2015-439 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20150439 Date Issued: Wednesday, October 14, 2015
This is to certify that work requested to be done as shown by Permit Number P20150439
has been completed.
Tax Map Number: 523400-303-020-0001-003-002-0000
Location: 364 DIX Ave
Owner: CLARK BRINK
Applicant: CLARK BRINK
This structure may be occupied as a:
Septic Alteration Commercial
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, j
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
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20150439 Application Number: A20150439
Tax Map No: 523400-303-020-0001-003-002-0000
Permission is hereby granted to: CLARK BRINK
For property located at: 364 DIX 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: CLARK BRINK
MC DONALD'S CORP. Septic Alteration Commercial
50 SEWARD St Total Value
SARATOGA SPRINGS,NY 12866-0
Contractor or Builder's Name /Address Electrical Inspection Agency
HUTCHINS ENGINEERING
169 HAVILAND ROAD
OUEENSBURY.NY 12804-0000
Plans&Specifications
2015-439
Commercial Septic Alteration
$75.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday, September 21,2016
(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 eens 1 n �. •ptember 21,2015
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
SEPTIC DISPOSAL PERMIT
Office Use Only
DATE 9/17/201 ) ', ETia'' _-
CD 1E,I1 .,x
TAX MAP ID 303.20-1-3 Permit 2.015-2151
SEP 1 $ 20R9rmi -e-Ic1'5
LOCATION OF INSTALLATION 364 DIX AVE L': Approv .
TOWN OF QUEENSBURY
BUILDING&CODES
APPLICANT MCDONALD'S OF DIX AVENUE / -MAIL (518)792-3056
ADDRESS 364 DIX AVENUE,QUEENSBURY NY 12804
INSTALLER/BUILDER: PHONE/E-MAIL
ADDRESS:
OWNER MCDONALD'S CORP.&CLARK BRINKPHONE/E-MAIL CWBRINK2@GMAIL.COM
Address 50 SEWARD STREET,SARATOGA SPRINGS NY 12866
CONTACT PERSON FOR BUILDING&CODES COMPLIANCE: HUTCHINS ENGINEERING PHONE (518)745-0307
RESIDENCE INFORMATION
Year Built #of bedrooms
X Gallons per bedroom =Total Daily Flow
1980 or older Garbage grinder installed _Y ✓ N
1981-1991 Spa or Hot Tub installed _Y ✓ N
1992 Present 58 SEATS 25 GPD PER SEAT
1 DRIVE-THRU 500 GPD PER DRIVE-THRU USE 2.000 GPD
PARCEL INFORMATION
Topography ✓ Flat rolling Steep slope %slope
Soil Nature ✓ Sand Loam Clay Other
Groundwater At what depth? >70"
Bedrock/Impervious Material At what depth? >70"
Domestic Water Supply ✓ Municipal Well(if well, water supply from any septic system absorption is ft.)
Percolation Test Rate:1-s MIN DESIGN per minute per inch (test to be completed by licensed engineering/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION
SEE PLAN:EXISTING SEPTIC TANK TO REMAIN
Tank Size 4,000 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 900 ft.; Each trench 18 x 50 (2 FIELDS)
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 per. it or approval granted which is based upon or is granted in reliance upon any material representation or
failure to make a ma - :1 fact or circum .nce know by or on behalf of an applicant, shall be void. I have read the regulations
and agree to abide , , - - - an. all req ir- ents of the Town of Queensbury Sanitary Sew..e a'so•,alOrdinance.
Print Name: IV.- A ► �' c Ih,7S Date: �r
Signature: 4!i �`i'_ Date: -j
Town of Queensbury Building& •de- Septic Disposal Permit my 2014
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection reques• - i •:
Queensbury Building &Code Enforcement Arrive: 3= ` a 'I' rt:
742 Bay Rd., Queensbury, NY 12804 I Inspector's Initials: _A
NAME: 1C OLD -5 PER NO.: 5--4.3C4
LOCATION: Cc.' \ PECT ON: I(,
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.
Well Casing Length 50' + / - Y N N/A
[150'to well required if NO]
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
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
Foundation to absorption .
Separation of Pits ft. —
Conforms as per Plot Plan _ N �'0��
Engineer Report and As-Built Y N
ETU Maintenance Contract _Y_ N
provided
Location of System on Property:
Front Rea Left Side Right Side Middle Front Middle Rear
S stem Use Sta .s:
Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved `t
L:\Pam Whiting\2010\Building Codes Forms\Inspection Forms\Septic Inspection Report 03 29 10.doc
169 Haviland Road
Queensbury, NY 12804
Hutchins Engineering Phone: (518) 745-0307
Fax: (518)745-0308
October 9, 2015
Mr. Mike Shaw, P.E.
NYS Department of Health
77 Mohican Street
Glens Falls NY 12801
Re: Septic System Installation, McDonald's of Dix Avenue
364 Dix Avenue, Town of Queensbury
Tax Map ID: 303.20-1-3.2
Dear Mr. Shaw:
Our office prepared a wastewater replacement design for McDonald's of Dix Avenue at the
above-referenced property. The system consists of an existing 4,000-gallon septic tank, one
existing 750-gallon and two existing 1,500-gallon grease traps, an existing 750-gallon pump
station, and the installation of two pipe-in-stone absorption fields, each consisting of 9 trenches
at 50 LF (450 LF per field), for a total of 900 LF.
A representative from our office visited the site numerous times during construction. Based
upon our site inspection and our discussions with the installer, it is my opinion that, with the
exception of surface finishing and turf establishment, the replacement absorption field was
installed in general conformance with the approved plans and the attached record drawing.
Please contact me if you have any questions or if you require additional information.
Best Regards,
G. omas u c ins, P. .
Enclosure
Cc: Mr. Clark Brink, McDonald's of Dix Avenue REcEivED
Town of Queensbury Building Department
Mr. Dean Burdick, Stone Industries
IC
I ay I L015
2.®1`J
G.Thomas Hutchins,P.E.
169 `Haviland Road
Queensbury, Nr 1..12804 29769=01 1
(518) 45 "0307',Phone
�g ,-(518 745-0308 Fax
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TANDARDS) 25/GPD PER SEAT;. 500/GPD PER- DRI VE- THRU
x58)+500 .1, 950 ,GPD (USE 2, 000 . GPD' DESIGN ,FLOW)
PTEMBER ,2009 JULY 2015: 1;427 AVERAGE GPD)
)00 GAL •' PRECAST `CONCRETE
NG 1,500 GAL , (1), -EXISTING 750 ,GAL. .
IN CURRENT CONFIGURATION.'
?&t1lN-STONE1 ABSORPTION TRENCHES
2 GPD/SF
REA REQUIRED 1,667 ,SF
ENGTH ' REQUIRED : >834
9 TRENCHES AT .50 L F. PER FIELD
MUNICIPAL : SUPPLY .., .
0 SEPARATION. BETWEEN WATER LINES AND ,WASTEWATER
ATIO NOTES
1ED '>RAINFALL AND `DIVERT.;SURFACE
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TANDARDS) 25/GPD PER SEAT;. 500/GPD PER- DRI VE- THRU
x58)+500 .1, 950 ,GPD (USE 2, 000 . GPD' DESIGN ,FLOW)
PTEMBER ,2009 JULY 2015: 1;427 AVERAGE GPD)
)00 GAL •' PRECAST `CONCRETE
NG 1,500 GAL , (1), -EXISTING 750 ,GAL. .
IN CURRENT CONFIGURATION.'
?&t1lN-STONE1 ABSORPTION TRENCHES
2 GPD/SF
REA REQUIRED 1,667 ,SF
ENGTH ' REQUIRED : >834
9 TRENCHES AT .50 L F. PER FIELD
MUNICIPAL : SUPPLY .., .
0 SEPARATION. BETWEEN WATER LINES AND ,WASTEWATER
ATIO NOTES
1ED '>RAINFALL AND `DIVERT.;SURFACE
Town of Queensbury Building &Code Enforcement
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Office No. (518)761-8256
Septic Inspection Report
Inspection request received: tt /q, S (le)RC
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Name: �J;�t` 14-- /mc .--- 1/41�] s Inspected on: I v/ 7/,
Location: 362 y b /)cf i"&£ Arrive: n Z�� �a.. 1 p.m -
Permit No.: 1 C 1— (/ 3 7 Inspector's Initials: rf�
ents andlor dia ram
Soil Typ:: an lay
Type of Water: I unici.- 0. - ater
Waterline separa on distance ft.
Well separation distance ft.
Other wells: ft.
Well Casing Length 50'+/- Y_N N/A
[150'to well required if NO]
Absorption Field: Total length clOO ft. Z C, ).a S-
Length of each trench Wt")ft.
Depth of trenches 14 t, ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank c r t r.)(‘
Tank to Distribution Box *1.-" ALN UF oQ L !i V
Distribution Box to Field/Pit / �!t I Qo •. c: t U' ' WC__V�NA W--V, —Opening Sealed: �/1' N
End Cap N
Inlet/Outlet Pipes&Baffles Y Y_N
Manholes 12"or less below grade V '
Y X[provide extension collar if Yes]0OY
Location/Separations vi. -V,-.-
Foundation to tank ft. ). 72701—
Foundation to absorption ft.
Separation of Pits ft
Conformsnineerasper Plot Plan Y_N '1 E— L � �
Engineer Report and As-Built Y N � x5 &�
ETU Maintenance Contract provided Y N ��
Location of System on Property: D12- 1-6 c Pitt /----�Ck__O
Front Rear Left Side Right Side Middle Front iddle Rear
System Use Status:
pproved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Ci
Disapproved
Septic Inspection Report