2008-255 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. P20080255 Date Issued: Monday, November 16, 2009
This is to certify that work requested to be done as shown by Permit Number P20080255
has been completed.
Tax Map Number. 523400-290-062-0001-004-000-0000
Location: 15 OVERLOOK Dr
Owner. THOMAS & SUSAN FORD
Applicant: THOMAS & SUSAN FORD
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,
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: P20080255 Application Number. A20080255
Tax Map No: 523400-290-062-0001-004-000-0000
Permission is hereby granted to: THOMAS & SUSAN FORD
For properly located at: 15 OVERLOOK 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. Type of Construction Value
Owner Address: THOMAS & SUSAN FORD
15 OVERLOOK Dr Septic Alteration Residential
QUEENSBURY, NY 12804 Total value
Contractor or Builder's Name/ Address Electrical Inspection Agency
Plans &Specifications
2008-255
septic alteration residential
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Saturday, May 30, 2009
(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 wn o ee ury t
, ay 30, 2008
SIGNED BY ' for the Town of Queensbury.
Director of Building&:Code Enforcement
OFFICE USE ONLY ______----_-_�- f ____-_. _____A
+ .
10 TAX MAP NO. PE IT NO. 2��IT FEE
+ } d + ) )
APPROVALS: ZONING l t TOWN CLERK ;
r---------------------------------------------------------------- -- 0' —i/ 1
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. P ffol'%e'
OWNER: /� l PJ O tA-ArC INSTALLER: i ICI
ADDRESS I t !!!�Crr 6C2 d'tADDRESS: ��G�<
PHONE NOS. d9ZZ1 PHONE NOS.- A� �
1
LOCATION OF INSTALLATION: �� /3 ",,w, X I A,
RESIDENCE INFORMATION:
BEDROOMS
YEAR BUILT NO.OF X GOMPUTA7lON= = TOTAL DAILY FLOW
GARBAGE GRINDER
1980 or older X 150 gallon per bedroom 2 INSTALLED?
1981 -1991 X 130 gallon per bedroom = SPA OR HOT TUB
1992-present X 110 gallon per bedroom INSTALLED?
PARCEL INFORMATION:
r
✓ TOPOGRAPHY: Flat rolling Steep slope %Slope
✓ SOIL NATURE: Sand Loam Clay Other
TT
✓ GROUNDWATER: At what depth?164
✓ 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 a 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) 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 septic tank for
each garbage grinder, spa or whirlpool tub.
SYSTEM TYPE: �
ABSORPTION FIELD (WITH NO. 2 STONE) Total lengthe�'1 ft` a�Fi 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.
I have read the regulations with respect to this application and
agree to abide by these and all requirements of the Town of QUESTIONS? CALL 761-8256 OR EMAIL
Queensbury S ary Sewage Disposal Ordinance. codes@pueensburv.net
VISIT OUR WEBSITE FOR MORE INFORMATION
www.pueensbury.net
Signature of Person Responsible Date
Town of Queensbury • Community Development Office - 742 Bay Road, Queensbury,NY 12804
B 5-LGL 6/06
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection requ c
7
Queensbury Building &Code Enforcement Arrive: -'W a / De rt: ar M
742 Bay Rd., Queensbury, NY 12804 Inspector's Initi
NAME: 0'11EPILQQV� A660(-A f M DK� RMIT NO.:
LOCATION: SSE ovr'pl. ye D',. INSPECT ON: -=Z`1-618
RECHECK:
Comments and/or diagram
Soil Type: Sand Loam Clay
Type of Water: Municipal/ Well Water
Waterline separation distance ft.
Well separation distance ft.
Other wells:
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
OpeninQ Sealed: Y N
End Ca Y N
Inlet/Outlet Pipes&Baffles Y N
Location Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan _Y N
Engineer Report and As-Built Y N
Location of System on Property:
Front Rear Left Side Right Side Middle Front Middle Rear
System Use 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
�� . ®0 �
Septic Inspection Report
Office No. (518) 761-8256 Date Inspe io request received:
Queensbury Building &Code Enforcement Arrive: am/p epart: am/pm
742 Bay Rd., Queensbury, NY 12804 Inspector's Initials: - e
NAME: PERMIT NO.:
LOCATION: f_Sr &—ro INSPECT ON:
RECHECK:
Comments and/or diagram
Soil Type: Sand L Clay
Type of Water: Munici I ell 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
Size of Stone 3
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box ly"
Distribution Box to Field / Pit Zj"
Opening Sealed: Y N
End Ca Y N
Inlet/Outlet Pipes &Baffles _Y_ N
Location Separations CIJ
Foundation to tank ft. � •-
Foundation to absorption ft. C�ccic�"clli
Separation of Pits ft.
Conforms as per Plot Plan Y N /Engineer Report and As-Built Y_ N G4ez
Location of System on Property:
Front Rear Left Side 6;1
Middle F;nt Middle Rear
4stemU
Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
Last revised 06/18/07 U\Building&Codes Forms-OLD\Building&Codes\Inspection Forms\Septic Inspection Report.doc
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