2013-558 fefila 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: P20130558 Date Issued: Monday, December 09, 2013
This is to certify that work requested to be done as shown by Permit Number P20130558
has been completed.
Tax Map Number: 523400-302-017-0001-036-000-0000
Location: 31 WINTERGREEN Rd
Owner: JOHN & ANN DALEY
Applicant: JOHN & ANN DALEY
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, 41
Variance, or other issues and conditions as a result of approvals by the Director of Building& ode E1rcement
Planning Board or Zoning Board of Appeals.
Oek• TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
f
Community Development-Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20130558 Application Number: A20130558
Tax Map No: 523400-302-017-0001-036-000-0000
Permission is hereby granted to: JOHN & ANN DALEY
For property located at: 31 WINTERGREEN 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: JOHN &ANN DALEY Septic Alteration Residential
31 WINTERGREEN Rd Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
SANITARY SEWER
GEORGE DRELLOS 792-7257
PO BOX 224
GLENS FALLS NY
Plans&Specifications
2013-558
Res. Septic Alteration
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Saturday,December 06,2014
(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 Quee sbury //
Fri 1 •, ,%ecember 06,2013
r F t(
SIGNED BY `�'v �,` for the Town of Queensbury.
Director of Building&Code Enforcement
ruN
Community Development Office 6E^ 0 5 2g13
Town of Queensbury • 742 Bay Road • Queensbury, New York •12804 `'
Office Use Only ��
TAX MAP NO. 3 O I [ ! -1'�(e PERMIT NO. / 3- 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.
OWNER: ?Dl/) P/97e INSTALLER: ,ql/..� Lt} . �X'- -e r �C'/(/� e /
ADDRESS: 3/ G� ''y/ am e� re ADDRESS: ! l/_ !✓D X� ZZ�( e /�"-s (r /
PHONE NOS./` 6:732f/C; PHONE NOS. (cF -72f7
LOCATION OF INSTALLATION: dienCh
RESIDENCE INFORMATION:
YEAR BUILT NO.OF X COMPUTATION = TOTAL DAILY FLOW
BEDROOMS (Gallons per bedroom) GARBAGE GRINDER
II 1980 or older X 150 = INSTALLED? -'
1981-1991 X 130 = SPA OR HOT TUB
1992-present 3 X 110 = go INSTALLED? ')
PARCEL INFORMATION:
✓ TOPOGRAPHY: FLAT ROLLING STEEP SLOPE %SLOPE
✓ SOIL NATURE: SAND X LOAM CLAY OTHER
✓ GROUNDWATER: AT WHAT DEPTH?
I 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).
TANK SIZE:/1: Z) 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 lengt07 ft. Each trench -me) X (7
❑SEEPAGE PIT(S)(WITH NO.3 STONE) How many? /1— Size?
o ALTERNATIVE SYSTEM Bed or other type? /L
❑HOLDING TANK SYSTEM Total required capacity? AV/42- 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 the regulations with respect to this application and agree to
abide by t nd all requirements of the Town of Queensbury QUESTIONS? CALL 761-8256 OR EMAIL
Sanity ag . r e. / codesCaqueensbury.net
ignature of Person Responsible Date VISIT OUR WEBSITE FOR MORE INFORMATION
www.queensbury.net
Town of Queensbury Building & Code Enforcement I /ohm
Office No. (518) 761-8256
Septic Inspection Report
Inspection request received:
Name: S t\n DA og Inspected on: icA
�
Location: `� I 11� (',\'4-t_°f'C re n Arrive: ��,_ p.m.
Permit No.: /r3-5 Sc Inspector's Initials: I'
, Ce ments and/or dia.ram
Soil Type Sam .... ,. lay
Type of Wate Munici al ell Water
Waterline separation.istance 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 length .7.,1:57) ft.
Length of each trench ft.
Depth of trenches Z 2.10.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank . )) T1 x6 j-I'f 6J1 uC�
Tank to Distribution Box )._f It
Distribution Box to Field/Pit i f)01-9).'7 445 0��J—�
Opening Sealed: �/Y//_N
End Cap 1/Y__
Inlet/Outlet Pipes&Baffles V Y N
Manholes 12"or less below grade N
[provide extension collar if Yes] Y N
Location/Separations
Foundation to tank 10 ft.
Foundation to absorption 2-tB ft.
Separation of Pits ft.
Conforms as per Plot Plan Vic N
Engineer Report and As-Built Y_N
ETU Maintenance Contract provided Y N
Location of System on Property:
Front Rear Left Side Right Side Middle Front fiddle
System Use Stat :
Approved
Partial Approved and needs to be re-inspected, please call the Building&Codes Office
Disapproved
Septic Inspection Report
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Reviewed By . Ail '
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Date: 1_. 61
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3/ W,, cv-Tetell\ eery SEPTIC PLOT PLAN
I HAVE SEEN OR OBSERVED ALL OBJECTS
---------- - - - . .______... -SUCH AS HOUSES;IAELLS,_TRE.ES, FENCES, ETC ___
SHOWN IS DOCUMENT.I HAVE PERSONALLY
MEASU"; HE DISLAT-F-GaTit0..,,,,,,,N .*dr.GRAM.
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SIGNAT *4 DATE