Piping Size Type
Building to tank L-Q
Tank to Distribution Box Lx
Distribution Box to Field/Pit qL
Opening Sealed: Y/ as
Location/Separations
Foundation to tank ft.
Foundation to absorption 1-41 � _..
Separation of Pits ft.
Conforms as per Plot Plan Y
Location of System on Property: � �
Front Rear Left Side Right Side
Middle Front Middle Rear
System UsVStatus
proved
ial Approved and needs to be re-inspected,please call theBuilding&Codes Office
approved
L:\SueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Rep ort.doc January 28,2003
4
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building &Code Enforcement Arrive: am Depart: am/pm
742 Bay Rd., Queensbury, NY 12804 Inspector's Initials:
NAME: -)rakoL PERMIT NO.: 2CC41 �/ l7
LOCATION: Rit 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.
Depth of trenches ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box
Distribution Box to Field/ Pit
Opening Sealed: Y NJ Partial
End Ca
Inlet/Outlet Pipes &Baffles Y—N
Location/ Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Engineer Report and As-Built Y^N
Location of System on Property:
Front Rear Left Side Right Side
Middle Front Middle Rear
System Use S s:
Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
Last revised 021006
Last revised 1/6/05
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Town of Queensbu * Warren County * New York L.820- P. 315
Scale: 1" = 30' December 27 2000 �� ��
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LANDS O"F
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Lice s d Land Surveyor E I V E D S_ 70=43-25' E
Glens F I s & Wevertown, N.Y. �
J9N 0 8 2001 f LPF
l I,WN OF QUEENS13URY
BUILDING AND CODE p
F out
DEPT•
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DEED REFERENCE.
REVIEWED By
KARA M. DOPMAN
To
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