SEP-000404-2017 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development-Building&Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: SEP-000404-2017 Date Issued: Thursday, July 13, 2017
This is to certify that work requested to be done as shown by Permit Number SEP-000404-2017
has been completed.
Tax Map Number: 295.17-1-48
Location: 5 PINEWOOD HOLLOW RD
Owner: SCOTT WODICKA
Applicant: Cook's Septic Service
This structure may be occupied as a: Residential Septic Alteration
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 Enforcement
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development-Building& Codes (518)761-8256
BUILDING PERMIT
Permit Number: SEP-000404-2017
Tax Map No: 295.17-148
Permission is hereby granted to: Cook's Septic Service
For property located at: 5 PINEWOOD HOLLOW 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
Owner Name: SCOTT WODICKA Septic Disposal-Residential $0.00
Owner Address: 5 Pinewood Hollow RD Total Value $0.00
Queensbury,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
Cook's Septic Service
7 Dunkley RD
Lake Luzeme,NY 12846
Plans&Specifications
Residential Septic Alteration
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday,July 7,2017
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the Town of eensb [ /�& y
SIGNED BY: !„M.rK►/ for the Town of Queensbury.
Director of Building&Code Enforcement
4WSEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury, NY 12804
ru,.n nM.mshun it#:
P:518-761-8256 www.gueensbury.net Perm4
Tax Map ID#: 24 P, Permit Fee:$ ; Invoice#:
Project Location: Septic variance? Yes No
PrimaryOwner(s)
Mailing Address f? '{ G�� �� ��✓
Phone & Email /1- Sr
Installer/Builder
Mailing Address l�
Phone & Email
Engineer ;------_---_--._.�._.
Mailing Address
Phone & Email JUL 0 6 2017
Contact Person for Building&Code Compliance: WVIC-CIVOOLINY !
RESIDENCE INFORMATION: NG&CODES
Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yes No
1980 or older Installed? (circle one)
1981-1991 r� 30 2 0 Spa or Hot Tub Yes No
�P Installed? (circle one)
1992-Present
PARCEL INFORMATION:
Topography _Flat Rolling _Steep Slope _%Slope
Soil Naturer/Sand _Loam _Clay _Other
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply —Municipal _Well (if well,water supply from any septic system absorption is_ft.)
Percolation Test Rate: per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size I L/`( 6' gallons(min.size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone Total length / ft.; Each Trench ft.
Seepage Pit with#3 stone How many: V Size: ,
Alternative System Bed or other type:
Holding Tank System Total required capacity? ;tank size ;#of tanks
NOTES: 1.Alarm system &associated electrical work must be inspected by a Town approved electrical inspection
agency;2. We will no longer allow systems to be covered until such time as an as-built plan is received and approved.
The installed system must match the septic layout on file—no exceptions.
Declaration:Any permit or approval granted which is based upon or is granted in reliance upon any material
representation 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 and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage
Disposal Ordinance.
w
PRINT NAME: DATE:
SIGNATURE: DATE:
Town of Queensbury Bui ng&Code Enforcement Revised February 2017
3EPTIC P_LCt1'P AN
I HAVE SEEN OR O"ERVED ALL OBJECTS 295.17-1-48 SEP-000404-2017
SUChI ASH USE$, LLS,,T EE CES, ETC WOCIICI(8, Scott
5H0�' 0 THIS OOCWMENT 6
-ER Y
MEASUREDiHEDI$iANCF.SE7F03HIS 5 Pinewood Hollow Rd.
Residential Septic Alteration
y�IGW uNt
TE
--------------
( ToWt\' OF OUEENSBURY
BlMil & CO S PT.
R.. wed By:
Z 7 h
t; �(.4^.- +t
t. .
.'SPY
JUL 0 C 6 2017
TOWN OF QUEENSBURY
BUILDING& CODES