2003-767 h TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development' Building&Codes (518)761-8256
CERT IFICATE OF COMPLIANCE
Permit Number: P20030167 Date Issued: Tuesday, September 16, 2003
This is to certify that work requested to be done as shown by.Permit Number P20030767
has:been completed.
Tax Map Number: 523400-295-019-0001-011-000-0000
Location: 3 KILEY Lt
Owner: RICHARD&JOAN YBORRA
Applicant: RICHARD&JOAN YBORRA
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: P20030767 Application Number: A20030767
Tax Map No: 523400-295-019-0001-011-000-0000
Permission is hereby granted to: RIC'HARD & JOAN YBORRA
For property located at: 3 KILEY Ln
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: RICHARD& JOAN YBORRA
3 BEY Ln Septic Alteration Residential
Total Value
QUEENSBURY,NY 12804-0000
Contractor or Builder's Name/Address Electrical Inspection Agency
I.B.S. SEPTIC
2 LOWER WARREN STREET
OTTEENSBTTRY. NY
Plans&Specifications
2003-767
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday, September 16, 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; Tuesday, September_16,2003
SIGNED BY for the Town of Queensbury.
trector ofBuilding C5o Enforcement
Application for Permit_Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518)'761-8256
1. OWNER INFORMATION:
............. ........,.....
Location of installation: -� �G L f 1.� ... . :...............................Office Use................ ..., _.
Tax Map No.
File Permit No.0 67
/ / �
/^�
Owner's Name: / 1 C_�/ C,, �j�_ rr. ._ Fee Paid
Address: llr7c L��-�7 �� _..............................................................„....,..................
2. INSTALLER'S NAME �y-
� z PHONE NO, 1,9
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 150 gal/bdrm S
1980- 1991 x 130 gal/bdrm =
1991 -present x 110 gal/bdrmREC
=
Garbage Grinder Installed yes / no*X M E
Spa or Hot Tub In yes_ / no �L_ SEp
2003
4: PARCEL INFORMATION: IN
. (circle applicable information&indicate measuremeTnTy OF Oi'EENSBURY
CODE
o a h r Na e Ground Water Bedrock or Impervious Material c ter Su 111
1 sand,-'
at 'h/aQt depth at what depth municipal
oiling am = eet ffeet Z__
Steep slope clay if well; water supply
_%slope other from any septic-system
depth: absorption is ft.
_
Percolation Test: (To be completed by licensed professional engineer or architect) other
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: L 0 0S 0 gallon (min.size 1,000 gal)
Tile Field: each trench t Total System Length: C-a8 ft.
Seepage Pit(s): number of size of each: f. by fl
Size of Stone to be used: # / depth or thickness feet!�/C i/� ��/ o`
Bed System Size: x
Alternative System: length and/or size
6. HOLDING TANK S"('STEM: (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.
_ & � ao�
Si nature of res�OnWbiie � Date
• ' "Tow of Que-e-li bury
Sq%voru and :iow the Dimposal t:11:1v[t•t•.
• Api, olilii x t% ! -
' �tI:I'l�lt/1.'I'It}P� IL•'Irt2L3�t�t*t4lT�:t�`I`;� � .
S C#tis tKM ,.
POND
L�/F:LL. iH tJ(�Tt:'IZ• .i � �..•„•,/ 4t }{'t3»t
rc
._.....�---�'--ice— ti ,—....,..�.t.••,,.,.,...y„ �J
3
.3 ..'' $t i't 1c.
3 � 71�•i tY,.
. �•+•• ,t�+Yst�R.Pt14a y
• �,,,,,..,,,,,,,,,,... ....ter•--• .
?. SZ ,NA."f Up 8Z Il�IFQR1viA'TIS g4�t �'vrtatxss• •,••�•,�►.•......=;` _• r
r. .
y
j
Septic Inspection Report
Office No. (518)761-8256 Date Inspection re est r ce' e .
Queensbury Building&Code Enforcement Arrive: mlp art: a
742 Bay Rd.,Queensbury,NY 12804 Inspector s Init'
NAME: RMIT NO.:
LOCATION: SPECT 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. SE 1 2 6 3
Length of each trench ft.
Depth of trenches `-- ft.
Size of Stone -�
See a e Pits: Number
Size: x
Stone Size:
piping Size Type
Building to tank
Tank to Distribution Box st
Distribution Box to ld it 9i -T jOpening Sealed Partial
Location/Separations
Foundation to tank
Foundation to absorption
Separation of Pits ft.
Conforms as per Plot Plan Y - N
Location of System on Property:
Front ear Left Side ight Side `
Middle Front fiddle Rea
System Use St us:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
-Disapproved
L:\SueHemingway113uilding.Codes.Inspection.FORMSVSeptic Inspection Report.doc January 28,2003
) IJ
T
a
JILUI
RE J11EWED B
-Vj �(
o � ►
J� peen or obse ved, or believe I saw evidence of,
s��,�rar s such as h uses, wells, trees fences etc.
n on this docu ent. I also re resent that p I have
personall easure t e distances set fort n the diagram."
SIGN TURE DATE
SEp 16 2003
�'OVVM or-C)JY-ENSIIURY