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2003-624 TOWN OF QUEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201 Community Development-Building&Codes (518)761.8256 CERTIFICATE COMPLIANCE Permit Number:. P20030624 Date Issued: Wednesday,August 27,2003 This is to certify that work requested to be done as shown by Permit Number P20030624" has been completed. Tax Map Number: 523400-308-017-0001-004-000-0000 Location: 137 WEST MT. Rd Owner: PAUL&SALLIE BRANDT Applicant: PAUL&SALLIE BRANDT 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: P20030624 Application Number. A20030624 Tax Map No: 523400-308-017-0001-004-000-0000 Permission is hereby granted to: PA1JT.,9zSAI.I,1FBRA-NDT For property located at: 137 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 I Value Owner Address: PAUL& SALLIE BRANDY Septic Alteration Residential 137 WEST MT. Rd Total Value QUEENSBURY,NY 12804 Contractor or Budder's Name/Address Electrical Inspection Agency Plans&Specifications 2003-624 SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS $25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Sunday,August 08,2004 (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 To / eensb)4ry; Fr*d August 08,2003 / SIGNED BY for the Town of Queensbury.Director of Budding -knf Code orcernent Application for Permit-Septic Disposal System Town of Queensbury 742 Bay Road Queensbury, NY 12804 (518) 761-8256 1. OWNER INFORMATION: ....................................................... ........................................ Location'of installation: Office Use File Permit No O'er f Tax Map No. 0 A-) Owner's Name: 4:�� Fee Paid ............... .......................................................... Address: 2. INSTALLER'S NAME PHONE NO. 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 x 1:50 gaL/bdm 1980- 1991 x 130 gal/bdrm 1991—present x 110 gal/bdrin Garbage Grinder Installed yes no Spa or Hot Tub Installed yes_ no 4: PARCEL INFORMATION: (circle applicable information&indicate measurements) .-Too p-ranliv Soil Nature Ground Water Bedrock or Impervious Material Domestic Water SUply Flat- --san at what depth at what depth municipa --roam feet —feet wet Steep slope clay if well; water supply %slope other from any septic-system depth: absorption is other Percolation Test: .(To be completed by U architect) engineer or architec 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,0ea 9' gallon (min. size 1,000 gal.) Tile Field: each trench (ER) ft. Total System Length: !<J5-n ft. Seepage Pit(s): number of size of each: _j?, by ft. Size of Stone to be used: # l depth or thickness feet Bed,System Size: x Alternative System: length and/or size 6. HOLDING TANK SYSTEM: (if required) Number of tanks: f Size of each: gallons TOTAL Capacity: gallons Note: Alarm System and associated electrical work must be inspected by a Town approved electrical inspection agency. 1,7. 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. > -N Si�qnatu�rof r�espon�sile�pefson � Date SoNverst used Srsvilge DbAj)<):ut1 (:It:tj)ter. • � /�'1�•:�+(3It,I'•''t'�C��`sl. II'II;I�I) '. • 9 -,'PAiLA'i' ON ttl;tZt.)itLI;R]I�:N'It.�t� POND In `••� - �` T `-"", L"fE:LL. tN tIAT1S'F�+ � +i^►-^ +��.,—,,,./ .fsi Lt'.a••t . ltovsr— G . g C�Z sy— fy - 7. SIGNATURE &INFORMAT1014 FOIL Fjgirvl,4axl;'Lr-rr-x,- x-q�•,��.....".:�; r 0;3 0 Septic Inspection Report Office No. (518)761-8256 Date Inspection re st r eive ................... Queensbury Building&Code Enforcement 'Arrive: mlp �In art: 742 Bay Rd., Qpp"ry,NY 12804 S ecto no NAME: IT NO.: LOCATION: SPECT ON: uU7M�� AL-49J----o RECHECK: Comments and/or diagram Soil and I lay DTe of KatS.- icipal 1 ell Water Waterline sepdzt-i-'QB:�' nce Well separation distance ft. Other wells: ft. Absorption Field: Total length & Len of each trench Depth of trenches Size of Stone Seepage Pits: Number Size: x Stone Size: Piping Size Building to tank Tank to Distribution Box Distribution Box to Field Pit C— Opening Sealed: Y/NI Partial Location/Separations V0" Foundation to tank ft. Foundation to_absorption -1z ft, Separation of Pits Z ft. Conforms as per Plot Plan Y_N Location of System on Property: Front Rear Left Side Right Side Middle Fro Middle Rear ,Sstem Use Sta s: Approved Partial Approved and needs to be re-inspected,please call the*Building&Codes Office Disapproved L:\SLieHeniingway\Building-Codes.Lnspection.FORMS\Septic Inspection Report.doc January 28,2003 Septic Inspection Report Office No. (518)761-8256 Date Inspection reque* eive Queensbury Building&Code Enforcement Arrive: a pa pm 742 Bay Rd., Queensbur-y, NY 12804 Inspector's Initia : — (oaL .�NAME: QCA- 01��- NN P NO.. LOCATION: _j ECT ON: P3 RECHECK A 01N in'Commentsand/ordiagram__-2m 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 Depth of trenches Size of Stone seepage Pits: Number Size: Stone Size: Tlm�\L Piping Size The Building to tank `� TaWc to Distribution Box Distribution Box to Field Pit Opening Sealed: Y/NI Partial Location Foundation to tank Foundation to absorption Separation of Pits Conforms as per Plot Plan YN Location of System on Property: Front Rear Left Si fight Side Middle Front Middle Rear system Use St tus: Approved Partial Approved and needs to be re-inspected,please call tbe'Building&Codes Office Disapproved L:\SueHemingway\13uilding.Codes.hispection.FORMS\Septic Inspection Report.doc January 28,2003 1`1 have seen or observed,orbdle"1 saw evidence of, all.objects such as houses,wells,trees,fences, etc., shown on this document. I also representthat h otI have the diagram.►` Personally measured the distances set fSIGN E D TE i 0 or S uo1 6v=- REVIEWED 3 TOWN10F UEENS =URY BUILDING D T, REVIEWED B GATE 121-2 12- ' l have seen or observed,orfelleve 1 saw evidence of, all objects such as houses,wellIsos,trees,fences, etc., showep n on this documehent. I also represent that I have distances to h on the diagram:' personalty measured t 02, c "- �ilbNAIUMC D TE 1 Ilk TF _ \J / I-A TOWf4 O OUEENS "U BUILDI� D T. REVIEWED B [SATE � 14 P