2012-176 .41W TOWN OF QUEENSBURY
*few 742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20120176 Date Issued: Tuesday, April 24, 2012
This is to certify that work requested to be done as shown by Permit Number P20120176
has been completed.
Tax Map Number: 523400-308-008-0001-033-000-0000
Location: 542A SHERMAN Ave
Owner: MATTHEW ELLSWORTH
Applicant: MATTHEW ELLSWORTH
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 Direc co. r:cement
Planning Board or Zoning Board of Appeals. '
TOWN OF QUEENSBURY
f742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
*-.04ir
' Community Development-Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20120176 Application Number: A20120176
Tax Map No: 523400-308-008-0001-033-000-0000
Permission is hereby granted to: MATTHEW ELLSWORTH
For property located at: 542A SHERMAN 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: MATTHEW ELLSWORTH
16 CONGDON Rd Septic Alteration Residential
SO GLENS FALLS, NY 12803-0000 Total Value
Contractor or Builder's Name/Address Electrical Inspection Agency
IBS SEPTIC
IVAN BELL
2 LOWER WARREN STREET
QUEENSBURY, NEW YORK
Plans&Specifications
2012-176
septic alteration
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday, April 19, 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 S3of eensbury• Th r d. , April 19, 2012
�!
SIGNED BY 0 4 l` for the Town of Queensbury.
Director of Building& Co:e Enfo cement
•
, Revised 4/14/2010
OFFICE USE ONLY
TAX MAP NO.,30 .,cA—/—33 PERMIT NO. I —/ /(QPERMIT FEE*L____'
III 11 il
APPROVALS: ZONING TOWN CLERK APR 1 y 7017 J
APPLICATION FOR SEPTIC DISPOSAL SYSTEM PERMIT:
A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS. APPLICATION IS SUBJECT TO REVIEW BEFORE ',/
ISSUANCE OF}A VALID PERMIT.
OWNER: r`'`U `I E`5 kik,D( h p INSTALLER: ILS S
L
ADDRESS: J 6T J keI r ri^O,. r 1Je ADDRESS:#' Lnt..?r �arr(7, St. Qt -i•
PHONE NOS. 1 1 PHONE NOS. J k 11‘6.-‘6.- `9t
LOCATION OF INSTALLATION:14 t-i;), J'<`_`er ,,NVZ
RESIDENCE INFORMATION:
YEAR BUILT NO.OF X COMPUTATION = TOTAL DAILY FLOW
BEDROOMS (Gallons per bedroom) GARBAGE GRINDER
1980 or older N tC x 150 = NN INSTALLED?
1981_1991 11. X 130 = rj Zn SPA OR HOT TUB
1992-present NX 110 = Mk - INSTALLED?
PARCEL INFORMATION: Ni✓ TOPOGRAPHY: FLAT ROLLING STEEP SLOPE Ic %SLOPE1\J N �,I
✓ SOIL NATURE: SAND . n
LOAM IV I\ CLAY gN.N OTHER I'l Pr
✓ GROUNDWATER: AT WHAT DEPTH? N ( `'
✓ BEDROCK/IMPERVIOUS MATERIAL: AT WHAT DEPTH? IV
✓ DOMESTIC WATER SUPLY: MUNICIPAL _ WELL`\A (If well:water supply from any septic system absorption is: ftt
N
I PERCOLATION TEST: RATE IS N PER MIINUTE PER INCH[mpi]
(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: \Q9Q GALLON(MIN.SIZE IS 1,000 GAL.)Add 250 gallons to the size of the septic tank for
e41, 3 each garbage grinder,spa or whirlpool tub.
SYSTEM TYPE: r
c'ABSORPTION FIELD(WITH NO.2 STONE) Total length�..3n ft. Each trench S X c
❑SEEPAGE PIT(S)(WITH NO.3 STONE) How many? N h Size? tV\' h
❑ALTERNATIVE SYSTEM Bed or other type? 1\
N nr i``''
❑HOLDING TANK SYSTEM Total required capacity? 'v Tank size?+�] Number of tanks? {V N
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 Queensbury QUESTIONS? CALL 761-8256 OR EMAIL
Sanitary Sewage Disposal Ordinance. codes(a�queensburv.net
L -\9-k)--, VISIT OUR WEBSITE FOR MORE INFORMATION
Sigo?rature Person Responsible Date Www.queensbur 1.net
Town of Queensbury* Community Development Office* 742 Bay Road, Queensbury NY 12804
1h u rsJest / 3 O
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building &Code Enforcement Arrive: am/pm Depart: /pm
742 Bay Rd., Queensbury, NY 12804 Inspector's Initials:
NAME: ► 1 ) 9-i) l�L LPERMIT NO.: 10 " 1
LOCATION :S' / ,S INSPECT ON: 43=
RECHECK:
Comments and/or diagram
Soil Type: Loam / Clay
Type of Water: Municipal/ Well Water Fa S
Waterline separation distance ft.
Well separation distanceft.
Other wells: ft.
Well Casing Length 50' + / - Y N N/A
Absorption Field: Total length c0 ft.
Length of each trench 0 ft.
Depth of trenches • ft. ---- -
Size of Stone 'L-. c'`1 c _
Seepage Pits: Number /— h 1��^-
Size: x
Stone Size:
Piping Size Type
Building to tank :-�---_ 1- C \�N rt_i)
Tank to Distribution Box � ��
vt
Distribution Box to Field / Pit
: ,-k
FC--1 f 2D
Opening Sealed: Y/ N
End Cap +�!Y ' N
Inlet/Outlet Pipes &Baffles ✓Y N
Location/ Separations
Foundation to tank _ ' . 04L �
Foundation to absorption ft.
Separation of Pits �ft.
Conforms as .-r P:.iGa. _✓Y _ N
Engineer Report an. As-Built 0 , N
Location of System- roperty:
Front Rear Left Side Right Side Middle Front Middle Rear
System Use Statu
Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
Last revised 06/18/07 L:\Building&Codes Forms-OLD\Building&Codes\Inspection Forms\Septic Inspection Report.doc
cOO &-§)—c�W \YA auos\-=:,ctab�`.6
ofncc\ w .H21
\M
0
4.,
- rt SIY -*
, 1 4 cr:. -- n' Mi•-•
As. ...Y___
Nil 50' crs' – (---i
. 1 —
-----
.)(,,i _____.------...
I ----
.
,Eli i.1 ‘-,...7 i._ ..,
d, or believe I saw evidence of, !
Li1... •
ti APR 1 9 2012
,%:.c
•,, c ? i
, • ., ,.. c;'.-,,,o;oant. I also represent that I have
/'
i)-
the distmces set forth on the diagram."
3ii!LDA•-; coo.,..:.c.3
#A ,1 1
_ I , WI -11,-. 1 ) ...„
—I
,-
OATE
$ 41 (-Af fe( -Cer(I. CIII ik 1
1\A „ rt Ei isf;--ft,
TOWN OF QUEENSBURY
- -
BUILDING & Ce i . 07T.
--- 1
.__
Reviewed By: #1,---
0_
( I.
Ni`--- i•
Date:
'e6-2i g
,--), I
ne( e.,-,(A,... t\v
)
)
)