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TOWN OF QUEENSBURY
r' 742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development-Building&Codes (518)761-8256
BUILDING PERMIT
Permit Number: BOTH-000150-2015
Tax Map No: 302.17-1-22
Permission is hereby granted to: Matthew Lusignan
For property located at: 27 LUPINE LN
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
Owner Address: Septic Disposal $0.00
Total Value $0.00
Contractor or Builder's Name/Address Electrical Inspection Agency
George Drellos
Plans&Specifications
Residential Septic Alteration
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES:
(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 Town of eensb • w
SIGNED BY: for the Town of Queensbury.
Director of Building&Code Enforcement
SEPTIC DISPOSAL PERMIT Office Use Only
DATE
Wil' " Z(' - / '' _ Received
r� e� �
TAX MAP ID 3d�r(7-/ -- ' oG ./ 0 2� ;e t 0� bd�'N -000a50-aOi.5
�7 L ►rgi'J y. Permfit'Fee JJ)`�72P�� - wvi c�5 0
LOCATION OF INSTALLATION of / *f 11d OW CC
_,��. „�„-� ,��f-•, Approvals:
Ck4 r7 /c
/61---- / ,7
APPLICANT 7174 4 f T- uf/ rrf/v' N PHONE/E-MAIL 0 Z a ” e .?�"-
ADDRESS a 7 ,ip/ )i
INSTALLER/BUILDER: ✓/9-iv1 f/J r _ �t( L �(�////L'r PHONE/E-MAIL 7/49 - 72£ 7
ADDRESS: U -o, 160 X 2Z y (9-/P F/4- /I/9 //rr49/
OWNER /37/4 /t 41 '
�� /`'`f y PHONE/E-MAIL
Address D27 (i✓.J, ,u Qi( . 4,42-5,2:-J-i%S,� , /2i'
CONTACT PERSON FOR BUILDING&COPES COMPLIANCE: (cel✓�. 6-7 A A `'/ PHONE 7l/' �e4
RESIDENCE INFORMATION (/
Year Built #of bedrooms X Gallons per bedroom =Total Daily Flow
1980 or older Garbage grinder installed Y .N
1981-1991 7 /5.--6'6' %s G) Spa or Hot Tub installed _Y N
1992-Present
PARCEL.INFORMATION
Topography Flat rolling Steep slope %slope
Soil Nature 'V Sand Loam Clay Other
Groundwater At what depth? J"'4
Bedrock/Impervious Material At what depth? r"'A
Domestic Water Supply V Municipal Well(if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: /-i per minute per inch(test to be completed by licensed engineering/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION
Tank Size /kr w, /G7'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 2C ' ft.;Each trench S c' ' 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 these and all requir9ments of the Town of Queensbury Sanitary Sewage Disposal Ordinance.
Print Name: - 'o/'LI _.Prz7ll Date: /n-' 2e --/r
Signature: G - �� � Date: /o —Zo--/J
Town of Queensbury Building&Codes Septic Disposal Permit July 2014
I
/7/ 4)4 L 14 S`5 N A iV r Maff Lusignan BOTH-000150-2015
,� Sanitary Sewer Service
27 Lupine Drive
�� Residential Septic Alteration
1•- zr _.�� Soy
tS` __ S"v' �: 1ST
FILE so'
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/ sl
- OCT 2015 J
TOWN OF QUEENSBURY
ERTI! PLOT PLAN BUILDING&CODES
I HAVE SEEN OR i BSERVED ALL OBJECTS o ,
SUCH AS HOUSES, :LLS, TREES, FENCES, ETC D 4`
SHOWN ON THIS DOC ENT I HAVE PERSONALLY 3 p
ME,;BRED THE DISTAN` . T F1• ON THIS DIAGRAM.
SIGNATURE / " 4Z 6-:_j_____31:___-/s,---
DATE
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021 614P'