2013-426 'O` TOWN OF QUEENSBURY
F
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20130426 Date Issued: Wednesday, September 11, 2013
This is to certify that work requested to be done as shown by Permit Number P20130426
has been completed.
Tax Map Number: 523400-308-018-0001-063-000-0000
Location: 28 NORTH CHURCH Ln
Owner: JOHN & LISA MOSSING III
Applicant: JOHN & LISA MOSSING III
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 ar, 4
74.5t
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.
-.
Oek` TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20130426 Application Number: A20130426
Tax Map No: 523400-308-018-0001-063-000-0000
Permission is hereby granted to: JOHN &LISA MOSSING III
For property located at: 28 NORTH CHURCH 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 Value
Owner Address: JOHN &LISA MOSSING III
28 NORTH CHURCH Ln Septic Alteration Residential
QUEENSBURY,NY 12804 Total Value
Contractor or Builder's Name/Address Electrical Inspection Agency
IBS SEPTIC
IVAN BELL
2 LOWER WARREN STREET
OUEENSBURY.NEW YORK
Plans&Specifications
2013-426
Res. Septic Alteration
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Tuesday, September 09,2014
(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 o uee bury; Alp s :y A..• i •mber 09,2013
SIGNED BY L ' \ for the Town of Queensbury.
Director of Building&Code Enforcement
Community Development Office
Town of Queensbury • 742 Bay Road • Queensbury, New York -12804 SEP 2813
Office Use Only
TAX MAP NO. _30 q . l CZ -1-(o'3 f PERMIT NO. 13 --I A IQ PERMIT FEE (Ib`"
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: 70 �'1r\ 1\1\
1 (-)(155 I r\ (� n INSTALLER: I. 5-e �1r 4 C-
ADDRESS: /. 1\1'or- l,�^Ur(, leu ' ADDRESS: I01iv -Qr wDr(-9!-J • Ql.<efN\l^'r`./
PHONE NOS. 7 (\ 1Z L6 C ,` PHONE NOS. L 1 O X 1 ()Li
LOCATION OF INSTALLATION: 2 O N O r Ls l.�CA r CL IQ 1
RESIDENCE INFORMATION:
YEAR BUILT NO.OF X COMPUTATION = TOTAL DAILY FLOW
BEDROOMS (Gallons per bedroom) GARBAGE GRIND R
1980 or older X 150 = INSTALLED? V
1981-1991 4 X 130 = 5.In .,,60\ SPA OR HOT TMJ L\
1992-present X 110 = INSTALLED? IN'[-1
PARCEL INFORMATION: J `r \r
✓ TOPOGRAPHY: FLAT ROLLI G STEEP SLOPE %SLOPE N 1 f `
sr SOIL NATURE: SAND LOAM 0CLAY 1y \-\ OTHER �V I' \
✓ GROUNDWATER: AT WHAT DEPTH? 1�
✓ BEDROCK/IMPERVIOUS MATERIAL: AT WH DEPTH?
i
✓ DOMESTIC WATER SUPLY: MUNICIPAL WELL I V ,(If well:water supply from any septic system absorption is: ft)
✓ PERCOLATION TEST: RATE IS PER MIINUTE PER INCH[moil (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: 100 n 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 lengthy 5 ft. Each trench \ I�+ X 3
❑SEEPAGE PIT(S)(WITH NO. 3 STONE) How many? l\/ \ r Size? ,�1 I
❑ALTERNATIVE SYSTEM Bed or. other type? \��V ( N (4.-\❑ HOLDING TANK SYSTEM Total required capacity? �V IIr\ Tank size? P‘ Number of tanks? u `I
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 a•d all requirements of the Town of Queensbury QUESTIONS? CALL 761-8256 OR EMAIL
Sanit.ryS �j•is ; ; Ordinance. I! .-.\'\ codes(aciueensburv.net
••^� .onsible Date VISIT OUR WEBSITE FOR MORE INFORMATION
Signatu ' r "erso 1 www.queensburv.net
-Tues -Iv
i\4‘ 144S144/
Septic Inspection Report
Office No. (518) 761-8256 Date In •- io • .e - •�.
Queensbury Building &Code Enforcement Arrive: MM ;-•art: am m
742 Bay Rd., Queensbury, NY 12804 Inspector's Initials: r.
NAME: 1fl SSS i , '' •MITNO.: ) 3 e'
LOCATION: c. ►� U t' (L4\ INSPECT ON: r_3
RECHECK:
Comments and/or diagram
Soil Ty•:. Sa • . Loam / Clay
Type of Water: l• •nic'.�. Well Water
Waterline separation distance d ft. EV-3C) \ ,t\��
Well separation distance ft.
Other wells: ft.
Well Casing Length 50' + / - Y N N/A
[150'to well required if NO]
Absorption Field: Total length 7 ft.
Length of each trench ft.
Depth of trenches j I ' --2, ' ft.
Size of Stone — 7
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box ` ( 17n t -
Distribution Box to Field/ Pit Lk'( Zjr,' "i-p U," �jV _3 L5 -\
Opening Sealed: N
End Cap � N
Inlet/Outlet Pipes& Baffles y/N
Manholes 12"or less below grade -7Y_ N
[provide extension collar if Yes] _Y T N
Location / Separations
Foundation to tank lift. \D
Foundation to absorption 7th_ ft.
Separation of Pits ft.
Conforms as per Plot ✓Y` N
Engineer Report and s-Bum ✓Y N
ETU Maintenance act Y_ N
provided
Location of System on Property:
Front Re.- . -` ide ide Middle Front Middle Rear
System 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
SeVit, \
ld c\\ c\ f C\., .
o •
�,,,��tr
vrit
c.
_
*1 5t. \-a tknK \�
y
\\ovsc \-o V . ' _
`Zs. titer\.., (\,,4_,(.N., k ›, 5 SoN ``A 'ezy`S
X!S�� r . (QY,C,re\it \ck,A\k
• ae
toff �x ; \
r
. _ ....\.
50 N`
a
Q
o 00, 0 , 0 ""' ffe:2(1
r
-75
X11 p pnpy
M 0 55 1 ^
TOWN OF QUEE,t•
BUILDING & CZ ;, •-�.
Reviewed By: Or h
Date: 1110,11r
Or lAteAP"-r
_ \4•40-k.
t�
r1orL