2010-469 elaki TOWN OFQ UEENSBURY
742 BayRoad,Queensbury,NY 12804-5902 (518)761-8201
to �
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20100469 Date Issued: Wednesday, November 23, 2011
This is to certify that work requested to be done as shown by Permit Number P20100469
has been completed.
Tax Map Number: 523400-296-015-0001-006-000-0000
Location: 65 COUNTRY CLUB Rd
Owner: STEVEN & LISA JACKOSKI
Applicant: STEVEN & LISA JACKOSKI
This structure may be occupied as a:
Test Pit/Perc Test Review
By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the " f ` f4 / ,! ,
property owner of the responsibility for compliance with Site Plan, (, '' ` 2 ; ,f
Variance, or other issues and conditions as a result of approvals by the Director of Building&Cade Enfaicement
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
` or 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20100469 Application Number: A20100469
Tax Map No: 523400-296-015-0001-006-000-0000
Permission is hereby granted to: STEVEN &LISA JACKOSKI
For property located at: 65 COUNTRY CLUB Rd
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: STEVEN&LISA JACKOSKI Test Pit/Perc Test Review
C/O 697 GLEN STREET, LLC
697 GLEN St Total Value
QUEENSBURY NY 12804-0000
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans&Specifications
2010-469
DEEP HOLE/PERC TEST
$200.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday,November 23,2012
(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.)
if
Dated at the 1.4kr‘ti sOlqueenskiiirye Argenesuray,November 23, 2011
SIGNED BY IV for the Town of Queensbury.
Director of Building&Code Enforcement
/0 47
Town of Queensbury• Building&Codes Enforcement Office•742 Bay Road■ ► sey,( ' tai ,
CT)
DEEP HOLE/PERC TEST
Request for Town Engineer Revie SEP 2 2 2010
TNF "UEENSBURY
Property Owner: STtsti , Lksn : /Q.ci o 1C1 Phone: & e■
Property Owner's
Address: �`
Location of Test: �7,� (e . i'/ u%).\? ::. Tax ID#: 796 1,4,
*Applicant's Engineer: .. ty(r..t ftj-3 &A/(,,r a.f Phone:
Applicant's Agent: Phone:
Additional Notes:
1. Reason for Request? 12 New Septic System I Replacement Septic System Failed Septic System
Subdivision Site Plan Review
2.Are Wetlands present? [X YES NO UNKNOWN
*Note: Applicant is required to engage an engineer for design and testing of the system. The Town
Engineer's responsibility is to witness system testing only.
PLOT PLAN: Plot plan, to scale, to be submitted with application
FEE SCHEDULE:
a. $200 Flat Fee Date Paid: 2
Check No.:
b. OR Fee to be determined during To Be Determined:
Site Plan/Subdivision review process
SIGNATURE:
In carrying out the provisions of Article IV, the Local Board of Health or the enforcement officer may
engage the services of a qualified professional consultant for expert review and recommendation arising
from the carrying out of the provisions of Art. IV, including but not limited to the review of plans,
specifications and reports, attendance at inspections, dye tests, deep hole test pits, septic related deep
hole and percolation tests, system installations, and any other aspect of any matter contained in this Art.
IV, and any costs incurred in such review shall be paid to the Town by the owner of the property before
any approval can be granted under this Art. IV shall become effective within 30 days of presentment of an
invoice for same, whichever is sooner. Such costs shall not exceed $1,500 without prior written notice to
the party to be charged with same.
My signature below indicates I have thoroughly read and understand the instructions, agree to the
submission requirements and have completed the application. I also fully understand that additional
engineering fees may be necessary per Town of Queensbury Local Law 136-14D.
SIGNATURE OF APPLICANT: ;_- Date:
ME
SIGNATURE OF AGENT: AM.' .44 ZA ���IOr Date: 22 /6
r
I
Original (B&C File) Canary(Planning) Pink(Applicant) Gold (Town Clerk)
12" MIN. COVER
,/. Q..
a r
2-
16"
4
APPROXIMATE
FINISH GRADE
LIQUID LEVEL
MINIMUM 2X WIDTH
MAXIMUM 4X WIDTh
18"MIN.
a d
CNK NOTES
SHALL COMPLY WITH THE REQUIREMENTS OF THE NEW YORK STATE
r OF HEALTH AND SHALL BE OF PRECAST CONCRETE AS
?ED BY UTOPIA ENTERPRISES OR EQUIVALENT.
rURES SHALL BE PLACED ON FIRM, COMPACT SAND OR GRAVEL
-RE EXISTING SOIL CONDITIONS ARE UNSUITABLE, CRUSHED STONE
LACED AS NECESSARY TO ACHIEVE A STABLE BASE.
'KS INSTALLED IN TRAFFIC AREAS SHALL BE OF EXTRA HEAVY
DN DESIGNED FOR H-20 WHEEL LOADING.
MUST BE SEALED WITH BUTYL SEALANT. JOINTS BELOW THE LIQUID
BE TESTED BEFORE BACKFILLING.
5d SLOPE
0o
Ute
13-E
475, 5
51,
AREA
70, 127. 18 sq.
1.61 acres
ZONING REQUIREMENTS
MODERATE DENSITY RESIDENTIAL (MDR)
FRONT SETBACK - 30'
SIDE SETBACK - 25'
REAR SETBACK - 30'
MAX BUILDING HEIGHT - 40'
PERMEABILITY - 50%
11
AL
AL
AL �a
SITE PLAN - ` \
30' �
AL AL
45780,
N81
1
r- SIGGESTED: POLYETHYLENE
1 � �
EATENSION TO GRADE WITH TAMPER
RESISTANT ACCESS COVER -�
2" MIN. DROP IRS
SUGGESTED: INSTALL POLYLOK BETWEEN INVERTS
PL -122 FILTER SUCH THAT IT IS
READILY REMOVABLE THROUGH 12" MIN. COVER
TANK ACCESS COVER
SEPTIC TANK DETAIL
NTS
OITLET
DISTRIBUTION BOX
" PVC
MIN. SLOPE
1/8" PER FOOT BAFFLE
USE SPEED LEVELERS TO
ASSURE ALL OUTLETS ARE AT
EXACTLY THE SAME ELEVATION
4" PVC SDR -35 SOLID HEADER
TO PERFORATED TRENCH PIPING,
1/8" PER FOOT MIN SLOPE
2" MIN.
WASTEWATER SYSTEM SETBACK SCHEDULE
PROPERTY LINE
BUILDING
SEPTIC TANK & GREASE TRAP
10'
10'
ABSORPTION FIELD
10'
20'
4" MIN TOPSOIL OVER THE 177RE
ABSORPTION FIELD;
SEED AND ESTABLISH TURF
FILTER FABRIC
MIRAFI 140N OR EQUIVALEN
-4" PERFORATED PVC LATERAL,
SLOPE 1116- - 1132- PER FT. D CAP
10'-0"
O. C. MAX 10
36" FENCE POST
DRIVEN MINIMUM 16"
INTO GROUND
SILT STOP EMBED
_ IN GROUND 8" MIN.
4" MIN TOPSOIL OVER THE
ENTIRE ABSORP77ON FIELD;
SEED & ESTABLISH TURF OVERFILL TO ALLOW
BACKFILL FREE OF FOR SETTLEMENT j� SOIL BACKFILL
STONES OVER 3"
0
PERSPECTIVE
FILTER FABRIC—,,,,
140N 6-12"
- M OR EQUAL 2' TRENCH WID7N
6" MIN.
--N
2» IN. 08
12" MIN.
6»
o�oQOO OO 000
r0 1-1/2"
CRUSHED Sr
" FENCE POST
T STOP EMBED
GROUND 8" MIN.
DISTURBED
OUND
MAP REFERENCE
DEQ
SEI
BASE INFORMATION FROM "MAP OF A SURVEY MADE
FOR STEVEN B. & LISA H. JACKOSKI" CREATED BY
VAN DUSEN & STEVES LCENSED LAND SURVEYORS.
QUEENSBURY, NY 12804
ONE SECTION DATED: JUNE 20, 2008
ABSORPTION TRENCH PROFILE ABSORPTION TRENCH SECTION SEDIMENT CONTROL FENCE DETAIL LAST REVISED: DECEMBER 23, 2009
NTS NTS NTS ADDI77ONAL INFORMATION FROM COUNTY GIS DATA
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SITE Loca rIoN LOCATION MAP
N TS
a
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I 'yed, or believe I saw evidence of,
2 2 2010 II { ses
, webs
hr_;trees, fer�eesetc
#i aI ' 1 ��IIt that
QUEENSBURY pe,. I have
TNG CODES e_ st . rth on th diagr "
DA
TAXMAP NO: 296.15-1-6
ALTERATION OF THIS DOCUMENT EXCEPT BY A LICENSED PROFESSIONAL
ENGINEER IS A VIOLATION OF NYS EDUCATION LAW.
0
PRELIMINARY
No.
Revisions
Date
SITE PLAN
prepared for:
Roger & Linda Jackoski
65 Country Club Road
Town of Queensbury, Warren County, NY
Drawn: LWD
Checked: GTH
Scale: NOTED J
Date: 9/1/2010
169 Havilond Road
Queensbury, NY 12804
Hutchins Engineering (518) 745-0307 Phone
g g
29437-01
518 745-0308 Fax