2009-191 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20090191 Application Number. A20090191
Tax Map No: 523400-289-007-0001-065-000-0000
Permission is hereby granted to: CAROL ANN EISENHARDT
For property located at: 564 MOON HILL 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: CAROL ANN EISENHARDT
564 MOON HILL Rd Septic Alteration Residential
LAKE GEORGE,NY 12845-0000 Total value
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans &Specifications
2009-191
septic alteration residential
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Friday, May 14,2010
(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 Queensbury; Thursday, May 14, 2009
SIGNED BY for the Town of Queensbury.
Director of B 'dine nforcement
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
4z Community Development- Building &Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number. P20090191 Date Issued: Thursday, August 26, 2010
This is to certify that work requested to be done as shown by Permit Number P20090191
has been completed.
Tax Map Number. 523400-289-007-0001-065-000-0000
Location: 564 MOON HILL Rd
Owner. CAROL ANN EISENHARDT
Applicant: CAROL ANN EISENHARDT
This structure maybe 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, r.Ld
Variance, or other issues and conditions as a result of approvals by the Director of Building&AdeEcement
Planning Board or Zoning Board of Appeals.
....................................................
OFFICE USE ONLY / {����-/7�_-„�,,,_
TAX MAP NO PER IT NO. RMIT FEE [E, 9 v
aOL __ J'-7 APPS: O ING c�' TOWN CLERK 2 9;
............................................ :��Y......... ... ...
APPLICATION FOR SEPTIC DISPOSAL SYSTEM P pppp.QUEENSBURY
L`tt'IiNG & CODES_
A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS.APPLICATION IS SUBJECT TO REV1E FORE ISSUANCE OF A VALID
PERMIT. /
OWNER: ( 5 n ko(f INSTALLER: �� +
ADDRESS: y ��C� �"} ADDRESS:
PHONE NOS. PHONE NOS.
5 �F C� RI �
LOCATION OF INSTALLATION: 6 I O C,
NO.OF RESIDENCE INFORMATION:
YEAR BUILT BEDROOMS X COMPUTATION= = TOTAL DAILY FLOW
1980 or older X 150 gallon per bedroom GARBAGE GRINDER
INSTALLED?
1981 -1991 X 130 gallon per bedroom $
SPA OR HOT TUB
1992-present X 110 gallon per bedroom = INSTALLED?
PARCEL INFORMATION:
✓ TOPOGRAPHY: Flat rolling Steep slope %Slope
✓ SOIL NATURE: Sand � Loam Clay Other
✓ GROUNDWATER: At what depth? _
✓ BEDROCK/IMPERVIOUS MATERIAL: At what depth? NO
✓ DOMESTIC WATER SUPLY: Municipal Well (If well: Water supply from any septic
system absorption is ft.)
✓ PERCOLATION TEST: Rate is minutes 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: GALLON (MIN. SIZE IS 1,000 GAL.)Add 250 gallons to the size of the se tic tank for
each garbage grinder, spa or whirlpool tub. n El i 5 Se
SYSTEM TYPE: Ps��PCA'%f ] h � U(AS�C 0 P j O f S 0 � Y
❑ ABSORPTION FIELD (WITH NO. 2 STONE) Total length ft. Each trench X
❑ 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.
1-3 7h-vtzSJ7
Septic Inspection Report
Office No. (518) 761-8256 Date Inspect�gr�,request received:
Queensbury Building &Code Enforcement Arrive: �_am/pXnWpart: am/pm
742 Bay Rd., Queensbury, NY 12804 Inspectors Initials: yV
NAME: 1 /'*Se PERMIT NO.:
LOCATION: INSPECT ON: — 5'
RECHECK:
Comments and/or diagram
Soil T Sa d / Loam Clay
Type of Water: Municipal Well Water
Waterline separation distance ft.
Well separation distance ft.
Other wells: ft.
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. ' &f'N jI
Separation of Pits ft.
Conforms as per Plot Plan Y N
Engineer Report and As-Built Y N
Location of System on Property:
Front ear Left Side Right Sid Middle Front Middle Rear
t
System us:
'^ 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
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