2012-191 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: P20120191 Date Issued: Monday, October 21, 2013
This is to certify that work requested to be done as shown by Permit Number P20120191
has been completed.
Tax Map Number: 523400-301-019-0001-002-000-0000
Location: 688 SHERMAN Ave
Owner: JOHN & TAMARA SCHROEDER
Applicant: JOHN & TAMARA SCHROEDER
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 bythe
pp . recto of Bui dine ol,` Enforcement
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
FoN 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20120191 Application Number: A20120191
Tax Map No: 523400-301-019-0001-002-000-0000
Permission is hereby granted to: JOHN &TAMARA SCHROEDER
For property located at: 688 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: JOHN& TAMARA SCHROEDER
688 SHERMAN Ave Septic Alteration Residential
QUEENSBURY,NY 12804-0000 Total Value
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans&Specifications
2012
septic alteration
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday, April 24, 2013
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the Town fQuee bury /Tue. i .y, A s ril 24, 2012
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
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Community Development Office � ,1 I Ati
it.A` Town of Queensbury - 742 Bay Road - QueensaRj, 3w11`a tk •1.280
Office Use Only Y
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TAX MAP NO. 30 1 . 1 9-1 `d PERMIT NO. /A-/9-/ r PERMIT FEE LIO1 1>1"
APPROVALS: ZONING TOWN CLERK
APPLICATION FOR SEPTIC DISPOSAL SYSTEM PERMIT: A PERMIT MUST BE OBTAINED
BEFORE WORK BEGINS. APPLICATION IS SUBJECT TO REVIEW BEFORE ISSUANCE OF A VALID PERMIT.
OWNER: -
2
ZJ•` ,'2k 11 C-42 r INSTALLER: . t1-f
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ADDRESS: S I 1:-'(-./f�r S (1ut4rt4- ADDRESS:
• 14bt.�!'y,,vL/lore`,
PHONE NOS. "? 9)`0 c 74, •7 "— (U t PHONE NOS.
2S
LOCATION OF INSTALLATION: & �C Peer—SA-7,14-1-4,4 40-e
RESIDENCE INFORMATION:
NO.OF COMPUTATION
YEAR BUILT X = TOTAL DAILY FLOW
BEDROOMS (Gallons per bedroom) GARBAGE GRINP
1980 or older 2, X 150 = 4---/ c U INSTALLED?
1981 -1991 X 130 = SPA OR HOT TU$i
1992-present X 110 = INSTALLED?
PARCEL INFORMATION:
✓ TOPOGRAPHY: FLAT ROLLING STEEP SLOPE %SLOPE
✓ 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 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).
E5\1 , /titt/i
TANK SIZE: l 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. t
SYSTEM TABSORPTION FIELD (WITH NO. 2 STONE) Total length L1 �5�, �F\L\Y�(�17��
l�/ 7 l � ft. Each trench X
❑ SEEPAGE PIT(S)(WITH NO. 3 STONE) How many? Size?
C ALTERNATIVE SYSTEM Bed or other type?
❑ HOLDING TANK SYSTEM Total required capacity? Tank size? 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 he read the egulations with respect to this application and agree to
abide y thes and all requir,ments of the Town of Queensbury QUESTIONS? CALL 761-8256 OR EMAIL
$anitaryitew ge(D' pos rdinance. f codes(a)queensburv.net
VISIT OUR WEBSITE FOR MORE INFORMATION
Signature of Person Responsible Date www.queensbury.net
Community Development Office
• Town of Queensbury • 742 Bay Road • Queensbury, New York •12804
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Septic Inspection Report
Office No. (518) 761-8256 Date In •-ctio�n ,-_ e - •d:
Queensbury Building &Code Enforcement Arrive:f - �' .epart: %7 am
742 Bay Rd., Queensbury, NY 12804 Inspector's I, 1r.
NAME: C-1.\('D eclar " IT NO.: / �'' 19/
LOCATION: L .�� �1 Pi U'`� r� SPECT ON: E'1—� 1"/ -J Z,
RECHECK:
Comments and/or diagram
Soil Ty•-• rr . .. ►- Cl.y
Type of Wat= . Munici•-Iy4Tn",,-ter
Wa - '- - -•aration 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
Depth of trenches _ _ft.
Size of Stone LTP
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank t t
Tank to Distribution Box
Distribution Box to Field/ Pit zk 'WA\ \ L
Opening Sealed: Y N
End Cap
Inlet/Outlet Pipes&Baffles 4 N
Location/ Separations
• Foundation to tank Zc ft.
Foundation to absorption k . �"�--
Separation of Pits ft.
Conforms as per Plot Plan YY N
Engineer Report and As-Built Y N
Location of System on Property:
Front Rear Left Side Right Side Middle Front Middle Rear
S stet Us- . :
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
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