SEP-0423-2018 i; itl
TOWN OF QUEENSBURY -
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development-Building& Codes (518) 761-8256
C
EIN'TIFICATE OF Cl��IPLIANE
Permit Number: SEP-0423-2018 Date Issued: Friday, July 6, 2018
This is to certify that work requested to be done as shown by Permit Number SEP-0423-2018
has been completed.
Tax Map Number: 301.7-1-18
Location: 14 CENTENNIAL DR
Owner: Scott Brownell
Applicant: IBS Septic
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&Cade Enforcement -
Planning Board or Zoning Board of Appeals.
i
K= TOWN OF QUEENSBURY
742 Bay Road;Queensbury,NY 12804-5904 (518)761-8201
4 •r___ B.Yr/-- -j+V - Community Development-Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: SEP-0423-2018
Tax Map No: 301.7-1-18
Permission is hereby granted to: MS Septic
For property located at: 14 Centennial_DR
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
Tvne of Construction
Owner Name: Scott Brownell Septic Disposal-Residential $0.00
Owner Address: 14 Centennial DR Total Value $0.00
Queensbury,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
IBS Septic
2 WARREN ST
Glens Falls,NY 12801
Plans&Specifications
Residential Septic Alteration
$ 75.00 PERMIT FEE PAID -THIS PERMIT EXPIRES: Friday,July 5,2019
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury beforeAhe expirati
Dated at the To of Qu e sb y,July 5,2018
SIGNED BY: VVV for the Town of Queensbury.
Director of Building&Code Enforcement
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SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,QueenyburtNY 12804
`*"I of ucensburY P:S18'7G1'8256 xvmom.nueensbwm`net Pernoit#: ��c�» -{�J����� ��>\9�
Tax Map |D#: ��,\ '�� - \ ~lA Permit Fee: � ��> Invoice#: U(Q-15
Project �mcati�n� Septic Variance? Yes *' No
Prirnary0m/ner��� *�- Q
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Mailing Address
| Phone /& Email
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| Installer/Builder
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| K4aiUn�Address �-���T — " \ ^y
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Phone & Email� Cl1u �
/ 0 K / 7 `1 �
| Engineer |
| '~^ |
| �
Mailing Address
| | �
Phone QiEmail '
� 1 �
' Contact Person for Building 6&Code Compliance: Phone:
RESIDENCE INFORMATION:
Year Built Gallons #ofbedroonns Xga||onsper =total daily flow �
perday bedroom Garbage Grinder Yes No
| 198Oorolder lSU Installed? (circle one)
' Spa ur Hot Tub Yes No
| 1981-1991 | 130 �� �� F� | -1C\y� |
Installed? /drc|eone\
| l992-Present | 110
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� |
PARCEL INFORMATION: /
Topography 00at Rolling Steep Slope %Slope ... .....
Soil Nature V sand Loarn (]ay Other |
| Groundwater At w6at depth? |
Bedmck/impemiousmateha| At Ohat depth?
| Domestic Water Supply u/munidpa| _Well (if well,water supply from any septic system absorption is_ft.) |
Percolation Test Rate'
______per minute per inch (test umbe completed bylicensed
SYSTEKFPR NEW
| PROPOSED CONSTRUCTION:
| Tank size | (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with#2 stbne Total length ft.; Each Trench
Seepage Pit with#3stone How many: Size: �
Alternative System Bed or other type:
| Holding Total required �#oft�nks
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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. �
PRINT NAME: ( yl DATE:
SIGNATURE:GNATURE� '^ DATE: D ./
Town of Queembupnml ingmume nfor ent Rewsedmam--7019 �
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