2012-368 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: P20120368 Date Issued: Monday, October 21, 2013
This is to certify that work requested to be done as shown by Permit Number P20120368
has been completed.
Tax Map Number: 523400-289-019-0001-022-000-0000
Location: 52 BLIND ROCK Rd
Owner: MICHAEL D. & LAUREN K. GILLIS
Applicant: MICI-IAEL D. & LAUREN K. GILLIS
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 nforcement
Planning Board or Zoning Board of Appeals.
1
_ TOWN OF QUEENSBURY
L. `.4 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518)761-8256
BUILDING PERMIT
•
Permit Number: P20120368 Application Number: A20120368
Tax Map No: 523400-289-019-0001-022-000-0000
Permission is hereby granted to: MICHAEL D. &LAUREN K. GILLIS
For property located at: 52 BLIND ROCK 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: MICHAEL D. &LAUREN K. GILLIS Septic Alteration Residential
52 BLIND ROCK Rd Total Value
QUEENSBURY,NY 12804-0000
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans&Specifications
2012-368
Residential Septic Alteration
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday,July 31,2013
(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 To of Que sbui, Tu•s'a, July 31,2012
SIGNED BY - for the Town of Queensbury.
Director of Building&Code Enforcement
Community Development Office
Town of Queensbury • 742 Bay Road • Queensbury, New York •12804 JUL- 3 1 2012
Office Use Only
TAX MAP NO. ( n ? 19—/a o� PERMIT NO./ -3/e g PERMIT FEE
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.
(�I
OWNER: !(,4(1(,kt I U. L Ii I�'jS� INSTALLER: M I(),4 1 G: i 15
ADDRESS: `7>�COO
l vt G�.r-+ l`0 Lk: `L - ADDRESS: 3` , �(J� C IROI
PHONE NOS. CIM -I( tia 3 PHONE NOS. (`1 14 S'3
LOCATION OF INSTALLATION: (r K 45 7 :115 5C fC- 9f S It
RESIDENCE INFORMATION:
YEAR BUILT NO.OF X COMPUTATION = TOTAL DAILY FLOW
BEDROOMS (Gallons per bedroom) GARBAGE GRINDER
1980 or older X 150 = INSTALLED?
1981-1991 X 130 = _ SPA OR HOT TUB
1992-present X 110 = j INSTALLED?
PARCEL INFORMATION:
✓ TOPOGRAPHY: FLAT ROLLI STEEP SLOPE %SLOPE '- vao
✓ SOIL NATURE: SAND V LOAM CLAY OTHER
✓ GROUNDWATER: AT WHAT DEPTH? {J
✓ 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(itct(unless� installed in a Plannin Bard approved subdivision).
NKs1"F t1� �T\0 L- 1�=1�7'�Q t'
TA Z -!_4:i1, GALLON(MIN. SIZE IS 1,000 GAL.)Add 250 gallons o the size of the septic tank for each garbage grinder,
spa or whirlp.o
SYSTEM TYP \\•F
[9'ABSORPTION FIELD(WITH NO. 2 STONE) Total length ft. Each trench X
0 SEEPAGE PIT(S)(WITH NO. 3 STONE) How many? Size?
❑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 have read"e regulations wit, respect to this application and agree to
abi.. t --e -J a req irj -n • the Town of Queensbury QUESTIONS? CALL 761-8256 OR EMAIL
Irrry fw-_or i sfo �'rdi :y e� tt codes(@queensburv.net
�_A .L • • i L- t VISIT OUR WEBSITE FOR MORE INFORMATION
ignature o •ers'on Respo t. e" Dae
9www.queensburv.net
Septic Inspection Report
7
Office No. (518) 761-8256 Date Inspection r-•Aati, - •:
Queensbury Building &Code Enforcement Arrive: a ,,epart: m
742 Bay Rd., Queensbury, NY 12804 Inspector's • itials•/moi
NAME: (1 t Lt h /LIT NO.: Z_-,3(UC
LOCATION: t t Y3 PQC_ Rk) INSPECT ON: —Z - 1 Z
�l
RECHECK:
Comments and/or diagram
Soil Ty.-,11111.•_„0-0-0r- / Clay
Type of Water• �•r��Well Water
Water Ine 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 lengthft. ice 572 ;>�
Length of each trench ft.
Depth of trenches 7 w.-ft.
Size of Stone
Seepage Pits: Number
Size: _ x
StoneSize:
OtfY<C41
pr• • Size Type
Building ti .nk,f' 1` t-7(, Lk6 4( � LA-0 A-1 r-4--\91-1
Tank to Distribution •,.x •
Distribution Box to Field/ Pit 1 c--
Opening Sealed: _ N
End Cap N
Inlet/Outlet Pipes&Baffles
Manholes 12"or less below grade Y N
[provide extension collar if Yes] Y_N
_ Location/ Separations
Foundation to tank \ ft.
Foundation to absorption ft.
Separation of P' - ft.
Conforms as per PI• Plan _ N
En_gineer Report a . As-Bui N
ETU Maintena e Cont - Y N
•vided
Location of System on Property:
Front Re. - ; Side Right Side Middle Front fiddle Rear
S stem Use Sta•.s:
Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
L:\Pam Whiting\2010\Building Codes Forms\Inspection Forms\Septic Inspection Report 03 29 10.doc
0G,Inscdc-q I --3
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection requ: Iv •
Queensbury Building &Code Enforcement Arrive: 1 c. 1,5- a ' epart: 11 3E) a /pm
742 Bay Rd., Queensbury, NY 12804 Inspector`s Initials: /! - ?1
NAME: &i I I i.S r RMIT NO.: / 3 to
LOCATION: L /;n d R!. {( INSPECT ON:
RECHECK:
Comments and/or diagram
Soil Type: Sand / Loam / Clay
Type of Water: Municipal/ Well Water
Waterline separation distance ft. _ C— (7 EPID_ 1 LL
Well separation distance ft.
Other wells: ft. �� Fc - RE 1 O b l `O K\
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
Tank to Distribution Box
Distribution Box to Field/ Pit
Opening Sealed: _Y N
End Cap Y�N
Inlet/Outlet Pipes&Baffles Y N
Location/ Separations
• Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Y^ N
Engineer Report and As-Built Y__- N
Location of System on Property:
Front Rear Left Side Right Side Middle Front Middle Rear
Ss -1 U -
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
-Wi7_72 , 1-k NRo J'QP‘k
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Septic Inspection • ~ •/,i t
Office No. (518)761-8256 Date Inspection •• - 'eived:
Queensbury Building &Code Enforcement Arrive: o • f Afbepart: ' pm
742 Bay Rd., Queensbury, NY 12804 Inspector's In''
NAME: tA1 C t\flEk L\\_LA\_Lt j P; ' 1T NO.:
LOCATION: 5Z. 2)1__A 1-, I 'PECT ON: 4 •- Z_o - 11
RECHECK: �'�EPT\C. F
Comments and/or diagrani
Soil Type: Sand/ Loam/Clay
Typeof Water: Municipal/Well Water
Waterline separation distance ft.
Well separation distance ft.
Other wells: ft. CO NI t .Tc 6) -E -
Well Casing Length 50' +/ - Y N N/A
[150'to well required if NO] L‘
OF -\\ \-f\b-Ck�R
Absorption Field: Total length ft.
Length of each trench ft. M� • (s� L_i 5 PL 4 Loa-fir
Depth of trenches ft. b F l`Oh B
Size of Stone
Seepage Pits: Number ;�� \--V- 30
Size:
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box
Distribution Box to Field/ Pit oF10 C5?
Opening Sealed: _Y�•N GpDe_
End Cap ^_Y N vFtQ
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 ft.
Foundation to absorption ft. tT !APC\-\t•
Separation of Pits ft. �\) �� O^ FUZ_
Conforms as per Plot Plan T Y N
Engineer Report and As-Built _Y N A
ETU Maintenance Contract Y— N L4 !5
provided
Location of System on Property:
Front Rear Left Side Right Side Middle Front Middle Rear
\ J
System Use Status:
Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
L:\Pam Whiting\2010\Building Codes Forms\Inspectlon Forms\Septic Inspection Report03 29 10.doc
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Septic Inspection Report
Office No.(518) 761-8256 Date Inspection reques v-•:
Queensbury Building&Code Enforcement Arrive: ‘22,... , a, fit It P . ., : am/pm
742 Bay Rd., Queensbury,NY 12804 Inspector's Initi.
NAME: ��N E8 R Pc, DEtj, PE'. IT NO.: Z_Oc — t7c:31-1
LOCATION: .5Z__ pk_i ,_)() Rnc_4 Ruhi IN%PECT ON: ,-—I —C)(0RECHECK: (v/
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.
Absorption Field: Total length — �— ,ft.
Length of each trench __ ft.
Depth of trenches _ft.
Size of Stone
Seepage Pits: Number
Size: I x
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box
Distribution Box to Field/Pit
Opening Sealed: Y/N/Partial
End Caps
Location/Separations
Foundation to tank ft.
Foundation to absorption _ ft.
Separation of Pits ft.
Conforms lot Y N
Engineer Ras per Pe orta As-Built Y N
Location of System on Property:
Front Rear Left Side Right Side
Middle Front Middle Rear
S stem Use St s:
Approved
Partial Approved and needs to be re-inspected, please call the Building& Codes Office
Disapproved
Last revised 1/6/05