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2003-101 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: P20030101 Date Issued: Thursday, March 27, 2003 This is to certify that work requested to be done as shown by Permit Number P20030101 has been completed. Tax Map Number: 523400-279-019-0001-02 1-000-0000 Location: 42 JENKINSVILLE Rd Owner: CLYDE & SHIRLEY SMITH Applicant: CLYDE & SHIRLEY SMITH 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: P20030101 Application Number: A20030101 Tax Map No: 523400-279-019-0001-021-000-0000 Permission is hereby granted to: CLYDE& SHIRLEY SMITH For property located at: 42 JENKINSVILLE 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. Tne of Construction - Value Owner Address: CLYDE& SHIRLEY SMITH Septic Alteration Residential 42 JENKINSVILLE Rd QUEENSBURY,NY 12804 Total value Contractor or Builder's Name/Address Electrical Inspection Agency OUEENSBURY SEWER JAY SWEET Plans &Specifications 2003-101 SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS $25.00 PERMIT FEE PAID THIS PERMIT EXPIRES: Saturday,March 27,2004 (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 Queensbury; Thursday,March 27,2003 SIGNED BY for the Town of Queensbury. Director of Building&Code Enforcement Application for Permit—Septic Disposal System Town bf Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256 1. OWNER INFORMATION: _........ Location of install .._..._....................................... installation: Office Use Tax Map No. / , / File Permit No. �6 , Fee Paid oo Owners Name: � _ I . . ��� � ....................................................................................._.,............,................_. Address: 2 �c �. ......... y 2. INSTALLER'S NAME `(3 PHONE NO. 3. RESIDENCE INFORMATION: (circle year of dwe ling, 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 Dai VE 1980 orrold = A-� 1980 19 x 130 g i d m = AR 2 6 2003 1991 —present x 110 gal/bdrm = MN OF QUEENSBURY Garbage Grinder Installed yes_ t BUILDING AND CODE Spa or Whirlpool Installed yes_ / 9 4:- PARCEL INFORMATION; (circle applicable information&indicate measurements) TovograDhy Soil Nature Ground Water Bedrock or Im ervious Material Domestic Water Sumply Flat nd at what depth at what depth municipal Rolling am feet feet we Steep slope clay well; water supply %slope other from any septic-s stem depth: absorp lion is ft. other/�S Percolation Test: (To be completed by licensed professional engineer or architect) Rate: �' T minute per inch 5. PROPOSED SYSTEM: For New Conscti2g: 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 eagh Garbage Grinder,Spa or Whirlpool Tub. Septic Tank: gallon (min, size 1,000 gal) Tile Field; each trench— ft Total System Length: fl Seepage Pit(s): number of size of each: ft. by ft Size of Stone to be used: # / depth or thickness feet Bed System Size: x Alternati starts .�; length and/or size / r 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 ofthe 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. _ 3 azC / U Sign`atu a dv responsible person Date l oWit of (111cell;11)11iry smVers and Sewage. Disposal (:ImptC1' Appemlix C • 1 RI:I'ARATION [UPAJI.J11t_OMENTS P0�1p • 1 1^li:.11_ ur 1rnTF'rt- Wfi ti'w•, ill*tuT CA51PI('; M `�... ,•- . G E L V� I r'�1Yf� s t:r'1 1 c, "^ny \ / �r'.•I .r_'-^ I VetiSlhStl lit •11 ni�>s ROAD _ ------ -ter 7. SIGNATURE &INFORMATION FOR I ESFUNbIO."rr-"w v u,,o��•.•••...•, TOWN OF QUEENSBURY (�'W BUILDING___&,_CODE .ENFORCEMENT 742 Bay Road Queensbury NY 12804 (518) 761-8256 SEPTIC DISPOSAL SYSTEM INSPECTION Name Z Location -9 U; j Date Permit # � SOIL TYPE: Sand-Loam-Clay- Results of Percolation Test- (if applicable) Rate-Minute/Inch TYPE OF SYSTEM: ABSORPTION FIELD: Total Length Length of each trench Depth of trenches Size of stone SEEPAGE PITS: Number- Size - ft. x ft. Stone size PIPING: Size Type Bldg. to Tank Tank to Dist. Box Dist. Box to Field/Pit Openings Sealed? Yes No Partial LOCATION/SEPARATIONS: Foundation to Tank feet Foundation to Absorption feet Separation of Pits _ feet Conforms as per Plot Plan Yes No LOCATION OF SYSTEM ON PROPERTY: . (circle one) Front - Rear - Left Side - Right Side Middle Front - Middle Rear COMMENTS: J SYSTEM USE APPROVED: YES NO Arrive t1 Dep ed: Build' Inspector Septic Inspection Report Office No. (518) 761-8256 Date Inspectionquest receive ---). Queensbury Building&Code Enforcement Arrive: a J1 am/ 742 Bay Rd.,Queensbury,NY 12804 Inspector's Initi NAME: ERMTT NO.: L 11�t LOCATION: ? �g;�La a '�;tt1S INSPECT ON: RECHECK: Comments and/or diagram Soil T Sand am/Clay Type of r: Munici a ell Water Waterline separation distan ft. Well separation distance ft. Other wells: ft. Absorption Field: Total length ft. Length of each trenc ° -- ' ft. Depth of trenches Size of Stone Seepage Pits: Number Size: x Stone Size: Piping Size Type Building to tank a L4i° Tank to Distribution Box I% Distribution Box field/PitAl Opening Sear : Y artial 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 Left Side Right Side Middle Front Middle Rear System Use Sta s• Approved Partial Approved and needs to be re-inspected,please call the Building&Codes Office Disapproved TOWN OF QUEENSB URY Office Stamp (received) 742 Bay Road , QUEENSBURY, N.Y. 12804-9725 — SEPTIC VARIANCE Application to be reviewed by Town Board of Health / r 1. Applicant's Name: _ti/f/ dto- 19 A/{^/L(/ Street Address: hKi n s eli// Q City, State, Zip: o 10p Telephone No. We) 17 l,E� .IV D 2. Agent's Name: Street Address: [MAR.2 6. 0 . City, State, Zip: `u.3 Telephone No. 7 F U EN, URY LII 3. Owner's Name: // _ . d-Qhir/LY Street Address: g/ -11,'C' /,/Ie dad/ City, State, Zip: (�„��„sbu�-,� . ,t/e�v Telephone No. 4. Location of property: A/�`7e�_fld�hsa;lle j ,gO4 IICC-pSbiteX 5. Description of how to find the, property: h 19_ e j?0ad- f�� h7r_Amr 11 '695 a AYS/le /?oad - /sT,CC�fTvnr�7enlfitisGi//TR.�l.�iiy,d/�o�lSF�3/� ��� 6. Tax Map Number: Section a7 gg , Block /y—/, Lot 7. Lot size: /acres/aq—fit. 8. Section of the Sanitary Sewage Ordinance from which you are seeking this variance: THE � E{'T-'1 c_ uec C_N FNEk �ELTE�J IyN DER�� "g i FFRC&A Ik ETABC1 e 9. Distance from well on property to septic system (if applicable) . _1 10. Is it possible to install a conforming eptic system on this property? Yes No if Yes, please explain and attach diagram. PAGE 1 11. Does proposed system meet setback requirements for distance from wells and septic systems on neighboring properties? A— Yes No if No, please explain: 12 . Is proposed system to be installed under a parking area? Yes _ No 13. List the names, addresses (including tax map number) of all adjoining property owners. You may obtain tax map numbers from the Assessor's Department as well as the names and addresses of neighboring property owners. Name: Aklle Redr�g�o�t/ Tax Map # Address S2 TGhKinsy�ll� IQd, NORTH Name: A'97-C-11e Aedih,Tan- Name: (Tonrzar 4-amb Tax Map # r WEST -�f* EAST Tax Map # Address Address C/Ch 4keAP12 SOUTH A/,Wa br'9C C'ng .gviIit, Name: ri�iaY�-�7�/-��L1 Tax Map # Address J enK1h5 �d- PAGE 2 5 L AUTHORIZATION TO ACT AS AGENT FOR I, seller F-1 owner ❑ of premises located at T Map Number: hereby designate: to act as my agent regarding an application for a se t1 ria at a above premises. Applicant's signature Date Applicant's agent signature Date STATEMENT I, (we), r 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 may increase risk of pollution. i Applicant's signature = Date o OFFICIAL RECORD OF MEETING - MINUTES "The parties hereto consent that the proceedings which result from the within application may be tape recorded and transcribed by the Town Clerk or his agent and that such minutes as may be transcribed shall constitute the official record of all proceedings regarding this application, unless the same may vary from the handwritten minutes taken by the Town Clerk, in which event the handwritten minutes as to such inconsistencies shall be deemed the official record." Applicant's signature Y ate 2 Applicant's agent signa ure Date PAGE 4 PROJECT I.D.NUMBER 617.21 SEAR ' • Appendix C Stale Environmental Quality Review SHORN ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I—PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT/SP ONSOR 2. PROJECT NAME 3. PROJECT LOCATION: Municipality Q�� County 4. PRECISE LOCATION(Street address and road Intersections,prominent landmarks,etc.,or provide map) 5. IS PROP9ED ACTION: New ❑Expansion ❑Modl[Ica llon/alteration d` 6. DESCRIBE vf�u- lrl\`O V�. c�i:- 7. AMOUNT OF LAND AFFECTED:Initially • ') acres Ultimately 2` b�" s acres 8. WILL.PKOPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Yes ❑No If No,describe briefly 9. WHY IS PRESENT LAND USE IN VICINITY OF PROJECT? Residential ❑Industrial ❑Commercial ❑Agriculture ❑Park/Forest/Open space ❑Other Describe: 10. DOES AC ON INVOLVE A PERMIT APPROVAL,OR FUNDING,NOW OR ULTIMATELY FROM ANY•OTHER'GOVERNMENTAL AGENCY(FEDERAL, STATE 9R LOCAL)? Yes ❑No If yes, list agency(s)and permitlapprovals 11. DOES ANY ASP CT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑Yes No It yes,list agency name and permlUapproval 12. AS A RESULT OF ROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? ❑Yes No f 1 CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE AppllcanVsponsor, name: Dale: / a2C Signature: 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 DEC 09 2002 6: 28PM HP LRSERJET 3200 P. 1 j S 169 Haviland Road,Queensbury,NY 12804 Phone-518-745-4400 Fax -518-792-85 11 Decmi ber 8,2002 Job#49097 Mr. Dave Hatin VIA FAX—745-4437 Town of Queensbury 742 Bay Road Queensbury,NY 12804 RE: Septic System Clyde Smith Residence,Jenkinsville Road Dear Dave: At the request of Mr. Jay Sweet, on November 27t', I performed a percolation test at the Clyde Smith residence on Jenkinsville Road in Queensbury. The test was performed beside the driveway in the location where construction of a replacement leach field is proposed. The results of the testing are as follows: Percolation test Stabilized percolation r e— 1"in 2 mi�-utes, The test was run in the native loamy sand at a depth of 24 inches in a 30 inch deep hole. The hole was presoaked with 6 gallons of water and the test was run 3 times until it stabilized with three consecutive runs at 1:50,2:21 and 2:11 respectively. Please call me if you have any questions. Sincerely, Gam. Thomas W.Nace,P.E. Fax copy:Jay Sweet-798-8875 5- ELJEN IN-DRAINS - PAGE 2 All Effluent is not Treated Equally primary treatment zone is located ; well above the native soil interface allowing for a BOD5 Treatment Up-Date highly concentrated mass of biomat to form which treats the effluent biologically as well as physically and induces favorable unsaturated flow. ♦ secondary treatment zone is created 2 by placing a level six inch layer of washed sand di- ' OSeptlarank @rluent rectly below and to the sides of the In-Drains creating I ■h-Drain S*M a secondary partial biomat formation on top of the washed sand. ♦ third treatment zone as the primary and Site Site Ske3 Site Site secondary treated effluent passes throughout the un- derlying six inch layer of washed sand. samples taken directly below the third treatment zone,prior to the native soil interface. All samples are obtained and tested by independent laboratories. MIR Stating point for conventional or chamber systems. New York State Required Length Eljen In-Drain Absorption Trench 2 Bedroom 3 Bedroom 4 Bedroom 5 Bedroom 6 Bedroom Min-/inch 220 260 300 330 390 450 440 520 600 550 650 750 660 780 900 6-7 31 37 '43 47 56 64 63 74 86 79 93 107 94 111 129 2 sI=10 35 4 4$ 2 62 . 1 fit) 835r 8;' t03. f119� 1q5;t � 4s <1A3::: _O H 11 —15 39 46 54 59 70 80 79 93 107 98 116 134 118 139A 161 O k6:-2a :.45 53 61 & 80 92 90 I IG 123 142 f33� t53 �59 1, W 21 —30 52 62 71 79 93 107 105 124 143 131 155 179 157 186 214 LLJ 3'E. 45 63 74: 86 '94 1: 1:. 129 426 143 17 15 186 2�4? 1897: 22 "25 :. 45—60 70 83 95 105 124 1 143 140 165 191 1 175 1 206 238 1 210 248 286 Number of In-Drain units required is accomplished by dividing the ABSORPTION TRENCH LENGTH by 4' and rounding un to the nearest whole number. ♦ 43 LINEAR FEET REQUIRED DIVIDED BY 4=10.7 ROUNDED UP TO 11 In-Drain units ♦ 129 LINEAR FEET REQUIRED DIVIDED BY 4=32.2 ROUNDED UP TO 33 In-Drain units . x ELJEN CORPORATION 1-800-444-1359 / FAX(860)610-0427 www.eljen.com Sm ■ th m� �Imm f I t- I. , 11-M...I 'm I I ---- \i m 1 1 Soo 0 500 9000 Fee# Qu builgin 9 s Qu geCw •shp Parcels at/angs•shp Qu Pi-n•shp ' 'Streets.shp Smith �i THIS P N ZZ ITE A ALL TIMES FOR THE DURATION OF erved, or b¢I°��� I saw evidence of, or obs y s fences, etc., - °`► have seen r r ,, j all objects sc�' ' ' �t t ,at i I12�ie , d+agram.' fsonvo ,.e .t c! ` - (13 — 64,�N.�� ,: N^ BUILiAGDEPARTMENT I �; �, F .seed on mtamh", campliarn our mmmenis shall not be as inWRA4ng the arts and are in full ccmotance a code. 0 TOWN UEENSRURY BUILDING t REVIEWED B q t x zo '�' _ j Y t DATE R o a i 11 e e (1 k�s N 40 0 40 80 Feet -1 -21 42 Jenkinsvitle Road �- Tax Map Number 279. 19 , This map was produce by the Town of Queensbury - December 9, 2002. It is intE.,nded to be used for graphical purposes only and shall not be construed as an actual, accurate property survey.