2009-383 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,IVY 12804-5902 (518)7b1-8201
4z Community Development- Building &Codes (518) 761-8256
C*"'NER' L IPICATE %F COMPLI-A-N- C.E
Permit Number. P20090383 Date Issued: Monday, August 24, 2009
This is to certify that work requested to be done as shown by Permit Number P20090383
has been completed.
Tax Map Number: 523400-265-000-0001-076-000-0000
Location: 1368 BAY Rd
Owner: GUY & TEANNA FULLEN
Applicant: GUY & TEANNA FULLEN
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 ,
df i
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 12804-5902 (518)761-8201
Community Development- Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20090383 Application Number. A20090383
Tax Map No: 523400-265-000-0001-076-000-0000
Permission is hereby granted to: GUY&TEANNA FULLEN
For property located at: 1368 BAY 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: GUY&TEANNA FULLEN
1368 BAY Rd Septic Alteration Residential
LAKE GEORGE,NY 12804-0000 Total value
Contractor or Builder's Name/Address Electrical Inspection Agency
SANITARY SEWER
DAN DRELLOS
PO BOX 224
GLENS FALLS NY
Plans &Specifications
2009-383
septic alteration residential
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Friday,August 20, 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 f Queeniury; Thursday,August 20, 2009
SIGNED BY for the Town of Queensbury.
Director of Building+ Goc�Enforcement
- �./__________________-1---"_` OFFICE USE ONLY % ;___________ -P�
012TA4 MAP NO. PERMIT NO. PERMIT FEE10
o APPROVALS: ZONING TOWN CLERK �� 5 '
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APPLICATION FOR SEPTIC DISPOSAL SYSTEM PE 'T.;
A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS.APPLICATION IS SUBJECT REVIEW BEF JUICE OF A VALID
PERMIT.
OWNER:,V Q if FtJ ( �2-fltr INSTALLER:
ADDRESS: O Js 3'r`7 1J ADDRESS:
PHONE NOS. `y `�`� PHONE NOS.
LOCATION OF INSTALLATION: ` �a i
RESIDENCE INFORMATION:
NO.OF
YEAR BUILT X COMPUTATION= = TOTAL DAILY FLOW
BEDROOMS GARBAGE GRIND R 0
1980 or older X 150 gallon per bedroom = INSTALLED?
1981 -1991 X 130 gallon per bedroom = SPA OR HOT TUB A
1992-present X 110 gallon per bedroom = INSTALLED? t" '
PARCEL INFORMATION:
✓ TOPOGRAPHY: Flat rolling Steep slope %Slope
✓ SOIL NATURE: Sand Loam Clay Other
✓ GROUNDWATER: At what depth?
✓ BEDROCK/IMPERVIOUS MATERIAL: At what depth?
✓ DOMESTIC WATER SUPLY: Municipal Well ✓/ (If well. Water supply from any septic
system absorption is Lan' t ft.)
✓ PERCOLATION TEST: Rate is per minute per inch.
(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 e, ineer or architect (unless installed in a Planning Board approved subdivision).
XI,Sa/.U6
TANK SIZE: I Q17J 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:
e �
j<ABSORPTION FIELD (WITH NO. 2 STONE) Total length ?j�rJ ft. Each trench ?i 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
CI
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building &Code Enforcement Arrive: am/pm Depart: am/pm
742 Bay Rd., Queensbury, NY 12804 Inspector's Initials:
NAME: PERMIT NO.:
LOCATION: INSPECT ON:
RECHECK:
Comments and/or diagram
Soil T cl jLoam / Clay
Type of Water: Well Water
Waterline separation distance ft.
Wells ration distance ft.
Other wells: ft.
Well Casin en 50' + / - Y N _N/A
Absor do Field: Tdtal length ft.
n th of ea trench ft.
Depth of tr nches ft.
Size of tone
page Pits: Nufter � —�
Si x
Stone Siz
Pipinq Nize Type
Buildinci to tank
Tank to Distribution Box /
Distribution:Box to Field Pit �j
Opening Seal Y N
End Up _Y
Inlet/Outlet Pipes &Ba es _Y
Location Separ4fions
Foundation 0 tank ft.
Foundation to ab or tion ft.
Sep§rati n of Pits ft
Conforms as` Plot Plan _Y�Nj
En ineer Re rt and As-Built Y
Location of System on Property:
Front Rear Left Side Right Side Middle Front Middle Rear
5ystem Use Status:
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
U ,
IL
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building &Code Enforcement ` Arrive: am/pm Depart: Y am/pm
742 Bay Rd., Queensbury, NY 12804 Inspector's Initials:�x l�,
NAME: PERMIT_NO.. (" 3 3
LOCATION: t INSPECT ON:
RECHECK:
Comments and/or diagram
Soil Ty i Loam/ Clay
Type of Water: ici / Well Water
Waterli aration distance ft.
Well separation distance
Other wells: ft.
Well Casing Length 50' + / - Y N_N/A
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenches 'Zt-'- ft.
Size of Stone
Seepage Pits: Number
Size:
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box au
Distribution Box to Field Pit
Opening Sealed: N
End Cap Y N
Inlet/Outlet Pipes&Baffles N
Location Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan _ N
E -Built Y N
Location of System on Property:
Rear Left Side fight Si Middle Front Middle Rear
s s:
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
! t evidence of,
� have seen of obsetneA,�wells-tree,
etc.,
ot-.
L Ii ehiects such as houses,we t 1 have
? ;, 4�rt on this docume t):e set f^..rthesent a n e dia
ter_ �,c,so i1y measure dist
-•r
SIGNS URE
DATE
TOWN OF OUEENSBURY BUILDING DEPARTM.-," i
Based on our limited examination,
compliance with our comments shall
not be construed as indicating the
plans and specifications are in full
compliance with the Building Codes of
New York State.
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