2008-548 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building &Codes (518) 761-8256
CERT I F I CAT E OF C 0 M P L I-A-N- C E
Permit Number. P20080548 Date Issued: Thursday, August 26, 2010
This is to certify that work requested to be done as shown by Permit Number P20080548
has been completed.
Tax Map Number. 523400-309-011-0002-02 1-000-0000
Location: 14 LUZERNE Rd
Owner. ROY & CATHY MITCHELL
Applicant: ROY & CATHY MITCHELL
This structure maybe occupied as a:
Septic Alteration Residential
By Omer of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the
owner of the responsibility for compliance with Site Plan
property P tY P ,
Variance, or other issues and conditions as a result of approvals by the Director of Building a otrement
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: P20080548 Application Number. A20080548
Tax Map No: 523400-3 09-011-0002-021-000-0000
Permission is hereby granted to: ROY&CATHY MITCHELL
For property located at: 14 LUZERNE 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: ROY& CATHY MITCHELL
14 LUZERNE Rd Septic Alteration Residential
QUEENSBURY,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
2008-548
SEPTIC ALTERATION RESIDENTIAL
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Thursday, October 15, 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 Tpi o ee ry�y
t"day, October 15, 2008
SIGNED BY it for the Town of Queensbury.
Director of Building&Code Enforcement
OFFICE USE ONLY .........................} %__________.__.___
TAX MAP NO. PERMIT NO. PERMIT FEE_
APPROVALS: ZONING TOWN CLERK ;
:......................------------.--------------.-------------------
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.
OWNER: " INSTALLER:
ADDRESS: ADDRESS: eo gox 2,Y/
PHONE NOS. PHONE NOS.-
LOCATION OF INSTALLATION:
RESIDENCE INFORMATION:
YEAR BUILT NO.OF X COMPUTATION= = TOTAL DAILY FLOW
BEDROOMS GARBAGE GRINDER
1980 or older X 150 gallon per bedroom = o 0 INSTALLED?_&I
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 wh depth?
✓ DOMESTIC WATER SUPLY: Municipal Well (if well: Water supply from any septic
system absorption is 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 engineer or architect(unless installed in a Planning Board approved subdivision).
TANK SIZE: 100,) 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 length /5'J ft. Each trench— -X v-0
❑ 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 QUESTIONS? CALL 761-8256 OR EMAIL
agree to abide by these and all requirements of the Town of codes@aueensburv.net
--QueensburySanitary Sewage Disposal Ordinance.
VISIT OUR WEBSITE FOR MORE INFORMATION
www.aueensbury.net
) 4
Signature of P rson Responsible Date
QTown of Queensbury - Community Development Office - 742 Bay Road, Queensbury, NY 12804
T` ra`C)o
Septic Inspection Report
Office No. (518) 761-8256 Date Ins"fr
Queensbury Building &Code Enforcement Arrive: t:
742 Say Rd., Queensbury, NY 12804 Inspector's Ini
NAME: N1 ���.- NO.: --15`1�LOCATION: 1 1.=,7 e •1C i� T ON: 1 ��5-C
RECHECK:
Comments and/or diagram
Soil T m/ Clay
Type of Water: a)DWell Water
Wate n 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 i � r
Opening Sealed: N
End Cap N
Inlet/Outlet Pipes &Baffles Y N
Location Separations
Foundation to tank ft.
Foundation to absorption
Separation of Pits �Y-N
Conforms as r Plot Plan
Engineer Report and As-Built Y N
Location of System on Property:
Front Rear Left Side Right Side Middle Front Ca�D-
Sys se
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
MFJVL-� community Development Office
Town of Queensbury • 742 Bay Rd.
Queensbury, New York -12804 PLOT PLAN;
00 Show all existing and proposed structures. Indicate the setbacks of all structures and buildings from all property lines.
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