2001-020 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: P20010020 Date Issued: Monday, January 22, 2001
This is to certify that work requested to be done as shown by Permit Number P20010020
has been completed.
Tax Map Number: 523400-026-000-0002-014-013-0000
Location: 80 OAK VALLEY Way
Owner: THOMAS &TERRI KUBRICKY
Applicant: THOMAS & TERRI KUBRICKY
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
cDo) -
Director of Building& Code E forced'-nt
TOWN OF QUEENSBURY
4-1 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20010020 Application Number: A20010020
Tax Map No: 523400-026-000-0002-014-013-0000
Permission is hereby granted to: THOMAS &TERRI KUBRICKY
For property located at: 80 OAK VALLEY Way
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: THOMAS & TERRI KUBRICKY Septic Alteration Residential
80 OAK VALLEY Way Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name/ Address Electrical Inspection Agency
THOMAS KUBRICKY
80 OAK VALLEY Way
OUEENSBURY,NY 12804
Plans &Specifications
2001-020
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID - THIS PERMIT EXPIRES: Wednesday,January 22,2003
(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 ensb • Mon a , nuary 22,2001
SIGNED BY / / dc1 for the Town of Queensbury.
Director of Building&Code En orcement
Application for Permit—Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
Office Use
Location of installation: SO (•-•'\61Z. irxteeyp ``\\
Tax Map No. / • / /tJ, z� File Permit No.IQ 1—Uc o
5. av
Owner's Name: Tati 0713e,C,CGf/ .z_a
Address: /�-, �-� JAN 1 6 2001
TOWN OF QuEiaNSBURY
2. INSTALLER'S NAME : n rr /C C9 9a/oe LNG b I . F/Z -a ddr-?
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 =
1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm
Garbage Grinder Installed yes / no `
Spa or Whirlpool Installed yes— / no V
4. PARCEL INFORMATION: (circle applicable information &indicate measurements)
• Topography So' Nature Ground Water Bedrock or Impervious Material Domestic Water Supply
Flat sari, at what depth at what depth municipal
o lin loam /kJd'—feet /sJ, feet well
Steep slope clay t if well; water supply
_%slope other 9 from any septic-system
depth: absorption is ft.
other wA7z%l.C,
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 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: MO o gallon (min. size 1,000 gal)
Tile Field: each trench 6.06 Vi. Total System Length: I d fl.
Seepage Pit(s): number of l size of each: ft. by ft.
Size of Stone to be used: # z / depth or thickness feet
Bed System Size: x
Alternative System: length and/or size
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: 1 / 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.
S gnature of responsible person Date
Cr,247/71?
TOWN OF QUEENSBURY .
BUILDING & CODE ENFORCEMENT
742 Bay Road •
Queensbury NY 12804 •
(518)761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name . i . U kV'i.c-k i.
Location go I L
I\QII
Date `-42- _emit, OO ,-_O .
SOIL TYPE: Sand-Loam= layi
Results of Percolation Te;.t- I
(if applicable) Rate-Mi.nu e/Inch
TYPE .OF SYSTEM: I: • 1
ABSORPTION FIELD: Total Lpn t/ l .
Length of each trench, ' ;OC,/
Depth of trenches _ ! ;/
� "
Size of stone 4j
SEEPAGE PITS: Number- j.
Size - ft. x ft.
Stone size f
PIPING: ' Si e Type
Bldg. to Tank I °` �.l
�z6 /
Tank to Dist. Box W
Dist. Box to Field/Pi I ; r i, 44
Openings Sealed? a No Partial
LOCATION/SEPARATIONS.
Foundation to Tank 4,,' feet
Foundation to Absorptt feet
. Separation of Pits . feet
Conforms as per Plot Plan Ye` No
LOCATION OF SYSTEM ON PROPERTY: -- ,
(circle one) f'----,,
Front - Rear -. Left Side - R(ght Side )
Middle Front - Middle Rear
COMMENTS: `�___----,
•
•
::)SYSTEM USE APPROVED: YES NO
Arrived:
(%
Departed: �t I "
J'kg .
Building Inspector
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