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2001-811 . TOWN OF QUEENSBURY Bay Road,742 Queensbury,Qu NY 12804-5902 (518)761-8201 Community Development- Building &Codes (518) 761-8256 CERTIFICATE OF COMPLIANCE Permit Number. P20010811 Date Issued: Monday, December 11, 2006 This is to certify that work requested to be done as shown by Permit Number P20010811 has been completed. Tax Map Number. 523400-301-006-0001-014-000-0000 Location: 12 PINION PINE Ln Owner. FRANCIS GIFFORD Applicant: FRANCIS GIFFORD This structure may be occupied as a: Septic Alteration Residential By Order of Town Board TOWN OF QUEENSBURY Issuance of this Certificate of Compliance DOES NOT relieve the property owner of the responsibility for compliance with Site Plan, Variance, or other issues and conditions as a result of approvals by the Director of Building&Co Enfo•ement Planning Board or Zoning Board of Appeals. Application for Permit—Septic Disposal System T own of Queensbury 742 hay Road Queeusbtu;y,NY 12804 (518) 761-8256 1. OWNER INFORMATION: 61- Offce use Location of installation: Alt / -a Al f 1,A'(t Filo Permit No V ( Al Tax Map No. / / o' Fi " � Fee Paid ' Owner's Name: cAA/ /z rr o I' d Addross: Plot_ I 2. INSTALLER'S NAME : .7; .11, f 5'f v C PHONE NO. 3. RESIDENCE INFORMATION: (circle year of dwelling, indicate I#bedroom(%) and multiply I1 of bedrooms with applicable gallons per bedroom to equal total daily flow) Year of I-louse: No. of Bedrooms x Computation = Total Daily Flow 1980 or older 3 x 150 gal/bdrtn = VS-61 1980- 1991 x 130 gal/bdrm = E 1991 —present x 110 gal/bdrttt = CE _CIE® TOWN Garbage Grinder Installed yes / no x' OCT 0 2001 Spa or Whirlpool Installed yes / no OF QUEENSBURY BUILDING AND CODE 4. PARCEL INFORMATION: (circle applicable information & indicate measurements) _':`%,g rap h a urn GrQu d Water Bedrock or Impervious Material D. MOIL ater Supply !%Teri .sand at wh tt depth at whadeptlh 4 municipal' ing n feet ,-feet Steep slope clay if well; water supply _%slope other from any septic-.system • depth: absorption is ft. oilier • • Percolation Test: (To be completed by licensed professional engineer or architect) • Rate: minute per inch 5. PROPOSED SYSTEM: For New Constniction: 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 lank and leach field for each Garbage Grinder,Spa or Whirlpool Tub. Septic Tank: /0 pU gallon (min. size 1,000 gal) Tile Field: each trench S c) fl. Total System Length: B ft. A//, ;f"' %� Seepage Pit(s): number of size of each: ft. by ft. • • Size of Stone to be used: III / depth or thickness fret Bed System Size: • x Alternative System: length and/or size • 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 road the regulations with respect to this application and agree to abide by these and all requirements of the Town of Queensbury Sani ry Sewage Disposal Ordinance. V c...76",____,..-- GP 6 -.A9 - c)-61'd/. . • Si 6 gnature of responsible person Date ��� TOWN OF QUEENSBURY �4742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201 Community Development- Building& Codes (518) 761-8256 BUILDING PERMIT Permit Number: P20010811 Application Number: A20010811 Tax Map No: 523400-301-006-0001-014-000-0000 Permission is hereby granted to: FRANCIS GIFFORD For property located at: 12 PINION PINE 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: FRANCIS GIFFORD Septic Alteration Residential 12 PINION PINE Ln Total Value QUEENSBURY,NY 12804 Contractor or Builder's Name/ Address Electrical Inspection Agency I.B.S. SEPTIC 2 LOWER WARREN STREET OUEENSBURY,NY Plans &Specifications 2001-811 SEPTIC ALTERATION AS PER APPLICATION $25.00 PERMIT FEE PAID - THIS PERMIT EXPIRES: Thursday, October 31,2002 (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 the a own Que s ty; eyi esday, October 31,2001 id cor SIGNED BY v for the Town of Queensbury. Director of Building&Code Enforcement _____, --- ?-)t:: TOWN OF QUEENSBURY BUILDING & CODE ENFORCEMENT 742 Bay Road Queensbury NY 12804 (518) 761-8256 SEPTIC DISPOSAL SYSTEM INSPECTION Name r„~k ,;, r _. Locati o1ff --, /nt ill's- i.---e Date - I Permit # a I-d /l SOIL TYP . San m-Clay- Resul is of Perco(TW on Test- (if applicable) ate Minute/Inch TYPE OF SYSTEM: ABSORPTION FIELD: Tota Length -77fi!. ,. Length of each tr- ch t!::,r cz ° 4.-- Depth of trenches 2' Size of stone ��RKca--p SEEPAGE PITS: Numb_r- Size - ft. x ft. Stone size PIPING: Size Type Bldg. to Tank F-4-t ---,et,` Tank to Dist. Box 1�4,bPV— j c, Dist. Box to Field/Pi 4,n ©Q.--'3;;-6 Openings Sealed? Yes ' No Partial tc.3Fi L LOCATION/SEPARATIi S. Foundation to Tank \ .feet Foundation to Absorption . 7.1Th .feet , Separation of Pits _ _ fee_ ) Conforms as per Plot Plan Yes im LOCATION OF SYSTEM ON PROPE'TY: (circle one) Front - Rear - t Si - --Side Middle Front - e dear COMMENTS: pF -v Y7. \ SYSTEM USE APPROVED: YES NO Arrive. Depa . .. _ �At ( 'ui '.ing Inspe'tb Septic Inspection Report Office No. (518) 761-8256 Date Inspection request received: Queensbury Building &Code Enforcement Arrive: amefr Depart: am/pm 742 Bay Rd., Queensbury, NY 128 4 Inspector's Initials: NAME: (7/1 2�7r PERMIT NO.: ZQQ!—8 I LOCATION: /2 T i k1 I(4\ h_e_ INSPECT 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. Length of each trench ft. Depth of trenches ft. Size of Stone Seepage Pits: Number Size: x�---- Stone Size: Piping Size Type Building to tank Tank to Distribution Box Distribution Box to Field/ Pit Opening Sealed: Y/ N/ Partial End Cap Inlet/Outlet Pipes&Baffles —Y N Location/ Separations Foundation to tank ft. Foundation to absorption ft. Separation of Pits _ ft. Conforms as per Plot Plan ____Y N Engineer Report and As-Built _._,.Y_N Location of System on Property: Front Rear Left Side Right Side Middle Front Middle Rear System Use Stus: ,K J Approved Partial Approved and needs to be re-inspected, please call the Building &Codes Office Disapproved Last revised 021006 Last revised 1/6/05 I - _ i i 1 i� 1 1 _have.seen or observed,or believe I saw evidence of, i all objects such as&houses,wells,trees,ifences, etc.; k '3—' —20 shown on this document 1(also represent that I — -have 1 1 J j=—r ,;____ -�— —- perso ally me sure d-tie-di to ces!set forth on-thel-diagram. ■ - SIGNATURE ATE&I. T ____LL___1"-y% ‘V----a-- 61*A 0 TOWN or QuENSBURy BUILD_ AND Cp®E 4 ,, • ,0 frt •• _d. IF tiy ct A-t( • Ci 11_0_,)o c„,6 /cut ji-z, LI Ti.: (1-4/-7-ou I I i-tra_A./ r i f•-i; rci 1 I 1 f1(1, nOPY b j(lt��r �,. t!^,a <Gii. �'I ��.n- @ gt `...o �. 1,Jii,LCe..^ _ -e.F i1 . t3oied of our limited examintion, _ 1 �_ conpliarice with our ooniments shall U I L 1 _ ' not pe canst��ed as indicating the I +EVEBIH — I— 1