2003-338 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: p20'030338 Date Issued: Tuesday,August 12, 2003
This is to certify that work requested to be done as shown by Permit Number P20030338
has been completed..
Tax Map Number: 523400-296-017-0001-051-000-0000
Location: 870 STATE ROUTE 9
Owner: ALEXANDER POTENZA
Applicant: MILLER HILL PLAZA
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Commercial TOWN OF QUEENSBURY
Director of Building&Code Enforcement
TOWN OF,QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20030338 Application Number.- A20030338
Tax Map No: 523400-296-017-0001-051-000-0000
Permission is hereby granted to: MILLFR HILL PLAZA
For property located at: 870 STATE ROUTE 9
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: ALEXANDERPOTENZA Septic Alteration CommercialFRANK BORK Total Value
403 GLEN St
GLENS FALLS,NY 12801
Contractor or Builder's Name Address Electrical Inspection Agency
Plans&Specifications
2003-338 MILLER HILL PLAZA
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$35.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday,May 28,2004
(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 0 of Q e esday,May 28,2003
SIGNED BY ?u� for the Town of Queensbury.
Director of Building&Code Enforcement
Al)l)lic.itioxi for Illel-Illit—Septic Disposal System
Rm,n (?f Queensbmy NY 12804 (518) 761-8256
I. OWNER INFORMATION:
..............._......................................................................................I
Office Use
Location of installation: 870 US Rt. 9
File Permit No.' 03 33
Tax Map No296.�w,177_ 1 51 Fee Paid __0C;7
Owner's Name: Frank Bork/Lynn Potenza
Address: 403 Glen St. Glens Falls
2. INSTALLER'S NAME PHONE NO.
3. RESIDENCE INFORMATION: (circleyear of dwelling, indicate fl bedrooln(y) and mulLIPI 71-fl EIVED
bedrooms with applicable gallons per bedroom to equal total claify4rLf
Year of House: No. of Bedroonis x CoinWitation = Total Daily Clow i.MY 2 8 2003
1980 or older x 150 gal/bdrm = TOWN OF QUEENSBURY
UL
-
1980—' 1991 x 130*gal/bdriii = ZR_UI 1-0111IG AND CODE
1991 —present x I ID gal/bdrm = 150 GPD
Garbage Grinder Installed yes no- X
Spa or Wiirlpool Installed' yes no X
4. PARCEL INFORMATION: (circle applicable information & indicate measurcinctits)
Bedrocic or Impervious N4ZACH.11 Domestic W.-iter Supply
-------—------
it 114urt ckpth nrtrnlci
Rolling loam 12.7 feet 12.7 feel, Ivell
Steep slope clay if well; water sul-Iii/j,
10 Yo slope other from ally septic-s),stem
depth:. absoqytion is
other
Percolation Test: (To be completed-by licensectl7rqlZusional engineer or architect)
Rate: < 5 111inute per inch
5. PROPOSED SYSTEM: For Nciv Construction: All individual sewage disposal systems must be designed by licensed
proressiotial ciigiiicer or architect(unless installed itia Planning 13oard.ipprovcd subdivision). Acid 250 gallons it)the size
of the septic lank:rid Icacli field for cacti Garbage Grinder, Spa or.Wltirlpool Tub.
SepticTauk: 1000 gallon (4nin. size 1,000 gal)
TileFiold: each trench fJ. Total System Length:
Seepage Pit(s): mu fiber of 1 size of each: 12 fl, by a ft.
�SimoofStoiiotobcused: 113/4"-2j" dV1.1111 Or thickness 3 fee!
Bed System Size: X
kltemativo System: length alidlor size '
G. HOLDING TANK SYSTEM: (if required)
Number of tanks:— Size of each: gallons /TOTAL Capacity: gallons
Note-: Alarm System and associated electrical work must be inspected by a Town approved
7. SIGNATURE &INFORMATION FOR RESPONSIBLE PERSON (please read)
For your protection, please jioto that pursuant to Section 136-29 of the Code of thoTowii
ofQuectisbury, any permit or approval granted which is Wised upon or is granted in
reliance upon any material iiiisrepresciitaLiort or failure to make a material fact or
circumstance kii,.owii by or oti behalf of au applicant, sliall be void.
I have read tlio rcgtrI oils with rospectto this application and agree toabide by these and
requirements of file ow of Qticclisbtffy Saintary Sewage Disposal Ordiiiatice.
S ature of responsible person l5ate
I'o%Vll of (111cellshilry
.9mvers Ind S(c%Vnge Disposal ( 11.11)(er
Appfuldix C
ABSORPTION FJliA.,D
SEPARATRM 111,MIJIRERUNTS
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Septic Inspection Report
Office No. (518)761-8256 Date'Inspection request received: /03 '
Bui
lding&Code Enforcement 'Arrive: /(,IK am/pm Depart: am/pm
/am/pm
742 Bay Rd.,Queensbuiy,NY 12804 Inspector's Initials: �a
NAME: --JA C�,QA
09
PERMIT NO.: .7 � 3 3
LOCATION: INSPECT ON:
RECHECK: L(2,
Comments and/or diagram
Soil Ty pe: Sand/Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length ft.
Length of each trench
Depth of-trenches
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
Opening Sealed: Y/NI Partial
Location/Separations
Foundation to tank
Foundation to absorption
Separation of Pits
Conforms as per Plot Plan Y N_
Location of System on Property:
Front Rear Left Side Right Side
Middle Front Middle Rear
System Use Status:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Di8approved
L:\SueHemingway\Building.Codes.inspection.FORMS\Septic Inspection Report.doc January 28,2003
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:
/1. V
NAME: 00 try
PERMIT NO.:
0
LOCATION: INSPECT ON:
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: ft.
Absorption Field: Total length
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
Opening Sealed: Y/NI Partial
Location/Separations
Foundation to tank ft.
Foundation to absorption
Separation of Pits
Conforms as per Plot Plan -Y,Y—N
Location of System on Property:
Front Rear Left Side Right Side
Middle Front Middle Rear
System Use Status:
Approved
X
Partial Approved and needs to be re-inspected,please call the*Building&Codes Office
Disapproved
L:\SueHemingway\Btiilding.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
NON-SHRINK
4" OUTLET TEE GROUT
MODEL A1801 -4x22 RESIDENTIAL PUMP
"ZABEL" FILTER OR EQUIVALENT
STATION
18"
t :.'r °.
4" PVC PIPE
�4
1
NOTE:
IF EXISTING OR NEW SEPTIC TANK CONTAINS A PRECAST CONCRETE TEE
OUTLET INSTEAD OF A 4" PLASTIC SANITARY TEE SUBSTITUTE ZABEL FILTEF
MODEL A1807-4x22 FOR MODEL A1801-4x22.
EFFLUENT . FILTER DETAIL
0 SCALE: N.T.S.
�y �