2006-839 TOWN OF QUE E NSBURY
v/To742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building &Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20060839 Date Issued: Wednesday, January 09, 2008
This is to certify that work requested to be done as shown by Permit Number P20060839
has been completed.
Tax Map Number: 523400-309-009-0001-047-000-0000
Location: 63 INDIANA Ave
Owner: FREDERICK & MARGARET RAWLINS
Applicant FREDERICK & MARGARET RAWLINS
This structure may be occupied as a:
Septic Alteration Residential
By Other of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the Csg° ,..0 4 --
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&Code Enforcement
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
Bay Road,742 Ba NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20060839 Application Number. a20060839
Tax Map No: 523400-309-009-0001-047-000-0000
Permission is hereby granted to: FREDERICK&MARGARET RAWLINS
For property located at: 63 INDIANA Ave
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: FREDERICK&MARGARET RAWL
63 INDIANA Ave Septic Alteration Residential
QUEENSBURY,NY 12804 Total Value
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans &Specifications
2006-839
septic alteration residential
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Tuesday,November 20,2007
(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 To of ens ,iii n �_ . = 'vember 20,2006
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
OFFICE USE ONLY j-. ;
V
TAX MAP NO. PERMIT NO > PERMIT F�SP' J I , ;
APPROVALS: ZONING TOWN CLERK ;
APPLICATION FOR SEPTIC DISPOSAL SYSTEM PERMIT:
A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS.APPLICATION IS SUBJECT TO REVIEW BEFORE ISSUANCE OF A VALID
PERMIT. IA
OWNER: op_j/ i Lei fl(+C.t.) /1..1 INSTALLER: k) • Xce) J ir)(:f C
ADDRESS: 63 J-/ti /AADDRESS: /
PHONE NOS. PHONE NOS. � 6 / T /c.SJ3
LOCATION OF INSTALLATION: /g —
NO.OF ( RESIDENCE INFORMATION:
YEAR BUILT BEDROOMS X I COMPUTATION= = TOTAL DAILY FLOW
GARBAGE GRIN DER
1980 or older X I 150 gallon per bedroom = ib0 INSTALLED? ""
1981 -1991 X £ 130 gallon per bedroom = _ SPA OR HOT TUB
1992 present X 110 gallon per bedroom '• INSTALLED? /v�
PARCEL INFORMATION: /
✓ TOPOGRAPHY: FLAT ROLLING STEEP SLOPE %SLOPE
✓ SOIL NATURE: SAND LOAM CLAY OTHER
✓ GROUNDWATER: AT WHAT DEPTH? BEDROCK/IMPERVIOUS MATERIAL: AT
WHAT DEPTH? ��
✓ DOMESTIC WATER SUPLY: MUNICIPAL �" WELL
(IF WELL:WATER SUPPLY FROM ANY SEPTIC-SYSTEM ABSORPTION IS FT. )
✓ PERCOLATION TEST: RATE IS PER MIINUTE PER INCH (TEST TO BE
COMPLETED BY A LICENSED PROFESSIONAL ENGINEER OR ARCHITECT)
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: DD GALLON (MIN. SIZE IS 1,000 GAL.) TILE FIELD: EACH TRENCH 24 FT.
✓ TOTAL SYSTEM LENGTH: ` FT. SEEPAGE PIT(S): HOW MANY? /LJ/f1--
✓ SIZE OF EACH 41 /óFT. X FT.
✓ SIZE OF STONE TO BE USED: # - /DEPTH OR THICKNESS /4—FT.
✓ BED SYSTEM SIZE: X
✓ ALTERNATIVE SYSTEM: LENGTH AND/OR SIZE
✓ HOLDING TANK SYSTEM: (If required) NO. OF TANKS: /SIZE OF EACH
✓ GALLONS./TOTAL CAPACITY: GAL.
NOTE: ALARM SYSTEM AND ASSOCIATED ELECTRICAL WORK MUST BE INSPECTED BY A TOWN
APPROVED ELECTRICAL INSPECTION AGENCY. PLEASE REVIEW LIST PROVIDED.
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 QUESTIONS? CALL 761-8256 OR EMAIL
Queensbury Sanitary Sewage Disposal Ordinance. codes@queensbury.net
c-NnVISIT OUR WEBSITE FOR MORE INFORMATION
�'] � / � www.queensbury.net
Signature flPerson Responsible Date
Town of Queensbury . Community Development Office • 742 Bay Road, Queensbury, NY 12804
Septic Inspection Report
Office No. (518)761-8256 Date Ins pn -•uest rece' ed:
Queensbury Building&Code Enforcement Arrive: /pm • am/pm
742 Bay Rd.,Queensbury, NY 12804 Ins•!�,•is Initials:
1iw' -/kiS • _PERMIT NO : *NAME: •LOCATION: /A,' 7/i4'4q- A7[6 . INSPECT ON: 11
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: T , _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
4/of 7 69 5
Location of System on Property:
Front Rear Left Side Right Side
Middle Front Middle Rear
System Use Status:
p►P
ved
rtial Approved and needs to be re-inspected, please call the Building&Codes Office
Disapproved
Last revised 021006
Last revised 1/6/05
-,\. /0 - 17 7 1A)E Js
H/244/06
Septic Inspection Report
Office No. (518)761-8256 Date Inspectio�uest ived:
P rev
Code Enforcement Arrive: ' 'P Vam/ �rt: am/pm
Queensbury Building& �j!
742 BayRd.,Queensbury, NY 12804 Inspect s Initials:
NAME: ii '' .1, / S
-` PERMIT NO.:
0fr83' 7
LOCATION: ‘`c MI,•►1a•_ INSPECT ON:
RECHECK'
Comments and/or diagram
Soil Type: n / ••m (Clay
Type of Wa . unid. .I/Well Water
Waterline separa ig, • = nce ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length
•
Length of each trench ft.
Depth of trenches
Size of Stone --V--
Seepage Pits: Number _ _
Size: --- ..---x
Stone Size:
Piping Sig- ,, Type,t6
Building to tank 460
Tank to Distributiox f `" j1 .#2.....e.)Distribution Box Fid/ Pit �` c°
Opening Sealed: Y /Partial
ill
End Cap
Inlet/Outlet Pipes&Baffles .. ..Y.,,_...,N
Location/Separations
Foundation to tank ft.
Foundation to absorption •
Separation of Pits ___ft.
Conforms as per Plot Plan Y,.......e.N
Engineer Report and As-Built ..,,.�."Y �,.N
Location of Sy ,- on Pro
Front eride Right Side
Middle Front fiddle Rear
•
Approved
Partial Approved and needs to be re-inspected, please call the Building&Codes Office
Disapproved
Last revised 021006
Last revised 1/6/05
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