2000-613 TOWN OF Q►UEENSBURY
742 Bay Road, Queensbury, NY 12804-5902 (518) 761-8201
CL Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
CIC Number: C20000613 CfC Date: Friday, August 18, 2000
Application Number: A20000613
Permit Number: P20000613
This is to certify that work requested to be done as shown by Permit Number P20000613
has been completed.
This structure may be used as a Septic Alteration Residential
Tax Map Number: 523400-050-000-0001-065-000-0000
Location : 9 SNUG HARBOR Ln
Owner• DICK & HELEN CUTTING
By Order of 'Town Board
TOWN OF QUEENSBURY
DirectiA of Bu o Enf r e
Application for Permit -- Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury, NY 12804 (518) 761-8256
1 . OWNER INFORMATION: .............................................................._._....................._........................_..._...._....
,�
office Use
Location of installation: igoz t=bt
u. +�n n..( S . $ File Permit N Z
Tax Map No, I f � {�(�
Fee Paid �['v F
Owner's Name: / --( ' 7`7�`-,'
Address: �? r / " ? - �} L1 h tl Y T + ..
2. INSTALLER'S NAME s u PHONE NO. 74
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate 0 bedroom(s,) and multiply ## of
bedrooms with applicable gallons per bedroom to equal total daily flow)
Year of House: No of BedrooMs x Computation Thal Daily Flow
� 1 x 150 galibdrin =
x 130 gal/bdrm =
1991 - present x 110 galfbdrm =
Garbage Grinder Installed yes 1AM
Spa or Whirlpool Installed yes � f
4. PARCEL INFORMATION: (circle applicable information & indicate measurements)
T4po vhv Soil Nature Ground Water Bedrock or Itngeryious Material Domestic Water Supply
n at what depth at what depth munici
Rolling loam feet feet
Steep slope clay dwell; water supply
% slope other from any septic-system
depth: 1absorption ft.
other
Percolation Test: (To be completed by licensed rafessional engineer or architect}
Rate; /r+� *InZr�� minute per inch �C -__-^"'`•..
5. PROPOSED SYSTEM. For New Construction: Ali 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 leach field for each Garbage Grinder, Spa or Whirlpool Tub.
Septic Tank:,/d� gallon (min. size 1, 000 ga1.)
Tile Field: each trench fl. Total System Length: `
Seepage Pit(s): number of size ofeach_ _ f1• by ll AUG1 7 2000
Size of Stone to be used: if / depth or thickness feet
Bed. System Size: x
Alternative System.: ;� �►'i 4,) length .and/or size
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: f Size of each: gallons / 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 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 Queensbury Sanitary Sewage Disposal Ordinance.
000v
Signs urelof responsible person Date
TOWN OF QUEEKSBURY
BUILDING,& GODE ENFORCEMENT
742 Say Road
Queensbury NY I.2804
(sis) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name `S"[" l :;�
Location _ 1 OpLj3 kQ! T-us .
Date — J `L�Permit # 2�-000 &J ,
SOIL TYPE : Sand- Loam-Clay--
Results of Percolation Test-
( if applicable ) Rate- M ' to/Inch
TYPE OF SYSTEM:
ABSORPTION FIELD: T al Le th
Length of each tren h
Depth of trenches
Size of stone
SEEPAGE PITS : N er-
Size - ft x ft .
Stone size
PIPING : ze Type
Bldg . to Tank
Tank to Dist . Bo
Dist . Box to it
Openings Sealed . Yes Na Partial
LOCATION/SEPARA IONS :
Foundation to T nk feet
Foundation to sorption feet
Separation of its feet
Conforms as pe Plot Plan No
LOCATION OF SY TEM ON PROPER
( circle one )
Front - Rear Left Side - Right Side
Middle Front - Middle Rear
COMMENTS : a
SYSTEM USE APPROVED : O
Arrived. ;.
Depa : ,r
K
S g ?spec
a
"I have seen or observed, or believe I saw evidence of,
all objects such as houses, wells, trees, fences, etc„
shown on this document. I also represent that 1 have
err � _ Banally measured istance set forth on the diagram."
SIGNATURE ! / DATE
`-c
a
TOWN OF QUEEN RY
BUILDING & T.
REVIEWED BY
DAT
i \
� 111
6
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CAI 0
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CA
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TOWN OF QUEEKSBURY
BUILDING_&_ CODE ENFORCEMENT
742 Bay Road
Queensbury NY_ i2804
(sis) 76A-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
H asneLocation
Date �c-, 1 -3� ,�ermi t #
SOIL TYP . and- asr lay-
Results of Percolation Test-
( if applicable ) Rate-Minute/ inch
TYPE OF SYSTEM:
h
ABSORPTION FIELD : To g #
Length of each trenc
Depth of trenche 1
Size of stone
SEEPAGE PITS : ft . be - ft . ��
Size -
Stone size S -e ype
PIPING:
Bldg , to Wank r�
Tank to Dist . Box
Dist . Box to Field/Pi
Openings Sealed ? s 1� o ar a
LOCATION/SEPARATIONS : feet
Foundation to Tank — 7 C feet
Foundation to Absorp ion - feet
Separation of Pits
Conforms as per Plot Plan Yet �_
LOCATION OF SYSTEM PROPERTY :
( circle one)
Front - Rear - Left Side - Right Side
Middle 'Front - Mid a Rear
COWENTS r
V�Q�tA Nc - h �
�V- A P6VE E NO r
Arrived ;
Depa
ui d nspect
3 Consulting
Joseph Biss III
553 State Route 149 - Suite B MIE MIE
Lake George, New York 12845-3515
Phone/Fax (518) 761-9888JBISS3@AOL.COMNYSDOH Lab ID# 11637
Rosick's Well Drilling
1175 Farley Road
Hudson Falls, NY ' 12839
Phone: (518) 746-0173 Fax: (518) 746-0175 E-mail: rosickdrillingQYahoo com
Client:
Karen Hurst
9 Snug Harbor Lane
Queensbury, New York
Results: Hose Outlet
120217F01 02/17/12 02/17/12 d2117112 Total SM <1 CFL1110i0' '51 CFU1100
1: 12 P 5:00 P Coliform 9222E ml ml
The results relate only to the sample(s) as received by the laboratory. The sample received was
analyzed in compliance with NYSDOH and NELAP approved .methods and within their accepted
holding times. The result(s) is (are) equal to or lower than the State's limits therefore it (they)
meets the requirements for NYSDOH Part 5 Drinking Water Regulations.
J133 Consulting's liability for any work performed is limited to the amount billed to the customer leading
to the cU11
ustomer.
Joseph
AnalysSunday , 2012
This is an original Certificate of Analysis, do not duplicate
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