2000-500 T' (JWN OF QUEENSBURY
742 Bay Road, Queensbury, NY 12804-5902 (518) 761 -8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF C+OMPEIANCE
C/C Number: C20000489 C/C Date: Tuesday, July 18, 2000
Application Number: A20000500
Permit Number: P20000500
This is to certify that work requested to be done as shown by Permit Number P20000500
has been completed.
This structure may be used as a Septic Alteration Residential
Tax Map Number: 523400-054-000-0007-037-000-0000
Location: 5 PINECRDFT Dr
Owner: JEFFR.E'Y & LA PELL
By Order of Town Board
T N5113LTRY
f 7�ty �ll..ii''TT1/l/JJ
Director of Building Sc 'Code Enforcement
TOWN OF QUEENSBURY
742 Bay Road, Queensbury, ANY 12904-5902 (518) 761 -8201
(aw Community Development - Building & Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20000500 Application Number: A20000500
Tax Map No: 523400-054-000-0007-037-000-0000
Permission is hereby granted to- JEFFREY & LA PELL
Owner of property located at: 5 PINECROFT Dr
in the Town of Queensbury, to construct or place a Septic Alteration Residential
at the above location in accordance with application together with plot plans and other information hereto filed
and approved and IP compliance with the NYS Uniform Building Codes and the Queensbury Zoning
Ordinance.
Owner Address: JEFFREY & LA PELL
LUNDGREN, TINA
5 PINECROFT Dr
QUEENSBURY, NY 12804
Contractor or Builder's Name / Address Electrical Inspection Agency
1111111
OUEENSBURY SEWER
JAY SWEET
Type of Construction: Septic Alteration Residential Value : $
Plans & Specifications
$25900 PERMIT FEE PAIR - THIS PERMIT EXPIRES: Sunday, July 14, 2002
(Ifa 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 To eens rya a ° 2000
SIGNED BY for the Town of Queensbury.
Director of Building & Code Enforcement
Application ror Pernut -- Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury, NJ' 12804 (518) 761-8256
1 . OWNER INFORMATION : ..... ....................... .......................... ,
Ott'ice Use
Location of installation: /r V
File Permit N
Tax Map No. =e' 7
' � ) +� �t c� C c�1 Fee Paid
Owner's Name: _ -
Address: � G r'
JUL 13 2000
2. INSTALLER'S NAME : e#lLfS. a r -v _ PHONE NO,
3. RESIDENCE INFORMATION: (circle year o dwelling, indicate # biedrotom(5) and multiply # of
bedrooms with applicable gallons per bedroom to equal total dailyflow)
Year of House: No of Bedrooms x ComRutation = Total Daily Flow
0 or alder x 150-gyalAArm
1980 — _+ x 30 ral/b —
1991 — present x 110 gallbdrm —
Garbage Grinder Installed yes / 6,p)
Spa or Whirlpool Installed es � ! no
4. PARCEL INFORMATION: (circle applicable information & indicate measurements)
Topoiata hy Soil Nature Ground Water Bedrock or lmpervious Materiel Domestic Water Supper
y at what depth at what depth municipal
Rolling It-lam feet feel e1
Steep slope clay dwell; water supply+
.W._°Q slope other from any septic-system
depth: I absorplion is ft.
other
Percolation Test: (7 o be completed by licensed pr(fessiotoal engineer or architect) --�
Rate: minute per inch
5 . 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 sire
of the septic tank and leach field for cacti Garbagc Grinder, Spa or Whirlpool Tub.
r
Septic Tank: /r0 ar c/ gallon (min. size 1, 000 gal.)
Tile Field: each trench f1. Total System Length: ff•
Seepage Pit(s): number nf_--- _ size of'each: _ by
Size bY —__.-_. .. ft•
Size of Stone to be used: 11 / depth or thickness �f vl
Bed System Size: x
Alternative System: jtll _4r ) length and/or size
b, HOLDING TANK SYSTEM: (if required)
Number of tanks: I Size of each : gallons I TOTAL Capacity: gallons
Note: Alarm System and associated electrical work must be inspected by a Town approved
electrical inspection agency.
7. SIGNATURE & INFORMATION FOR RESPONSIBLE PERSON (please read)
For your protection, please note that pursuant to Sectioati 136-29 of the Codo orthe 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 Queensbury Sanitary Sewage Disposal Ordinance. ,+
lam' I _ / -- // Z- - , ✓ �./
S t roof responsible person Date
T{ IWK OF QUEFIISBURY
BUILDING A CODE ENFORCEMENT
742 Say Road
Queensbury NY 12804
(sis) '761-825e
SEPTIC DISPOSAL SYSTEM INSPECTION
Name C�►'P+� "�-_�
Location '
Date — jam Permit #_ ?. C? C)
SOIL TYPE. Saner lay-
Results of Percolation Test-
( if applicable) Ra -Minute/Inch_
TYPE OF SYSTEM: 4_ 1 3' "L '1 s
ABSORPTION FIEL Total ength s
Length of each reach
Depth of trench s 2"-
Size of stone
SEEPAGE PITS : umber- fte
Size
Stone size S ze YPe
PIPING:
Bldg . to Tank
Tank to Dist . BOX
Dist . Box to Field Pit artsa
openings Sealed? o
LOCATION/SEPARATI feet
Foundation to Tank feet
Foundation to Absorptionfeet
Separation of Pits lot Pl n +es o
Conforms as per P
LOCATION OF SYSTEM ON P P RT Vf�314�w
( circle one) t Sid
ti
Front - Rear Middle Front _ Mi dd ems.
COMMENTS :
a �
YES NO
SYSTEM USE APPROVED :
7=OL
JUL2000 TC}Vil OF: CLUE RY
.. , BUILDING ., PTI
REVIEWED BY
DATE
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"I have seen or observed, or pel'eve I saw evidence of,
all obiects such as houses, wells, trees, fences, etc,,
shown on this document. I also represent that I have
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perso y measured the s ances set rth on the diagram."
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I
SI NATURE DATE
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