2012-107 TOWN OF QUEENSBURY
IF4T 742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20120107 Date Issued: Tuesday, April 03, 2012
This is to certify that work requested to be done as shown by Permit Number P20120107
has been completed.
Tax Map Number: 523400-296-014-0001-007-000-0000
Location: 78 MONTRAY Rd
Owner: GRAYSON PROPERTIES LLC
Applicant: GRAYSON PROPERTIES LLC
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
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.
1
Olbk TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20120107 Application Number: A20120107
Tax Map No: 523400-296-014-0001-007-000-0000
Permission is hereby granted to: GRAYSON PROPERTIES LLC
For property located at: 78 MONTRAY 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: GRAYSON PROPERTIES LLC Septic Alteration Residential
1004 CHESTNUT St Total Value
MECHANICVILLE,NY 12118
Contractor or Builder's Name/Address Electrical Inspection Agency
DOUG SIMMONS
669-4588
241 SUGAR HILL Rd
REXFORD NY
Plans&Specifications
2012-107
Lot 17 78 Montray Rd- Replacing Existing Tank
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday,March 21, 2013
(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 ensbury A, We' I es,ay, March 21, 2012
SIGNED BY41
1 for the Town of Queensbury.
Director of Building&Co•e Enforcement
1�pp,Q } '— / OFFICE USE ONLY/
TAX MAP NO�LP'I 47'' PERMIT NO./ —JO l PERMIT FEE u v
APPROVALS: ZONING TOWN CLERK
MAR 21 2012 ;
APPLICATION FOR SEPTIC DISPOSAL SYSTEM PE . IThUN DOF
NGU& CODES
A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS.APPLICATION IS SUBJECT TO REVIEW BEFORE ISSUANCE OF A VALID
PERMIT.
OWNER: 1-7 re y_rdt7N INSTALLER: ID °L`�( L�'
I
�� �J vim- w\c�./�/�
ADDRESS: /009 64e. /,,vA .S ckci,vc✓,I k ADDRESS: ZV/ Jc1.4 r //:7/ /e Ex) r1 ///
PHONE NOS. .5-7k" -Z Z ?- 2 7 82 PHONE NOS. J74 '- 4'J ?d'
LOCATION OF INSTALLATION: 72 14 vre y AK C ,Co/ /7
YEAR BUILT NO.OF X COMPUTATION= RESIDENCE INFORMATION:
BEDROOMS = TOTAL DAILY FLOW
1980 or older X 150 gallon per bedroom = GARBAGE GRINDER ,
INSTALLED? +'3 '�/(J
1981 -1991 X 130 gallon per bedroom = g
1992-present X 110 gallon per bedroom = SPA INSTALLEOD?
ETUB :)
PARCEL INFORMATION:
✓ TOPOGRAPHY: Flat rolling / Steep slope %Slo e
P
✓ 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 minute 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).
TANK SIZE: /o0O GALLON (MIN. SIZE IS 1,000 GAL.) Add 250 gallons to the size of the septic tank for
each garbage grinder, spa or whirlpool tub.
SYSTEM TYPE:
❑ ABSORPTION FIELD (WITH NO. 2 STONE) Total length ft. Each trench
X
O SEEPAGE PIT(S) (WITH NO. 3 STONE) How many? Size?
❑ ALTERNATIVE SYSTEM Bed or other type?
❑ HOLDING TANK SYSTEM Total required capacity?
Tank size?
J ;s IA- Number of tanks?
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@queensburv.net
,(7 VISIT OUR WEBSITE FOR MORE INFORMATION
Vz-///
www.queensburv.net
Signatuof Person Responsible
: , . Town of Queensbury • Community Development Office • 742 Bay Road, Queensbury, NY 12804
B 5-LGL 6/06
Septic Inspection Report
Office No. (518) 761-8256 Date Inspe, req �-; e•
Queensbury Building &Code Enforcement Arrive: 17 at•
L. p / ,.rt: i C7m/pm
742 Bay Rd., Queensbury, NY 12804 Inspectors Initials:
NAME: C--6A �inn !1rOp - PEr IT NO.: `1017
LOCATION: 'ICNna41-64, Rapt I SPECT ON: 330- 1
RECHECK:
Comments and/or diagram
Soil Type: :,,*P' .. • Clay
Type of Water: I ell Water
Waterli - eparation distance ft.
Well separation distance ft.
Other wells: _ft.
Well Casing Length 50' + / - Y N N/A
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 CA VIC)
Tank to Distribution Box 'Lk`` 1�t up ems% LA-%
Distribution Box to Field / Pit f
Opening Sealed: VY
End Cap Y_N
Inlet/Outlet Pipes &Baffles
Location/ Separations
• Foundation to tank Vl> ft.
Foundation to absorption
Separation of Pits ft.
Conforms as per Plot Plan i/Y N
Engineer Report and As-Built Y N
Location of System on Property:
Front • -ar Left Sid ' ht Side Middle Front Middle Rear
S s - Us- i .
Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
Last revised 06/18/07 \Building&Codes Forms-OLD\Building&Codes\Inspection Forms\Septic Inspection Report.doc
Aft Community Development Office
F � Town of Queensbury • 742 Bay Rd.
Queensbury, New York •12804 PLOT PLAN
Show all existing and proposed structures. Indicate the setbacks of all structures and buildings from all property lines.
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