2007-575 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. P20070575 Date Issued: Monday, September 17, 2007
This is to certify that work requested to be done as shown by Permit Number P20070575
has been completed.
Tax Map Number: 523400-226-019-0001-053-000-0000
Location: 3 NORTH Ln
Owner. CHARLES W CHRISTOPHER
Applicant: CHARLES W CHRISTOPHER
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 ('-� j
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property owner of the responsibility for compliance with Site Plan,
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Variance, or other issues and conditions as a result of approvals by the Director of Building&Obde E orcement
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
742 Bay Road,Qmensbury,NY 12804-5902 (518)761-8201
Community Development- Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20070575 Application Number. A20070575
Tax Map No: 523400-226-019-0001-053-000-0000
Permission is hereby granted to: CHARLES W CHRISTOPHER
For property located at: 3 NORTH Ln
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 QueensburyZoning
Ordinance. Type of Construction Value
Owner Address: CHARLES W CHRISTOPHER
4B DERRY Ln Septic Alteration Residential
LATHAM,NY 12110 Total value
Contractor or Builders Name/Address Electrical Inspection Agency
MORNING STAR SEPTIC
Plans &Specifications
2007-575
tank replacement only
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Wednesday, September 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 T o tiv
4ts
eptember 17, 2007
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
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TAX MAP NO. PERMIT NO. PERMIT FEE O2 J ,
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APPROVALS: ZONING TOWN CLERK_ , d
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APPLICATION FOR SEPTIC DISPOSAL SYSTEM P DINS
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A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS.APPLICATION IS SUBJECT TO REVIEW BEFORE ISSUANCE OF A VALID
PERMIT.
OWNER: /��T� 41Q IIq INSTALLER:
ADDRESS: ADDRESS:
PHONE NOS. C�9 PHONE NOS.
LOCATION OF INSTALLATION: I'-t-bc y-e—
......................................................................................................................................................._......... RESIDENCE INFORMATION.
iNO.OF ; } i.....................................................................................
YEAR BUILT I BEDROOMS I X I COMPUTATION= _ TOTAL DAILY FLOW
! NC ,
._.............................................1.........,...........,......................i........... ...................:...............-...........................,..................1 G
1980 or older , IX 150 gallon per bedroom i = 3C.1G 1 INSTALLED?RINAli R A �(�
i
_.........._. ..................:.........................._................;....................................................................................t....................................................................................
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1981 -1991 X 's 130 gallon per bedroom ? _ 1 SPA OR HOT TUB
_..........................................:..............................................a...........a......................._................................._..........,..s...........;..........................................................................
;
I 1992 present X 110 gallon per bedroom i ; INSTALLED?.? o
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 FT. )
✓ PERCOLATION TEST: RATE IS A14 PER MIINUTE PER INCH (TEST TO BE
COMPLETED BY A LICENSED PROFE SIONAL 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 [each field for each garbage grinder, spa or whirlpool tub.
�� � ✓ SEPTIC TANK: 10 6 o GALLON (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.
✓ SIZE OF STONE TO BE USED: # /DEPTH OR THICKNESS FT.
✓ BED SYSTEM SIZE: X
✓ ALTERNATIVE SYSTEM: LENGTH AND/OR SIZE
✓ HOLDING TANK SYSTEM:(if required) NO. OF TANKS: 1 SIZE OF EACH
✓ GALLONS./TOTAL CAPACITY. GAL.
..............................:...................:..:.:.:.........:...........................:...............:...:.:...:.:.:...:.:...:,.,.:.:.:.:.....:.......:,.....,.:.:.:.:.:.:...:...,...:.:...........:.:.:.:.:.:...:.........................:.:.,.:.,...........:.,...........................,...............:.,.........,....,..:...........
E: AL
NOTE: SYSTEM AND ASSOCIATED ELECTRICAL WORK MUST BE INSPECTED BY A TOWN 1
.1 APPROVED ELECTRICAL INSPECTION AGENCY. PLEASE REVIEW LIST PROVIDED.
......................................................................:.............,,....:.,..,.,,,,,.,.,,.,,:,.,.....,..........:.,.,:..............,...:.:......................... :....,...::........................................................................
1
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 itary Sewage Disposal Ordinance.
nodes O cueensburv.net
VISIT OUR WEBSITE FOR MORE INFORMATION
www.aueensburv.net
Sig re of Pers esponsible Date
Town of Queensbury - Community Development Office - 742 Bay Road, Queensbury, NY 12804
Septic Inspection Report I
Office No. (518) 761-8256 Date InsP�Ion uest received: 1 jo-7
Queensbury Building &Code Enforcement Arrive: . ` am/l epa : am/pm
742 Bay Rd., Queensbury, NY 12804 Inspecto 's Initials.
NAME: PERMIT NO.:
LOCATION: 2, INSPECT ON:
RECHECK: 1� 1 *1
Comments and/or agram
Soil T nd Loam la
Type of Water: Munici e I Water .�
Waterline separation distance ft. /�j�/k �� �f�C�C—h(f:4) '`-�
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 Si Type
Building to tank
Tank to Distribution Box of
Distribution Box to Field / Pit
Opening Sealed: Y N
End Cap 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 Prope
Front Re Left Side Right Side Middle Front Middle Rear
S U t
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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