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SEP-0672-2022 ....1:.. ... .... .. ....... .. ..... .. V. Office Use only Permit#: 6A2—,. 00Z2— { Pe rmit Fee:$ .42 Bdy:Road.-QueenSb'u V,W 12804 k SW 61r8250::"Lywmqueensli r met 111VOICe Flood Zone? Y evievved. y:. SE°PTIC DISPOSAL'PERiUIIT APPLICATION V oQ,,p fro Pro•ect Location, 4,.Tax IVIap.#: 3 02 L _ 6 _......... RESIDENCE INFORMATIOM: TOWN OF C�I.�El..i�ISIBU Y �^ p Year:.8Uilt Gallons #of bedrooms. X`gallons per- =total daily flow: -LL� t;Uli C°i�l�i per day ,: bedroom Garbage.Grinder: Yes_ No 1980 or.:older I. I. ® I Installed d slcircle;orre) . 1981-1991: 13U `Spa;,dr Hot Tube Yes No .__ Insta.11ed?:{eircle an '} a' 1992=Present. llia PARCEL INFORMATION:. .. .. .. . .. . : .. .. . Flat Rollin opograp y Steep Slope: .% Slope: g. . . . . .. Sol Natuee Sand Loam Clay _.Other, explain;; Groundwater At.what depth? Beth-ocklfrriperui:ous material At what.depth? incI , Liq�r D.ome-stiC Wator'Supply _ municipal Well Lake" (if well or lake, water supply.from any septicsystem absorption is Perco anon:Test Rate: 1 ,„per minute per'Inch (test to be corrrpieted by a a . _._ licensed.engin+�er/ar..chitect) PROPOSED 5YSTEM INFORMATION. Tank sie: doc7 gallons {miiri. size.1,000 gallons, add:250:gallons far each' . cylinder or ... .spa . .ot to.. ft . Each:Tren.ch ft. System Absorption field w :#2 stone Total length 2i® ; Seepa e Rt"w #3 stone Now man. ; Size: _ Alternative System Bed or bother..type.:. P-PQSlw�-e � � ►' - Holding Tank°System Total required capacity? ;tank::size -- .—_- # of tanks.. Septic Application Revised December 250M 3 QQW-AZT INFORMATION: PLEASE PRINT LEGIBLY_OR.TYPE, PLEASE..IN.CLUDE:AN:EMAIL Nameis); 5 je®9c Or4i"►) MailirtgAddress,C/S/Z . , 2 10wer- �ti airre � t dL 6 Lan ine: _)__ �'` `r . Cell Phone: i 1 -t/(���� _ l 4 Email: Q xj l 44 02 i bri e C�,n-• •.. Rrimary.Ownedsl: Names Mailing Address S/Z� -2 ST Land Line: .Email, ie CP -1 �'i+-1r��rv, 7.ciltieir"/, ler" :Check"ii f all wbrk will.be performed by property owner ©nl • Contractor: Contact,Name s : Contractor Trade: Mailing Address; C/S/Z:- : Cell Phone:._(.... �: . . Land Line: _{ ) Emai : "Workers" Comp documentation must be submitted with this'ap�alkat!00 •: Engineer: s : Name�s :: K ,(.�v►5.�4.�`.. . IL ) :: khg- ........ . . Ma'ling Address, C/S/Z: . . Kell Phone:.:_( ) Land trine: { 5_2 Ij .` V/7'.0216I Email: ........ Contact Person for Compliance:in regards.to_this project; Er i C 0 Cell Phone. _( l ..).. 7.�/ �5.� Land Line: �. Ernall: e!q .,fp�i S'i eol'c ra k- - --- NCITES: I:::Alarm.system..and associated electrical work.must_be;inspectedley a.Town:appro, d electriical inspection agency; 2.We Will no longer allow systems-to be covered.until:such time as an:as-built.plan:U received:and approved.The installed;system:must match the_septic layout on file- nQ exceptions'.3.As- built'draWings must be subrnitted prlor WIN,inspection; if there has bee n a change to.<the submitte plans. . If >for any reason; the building permit application is withdrawn,:30%of the fee:is retained.by the Town of Queensbury.:Aftet 1 year from the initial application.date, 100ro pf the fee is retained. -declaration:Any permit.or approval granted which:is based upon.or is granted in.;.reliance upon.any material representation or failure.to mare:a:material fact or circumstance known by.or.on behalf of an applicant,shall be: void::l'have read the regulations and agree to abide by-these and.ail requirements oftheTiwn of Queerisbury sanitary'6wage:Disposal Ordinance. /r� I . pRINT:NAME::- L+:r•c:.. l;t r _e r �: :'X­'V ;SIGNATURE: �� DATE Septic:Application Revised December 2020 STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la.Legal Name&Address of Insured(Use street address only) lb.Business Telephone Number of Insured (518)798-8194 IBS Septic&Drain Service Inc 2 Lower Warren Street lc.NYS Unemployment Insurance Employer Queensbury,NY 12804 Registration Number of Insured ld.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically or Social Security Number limited to certain locations in New York State, i.e., a Wrap-Up 141819578 Policy) 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Michigan Millers Insurance Co. 3b.Policy Number of entity listed in box"1a" Town of Queensbury W05152021 Building Codes 742 Bay Road 3c. Policy effective period Queensbury NY 12804 5/15/2021 to 5/15/2022 3d. The Proprietor,Partners or Executive Officers are included. (Only check box if all partners/officers included) X all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "la" for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of insurance to the entity listed above as the certificate holder in box"2". The Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofprentiums or within 30 days IF there are reasons other than nonpayment ofprenihans that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be.sent by regular mail.) Otherwise,this Certificate is valid for one year after this forme is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box 9c"'whichever is earlier. Please Note:Upon the cancellation of the workers' compensation policy indicated on this form,if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Linda Abodeely (Print name of authorized representative or licensed agent of insurance carrier) Approved by: t. t_ 41 May 19,2021 (Signature) (Date) Title: President Telephone Number of authorized representative or licensed agent of insurance carrier: 518-793-3131 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issrre it. C-105.2(9-07) www.wcb.state.ny.us o Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department,board,commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter,and notwithstanding any general or special statute requiring or authorizing the issue of such permits,shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter.Nothing herein,however, shall be construed as creating any liability on the part of such state or municipal department,board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department,board,commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter,notwithstanding any general or special statute requiring or authorizing any such contract,shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter. C-105.2 (9-07) Reverse RUCINSKI HALL ARCHITECTURE Ronald Richard Rucinski Ethan Peter Hall 134 Dix Avenue Glens Falls NY 12801 Voice 518 741 0268 Fax 518 74.1.0274 Email ephall@nycap.rr.com Bittman Residence-28 Pershing Road 23 November 2022 Town of Queensbury Building Department 742 Bay Road Queensbury NY. 12804 Re: Installation of New Sewage Disposal System At the above referenced project location this office observed the installation of the new pump chamber, and stone absorption bed.,Due to slight slope of the property and meeting the minimum. 24 inches to groundwater, the bed of stone was elongated to be 10 feet by 50 feet meeting the minimum square footage as originally designed. A sand and topsoil taper was finished to meet 3:1 maximum pitch:and the edge of taper meets a 10 foot minimum to the side property line. This installation is acceptable to this office. if there are any questions please contact our office to' discuss. r Regard Ethan Peter Hall Architect NOV 2 9 2022 ..TOWN OF QUEENSBURY ��- BUILDING &CODES .5ER - Zc o 1-2. -Za 22 B 1