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2001-806 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: P20010806 Date Issued: Wednesday, October 31, 2001 This is to certify that work requested to be done as shown by Permit Number P20010806 has been completed. Tax Map Number: 523400-296-069-0001-001-000-0000 Location: 4 QUEENS Way Owner: ELEANOR KOBYLARZ TRUST Applicant: ELEANOR KOBYLARZ TRUST This structure may be occupied as a: By Order of Town Board Septic Alteration Residential TOWN OF QUEENSBURY (- 0-Arifil 4 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: P20010806 Application Number: A20010806 Tax Map No: 523400-296-069-0001-001-000-0000 Permission is hereby granted to: ELEANOR KOBYLARZ TRUST For property located at: 4 QUEENS 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: ELEANOR KOBYLARZ TRUST Septic Alteration Residential DANIEL KOBYLARZ-HUGHES TRI Total Value 4 QUEENS Way QUEENSBURY,NY 12804 Contractor or Builder's Name/ Address Electrical Inspection Agency SANITARY SEWER DAN DRELLOS PO BOX 224 GLENS FALLS NY Plans &Specifications 2001-806 SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATION $25.00 PERMIT FEE PAID - THIS PERMIT EXPIRES: Tuesday, October 29,2002 (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 6wn of uee sb , onday, October 29,2001 SIGNED BY L for the Town of Queensbury. Director of Building Code Enforcement a � Application for Permit—Septic Disposal System Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256 1. OWNER INFORMATION: /2�e ee d✓ Li-Ay Office Use Location of installation: UDC /�� File Permit No.' )—v Tax Map No. o c7 J J 6 t�G�� � • Fee Paid C Owner's Name: -� FI � v g Address: Ou ee,J5 /Cu/1 y 2. INSTALLER'S NAME �Y�\ +f�� PHONE NO. 3. RESIDENCE INFORMATION: (circle year of dwe mg, 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 1%*<? x 150 gal/bdrm = � O 1980- 1991 x 130 gal/bdrm = 1991 -present x 110 gal/bdrm = —fiecEI VE® Garbage Grinder Installed yes / no X OCT 2 Spa or Whirlpool Installed yes / no 0( 9 2001 TOWN Or BUl DING EENseim 4. PARCEL INFORMATION: (circle applicable information&indicate measurements ND--. CODE V T. t raphy So' Nature Ground Water Bedrock or Impervious Material D 'c Water Supply sand ' at what depth at what depth mu ' + : rig oam feet feet well Steep slope clay if well; water supply slope other from any septic-system • depth: absorption is ft. other 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 le ch field for each Garbage Grinder,Spa or Whirlpool Tub. r543-71,4)6) Septic Tank: IOC) gallon (min. size 1,000 gal) Tile Field: each trench ft. Total System Length: ft. e.eu ,�� 2 Row.T© ' -' cl Seepage Pit(s): number of o fr size of each: ft by ft. Size of Stone to be used: # Q1 l n / depth or thickness feet Bed System Size: /v ifr x Alternative System: 9 2,t.1 length and/or size o2 ;X alc o 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 requirem-• - , the Town of Queensbury Sanitary Sewage Disposal Ordinance. /0 t717A/ S gn. ure of respons e person.. Date '' GC.-k-41/// TOWN OF QUEENSBURY Itil4E1) BUILDING & C ODE ENFORCEMENT 742 Bay Road Queensbury NY 12804 (518) 761-8256 SEPTIC DISPOSAL SYSTEM INSPECTION Name "11 eo,c\ \e )4,0\3 ),Y-7 () Location " 1 ( () P e,j�� ,2 Date 7 4 - Permit # SOIL TYPE Sand m-Clay- Results of Perc lati n Test- (if applicable) ate- inute/Inch TYPE OF SYSTEM: //- ABSORPTION FIELD: Tota Lengthaf Length of each tre ch ?�� Depth of trenches 2- Size of stone CL 4_4) - SEEPAGE PITS: ' umb-v- Size - f x ft. Stone size •, PIPING: S,ize Type Bldg. to Tank C "Tank to Dist. Box , era D Dist, Box to Field/P" - " 5 35' Openings Sealed? - p No Partia LOCATION/SEPARATION . Foundation to Tank �eet Foundation to Absorptio . 0 feet . . Separation of Pits _ feet Conforms as per Plot Plan tip No LOCATION OF SYSTEM ON PROPS' (circle one) Front - Rear - Left Side c:(111i::::--) e Middle Front - Middle Rea COMMENTS: • SYSTEM USE APPROVED: lb NO Arrived: Departed: j - Building Inspector 640-04-FCT 1DcJuj 1-57D cr d 0,6 t 3y I/ "I have seen or observed, or believe I saw evidence of, all objects such as houses, wells,trees, fences, etc., VioNon this document. I also represent that I have pgrso ally measured , 1. stance z.t orth on the diagram." P.- 11 #T 1 /0/2q/0, ( SIGNATIP DATE TOWN j QUEE ls5 „Aw3�boN, ( � - t,,r'"l ,:TT. tvmoi 100Z z 100 REVIEWED BY 4 AMMO dBUILDING &, st, 4/1 .*,), b, ju �n 934,130-1 DATE .._...n._.._... .. .r�.____._