2007-439 TOWN OF QUIEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development- Building &Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number. P20070439 Date Issued: Wednesday, January 09, 2008
This is to certify that work requested to be done as shown by Permit Number P20070439
has been completed.
Tax Map Number. 523400-302-017-0002-010-000-0000
Location: 28 ARBUTUS Dr
Owner. DAVID & MICHELLE HERTZNER
Applicant: DAVID & MICHELLE HERTZNER
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
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: P20070439 Application Number. A20070439
Tax Map No: 523400-302-017-0002-010-000-0000
Permission is hereby granted to: DAVID &MICHELLE HERTZNER
For property located at: 28 ARBUTUS 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 Unifonn Building Codes and the Queensbury Zoning
Ordinance. Type of Construction Value
Owner Address: DAVID &MICHELLE HERTZNER Septic Alteration Residential
28 ARBUTUS Dr Total value
QUEENSBURY, NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
IBS SEPTIC
IVAN BELL
2 LOWER WARREN STREET
QUEENSBURY,NEW YORK
Plans &Specifications
2007-439
septic alteration
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Thursday,July 17,2008
(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 Towalof Queensb"wr' T,u¢sd4y,,July 17,2007
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SIGNED BY for the Town of Queensbury.
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Director of Building&Code Enforcement
...III..III.III.....---I..-.-.------ ..----.-.- _ r.....................0
OFFICE USE ONLY I ! ;
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i AX MAP FNO. PERMIT NO. PERMIT FEE
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' APPROVALS: ZONING TOWN CLERK o
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: --.. �Zc / INSTALLER:
ADDRESS: �) � � 6�I/ �_ ADDRESS: �/
PHONE NOS. PHONE NOS. �/ f
LOCATION OF INSTALLATION:
.................................................................................................!............,.........................................................................; ........,.......................................................................... RESIDENCE INFORMATION.
I NO.OF
YEAR BUILT X COMPUTATION= i TOTAL DAILY FLOW
I BEDROOMS
_...................... ..................................,...........a......................................................................... ,.....,........................................;�...........:.... GARBAGEGRINDER
j 1980 or older ? X i•. 150 gallon per bedroom i = € INSTALLED
i............................_..................i........................I............ L..........}...................................................................................L......................................................................... '
i 1981 -1991 1 i X '• 130 gallon per bedroom ' 1 SPA OR HOT TUB
...................._.......................;..............................._..........._;..........a...................................................._......................s...y....................................................................... INSTALLED?
�......1992-present. ..........................�_. X 110 gallon per bedroom {....-...!.........................................................I................
i
PARCEL INFORMATION:
✓ TOPOGRAPHY: F OLLING STEEP SLOPE °t°SLOPE
✓ SOIL NATURE: SAND LOAM CLAY OTHER
✓ GROUNDWATER:
AT WHAT DEPTH? BEDROCKAMPERVIOUS MATERIAL: AT
WHAT DEPTH?
✓ DOMESTIC WATER SUPLY: MUNICIPAL WELL
(IF WELL:WATER SUPPLY FROM ANY SEPTIC-SYSTEM ABSORPTION IS FT. )
✓ PERCOLATION TEST: RATE IS PER MIINUTE 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).Add 250
gallons to the size of the septic tank and leacfield for each garbage grinder, spa or whirlpool tub.
✓ SEPTIC TANK: 600 GAL ON (MIN. SIZE IS 1,000 GAL.) TILE FIELD: EACH TRENCH FT.
✓ TOTAL SYSTEM LENGTH: FT. SEEPAGE PIT(S): HOW MANY?
✓ SIZE OF EACH FT. X FT. f
✓ SIZE OF STONE TO BE USED:# /DEPTH OR THICKNESS-1—FT.
✓ BED SYSTEM SIZE: X
✓ ALTERNATIVE SYSTEM: LENGTH AND/OR SIZE
✓ HOLDING TANK SYSTEM:(If required) NO. OF TANKS: /SIZE OF EACH
✓ GALLONS.!TOTAL CAPACITY: GAL.
( ..: . . :.:...:......:..:.:.:..:.......:...c....tv.......,...:...:.: :.:.....::.ass.:........:.:..:............::...:...........:. ..................
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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 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 codesGaueensburv.net
Queensbury S itary Sewage Disposal Ordinance.
/ VISIT OUR WEBSITE FOR MORE INFORMATION
` 1d www.aueensbury.net
Signa ure of Person Responsible Date
QTown of Queensbury - Community Development Office - 742 Bay Road, Queensbury,NY 12804
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Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received: n/1-)-7
Queensbury Building&Code Enforcement Arrive: am/prn Depart: am/pm
742 Bay Rd., Queensbury, NY 12804 Inspector's Initials:
NAME: PERMIT NO.: � `—
LOCATION: VC.I INSPECT ON:
RECHECK:
Comments and/or di ram
Soil T LoajU.4 Clay
Type of Water: MpwWell Water
Waterline separabufflEstance ft.
Well separation distance ft.
Other wells ft.
Absorption Field: Total lengthZ ft.
Length of each trench ft.
Depth of trenches
Size of Stone
See Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box
Distribution Box ieid Pit
Openi Sealed:&NJ Partial
End Ca
In Outlet Pipes&Baffles Ny
Location Se rations
Foundation to tank ft.
Foundation to absorption ft.
Se ration of Pits ft.
Conforms as r Plot Plan N
Engineer Report and As-Built N
Location of System Property:
Front 0earLeft Side Right Side
Middle Front Middle Rear
m s:
Approved
Partial Approved and needs to be re-inspected, please call the Building&Codes Office
Disapproved
Last revised 021006
Last revised 1/6/05
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