2015-196 gift TOWN OF QUEENSBURY
otoBay rY742 Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20150196 Date Issued: Wednesday, August 19, 2015
This is to certify that work requested to be done as shown by Permit Number P20150196
has been completed.
Tax Map Number: 523400-308-014-0001-052-000-0000
Location: 183 PITCHER Rd
Owner: FOREST PARK -- 65 GREGWOOD CIRCLE
Applicant: FOREST PARK -- 65 GREGWOOD CIRCLE
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 (DJ 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
Fitiv,ro 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20150196 Application Number: A20150196
Tax Map No: 523400-308-014-0001-052-000-0000
Permission is hereby granted to: FOREST PARK MHC. LLC
For property located at: 183 PITCHER 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: FOREST PARK MHC, LLC Septic Alteration Residential
31200 NORTHWESTERN Hwy Total Value
FARMINGTON HILLS MI 48834-00
Contractor or Builder's Name /Address Electrical Inspection Agency
Plans&Specifications
2015-196
Septic Alteration
65 Gregwood Circle
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday, May 26,2016
(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 n of ens ;/J es of. ' ' ay 26, 2015
i
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
SEPTIC DISPOSAL PERMIT Office Use Only
DATE 51 1 I if Received
Tax Map ID
TAxMAPID i 1i Permit No. ���"t`�So
D
S l,tj. f. f'L 7 � 1�� Permit Fee f
LOCATION OF INSTALLATION . A+ t, - Approvals:
•�t ., . QUEENS'
JPI.W_r'IAIf ° !'OCA
Forel f' Park rn}-IC LLC,, __ (51e) Jbrestpk
APPLICANT PHONE/E-MAILIyS Mtns
rho-prcpertiea.crrm
ADDRESS 03 P any . 0 sc9i N 1 1 g WI
j,� �j '
(5--/6)
INSTALLER/BUILDER: StOralrigiz�t�lati OA S PHONE/E-MAIL 5-S1A-t 8
ADDRESS: 4305 at,O SGi-rc t1cA rimy Icy to A'�l 0
OWNER Fere.5t V K WIl ,LLC. `J PHONE/E-MAIL\.0i . 1,A(2.0
Address 4Zar'ei oGli l_lretC 4 C'X'1Sk)Lt-VL4-- Nv I dgo7
Q /cid)
CONTACT PERSON FOR BUILDING&CODES COMPLIANCE: )1161)1 0.II a VI�� c VI PHONE 1Mb` 17
,
RESIDENCE INFORMATION JJ
Year Built #of bedrooms X Gallons per bedroom =Total Daily Flow
1980 or older Garbage grinder installed Y J`N
1981-1991 Spa or Hot Tub installed Y 711
1992-Present 3 X30
PARCEL INFORMATION
Topography Y/ Flat rolling Steep slope %slope
Soil Nature /Sand Loam Clay Other
Groundwater At what depth? Dine i‘i ,wA .k ^t el T'
Bedrock
Bedrock/Impervious Material At what depth? NOp1V. 'c'C Q(Dri,v\< V '\
Domestic Water Supply /Municipal Well(if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: '"1 1 per minute per inch(test to be completed by licensed engineering/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION /97Z6- 4, ,,✓.//r S 5�f .�.i r_!`
_s,
Tank Size I i(.(.,l, gallons(minimum size 1,000 gallons,add 250 gallons to size for each garbage grinder or spa or hot tub)
System Type Absorption field with#2 stone Total length / 7.. ' ft.; Each trench ,)2 ' x '
Seepage Pit with#3 stone How many: ;size
Alternative System Bed or other type?
Holding Tank System Total required capacity? Tank size #of tanks
Notes: 1)Alarm system&associated electrical work must be inspected by a Town approved electrical inspection agency;2)We will no longer
allow systems to be covered until such time as an As-Built plan is received & approved. The installed system must match the septic system
layout on file—no exceptions.
DECLARATION: Any permit or approval granted which is based upon or is granted in reliance upon any material representation or
failure to make a material fact or circumstance know by or on behalf of an applicant, shall be void. I have read the regulations and
agree to abide by hese and all res irements of the Town of Queensbury Sanitary Sewage Disposal Ordinance.
Print Name: ail a e_ v ,L Vi Date: 51a1/0
Signature: �,�L(Cthlir if 'l i'o'V\ Date: 51 Q l l
Town of Queensbury Building&Codes Septic Disposal Permit July 2014
Town of Queensbury Building &Code Enforcement
Office No. (518) 761-8256
Septic Inspection Report
Inspection request received:
Name: eelefZire Inspected on: S C
Location: �� (al Arrive: -1E0a.m.l p.m.
Permit No.: / 5 — (cC ic �' '— /Cl( Inspector's Initials:
Comments and/or diagram
Soil Type: Sand/Loam/CI��
Type of Water: Municipal/W: I Water
Waterline separation distance ft.
Well separation distance ft. '
Other wells: ft.
Well Casing Length 50'+I- Y N N/A
[150'to well required if NO]
Absorption Field: Total length \
ft.
Length of each trench ft. \)('
Depth of trenches ft. c� •
Size of Stone
Seepage Pits: Number
Size:
Stone Size: /v
Piping •ize Type I —
Building to tank
Tank to Distribution Box
Distribution Box to Field/Pit
Opening Sealed: Y N
End Cap _Y N
Inlet/Outlet Pipes&Baffles Y N
Manholes 12"or less below grade Y N
[provide extension collar if Yes] Y N
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan N
Engineer Report and As-Built N
ETU Maintenance Contract provided N
Location of System on Property:
Front Rear Left Side Right Side Middle Front Middle Rear
system Use Statu _
pprov
a ial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
Septic Inspection Report
G. Peter Jensen
17 West Road . .".}
o
South Glens Falls
New York 12803
(518) 798—3859 ' - :8d2U\
ly f
June 05, 2015 TOv��i p Q�LIfTgauRY
BUILDING& CODES
To Whom It May Concern:
I have designed(plan 14-1103)and observed the installation of the septic system
at lot 65 & 67 Gregwood Circle, Forest Park MHC, Town of Queensbury, Warren
County,New York. It would appear that the installation is within the intent of the design
documents. To the best of my knowledge and belief, no field conditions were
encountered that would require a re-design of the septic system. Hancor ARC 24
chambers, with a 25%reduction, have been substituted for the stone and pipe system.
To the best of my knowledge and belief all of the distance separation requirements
have been met.
Sincerely,
G. PeteYi3'ensen o ,�A c4'
(1.;;;E
� q41ERJE%
4 * 6,
\4:1)ATF OF N� (�
()C
CAV.
� I
Town of Queensbury Building & Code Enforcement 1 ° 43— Com)
Office No. (518)761-8256
Septic Inspection Report '
A
Inspection reques received: . a . 4
Name: ire/SrJ Inspected on: . 1 rs
Location: 05 61 Jc%C C(VZ"Qf,-- Arrive: I MIA a.m./p.m.
Permit No.: 09415— I SD Inspector's Initials: _Mir
Comments and/or diagram
Soil Type:�nCn /L lay
Type of Water: unici /Well Water
Waterline separa ion distance ft.
Well separation distance ft. 1)-61)4L ,
Other wells: ft.
Well Casing Length 50'+/- Y N N/A `` ,,,n, CC
[150'to well required if NO] /ie �VIJ 43Y�
Absorption Field: Total length k-1 ft. 2 — /_ ! i
Length of each trench ft. J (0 7 1
r�
Depth of trenches ft. --�
Size of Stone t �' '�Tlx
Seepage Pits: Number � ��1'�`�--�%+' ��
Size:, x�
Stone Size:
Piping Size
Building to tank
ti
-� Type f
5
Tank to Distribution Box 1
Distribution Box to Field/Pit / — ilk44V Com/ `r-r `�
Opening Sealed: J Y N h
End Cap N L4 A,
Inlet/Outlet Pipes&Baffles _Y N
Manholes 12"or less below grade _Y N
[provide extension collar if Yes] Y N
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.
-----.14.2517,11.0....... U
Separation of Pits ft.
Conforms as per Plot PlanN �� Ft4444�
Engineer Report and As-Built Y N
ETU Maintenance Contract provided Y N
cr.R6wale ricl-Co t y1/4)-C—C—Q._
Location of System on Prope i k- -r A.�' ' 1 ��
Front Rear Left Side Right Side Middle Front Middle Rear '�—C
System Use Status:
iApprov �.,
Pa al Approve nd needs to be re-inspected, please call the Building&Codes Office
Disappr ee t e.,
a
•0
Septic Inspection Report
41
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BUILDING & C
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It Is a Victitsor of the 'Law for any pocson,
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Liren38j Ar(tijtlill to Alter liy Port,on of This
Docurnent in any way. 11 any PoMon of this
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Docurnpun S So A�Ier�d, lai,�q ui A*er;ted
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the Norattori -Atlered By* Fujioged Cy Ns
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A Ageration, wo SignaKute aW the Date of Suct,
f e a Spe*fic 0"cril:Xior, fV ft4 Alle(ah-an.
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T A
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It Is a Victitsor of the 'Law for any pocson,
0 Unless Avina Uncer ine Direction of a
Liren38j Ar(tijtlill to Alter liy Port,on of This
Docurnent in any way. 11 any PoMon of this
Arch
Docurnpun S So A�Ier�d, lai,�q ui A*er;ted
SW MIA IoIhf,,P(jif1ionsc AIter0his Seat and
the Norattori -Atlered By* Fujioged Cy Ns
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A Ageration, wo SignaKute aW the Date of Suct,
f e a Spe*fic 0"cril:Xior, fV ft4 Alle(ah-an.
STR A I IGIHT'S SEPTIO SEW ICX;:
4
I R>Rms�r PAIR K
G. ETER JI
17 Pw
EST ROAC
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t-" s
NEW YORK 280'�
(518) 7W3,R--,'1_l 'A
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TOWN OF OU
BUILDING & C
Reviewed By/
Jr
AMMEM26L,
LZV15,- 71�N,,*H'
> <
4'
FK l-4
m!
i 11
T A
O?CZ
It Is a Victitsor of the 'Law for any pocson,
0 Unless Avina Uncer ine Direction of a
Liren38j Ar(tijtlill to Alter liy Port,on of This
Docurnent in any way. 11 any PoMon of this
Arch
Docurnpun S So A�Ier�d, lai,�q ui A*er;ted
SW MIA IoIhf,,P(jif1ionsc AIter0his Seat and
the Norattori -Atlered By* Fujioged Cy Ns
r.
A Ageration, wo SignaKute aW the Date of Suct,
f e a Spe*fic 0"cril:Xior, fV ft4 Alle(ah-an.
STR A I IGIHT'S SEPTIO SEW ICX;:
4
I R>Rms�r PAIR K
G. ETER JI
17 Pw
EST ROAC
SOUTH GLENS
t-" s
NEW YORK 280'�
(518) 7W3,R--,'1_l 'A
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TOWN OF OU
BUILDING & C
Reviewed By/
Jr
AMMEM26L,
LZV15,- 71�N,,*H'
> <
4'
FK l-4
m!
i 11
T A
O?CZ
It Is a Victitsor of the 'Law for any pocson,
0 Unless Avina Uncer ine Direction of a
Liren38j Ar(tijtlill to Alter liy Port,on of This
Docurnent in any way. 11 any PoMon of this
Arch
Docurnpun S So A�Ier�d, lai,�q ui A*er;ted
SW MIA IoIhf,,P(jif1ionsc AIter0his Seat and
the Norattori -Atlered By* Fujioged Cy Ns
r.
A Ageration, wo SignaKute aW the Date of Suct,
f e a Spe*fic 0"cril:Xior, fV ft4 Alle(ah-an.
STR A I IGIHT'S SEPTIO SEW ICX;:
4
I R>Rms�r PAIR K
G. ETER JI
17 Pw
EST ROAC
SOUTH GLENS
t-" s
NEW YORK 280'�
(518) 7W3,R--,'1_l 'A