2011-008 � TOWN OF QUEENSBURY
742 BayRoad,Queensbury;NY 12804-5902
�� (518) 761-8201
Community Development- Building &Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number. P20110008 Date Issued: Monday, January 31, 2011
This is to certify that work requested to be done as shown by Permit Number P20110008
has been completed.
Tax Map Number. 523400-302-017-0001-042-000-0000
Location: 41 WINTERGREEN Rd
Owner. JAMES & KATHY FLORES
Applicant JAMES & KATHY FLORES
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 () /7:54te---Q
property owner of the responsibility for compliance with Site Plan, �•/(41V /G 7""
t 'al
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: P20110008 Application Number: A20110008
Tax Map No: 523400-302-017-0001-042-000-0000
Permission is hereby granted to: JAMES &KATHY FLORES
For property located at: 41 WINTERGREEN Rd
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: JAMES &KATHY FLORES
41 WINTERGREEN Rd Septic Alteration Residential
QUEENSBURY,NY 12804 Total Value
Contractor or Builder's Name/Address Electrical Inspection Agency
IBS SEPTIC&DRAIN
ATTN: IVAN BELL
2 LOWER WARREN St
QUEENSBURY,NY 12804
Plans&Specifications
2011-008
septic alteration residential
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday,January 20,2012
(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 Town o ee ury; Thu0 I a /J:_ ary 20,2011
or
SIGNED BY '" , for the Town of Queensbury.
Director of Building&Code Enforcement
Revised 4/14/2010
OFFICE USE ONLY � 00
��
/
TAX MAP NO. `/+ 1� 7"_PERMIT NO. i __PERMIT FE
• APPROVALS: ZONING TOWN CLERK
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.T. /_ r
OWNER: �`"/C 5/ C D rC S� INSTALLER: L , de fe ���l / C
ADDRESS: /!t V w I' A/ �C/1 fr nG4V ADDRESS: a Co c.L p f((..-(�f,r'('✓ f i
PHONE NOS. PHONE NOS. [[l�''�ye-_ rt.
LOCATION OF INSTALLATION:
RESIDENCE INFORMATION:
YEAR BUILT NO.OF X COMPUTATION = TOTAL DAILY FLOW
BEDROOMS (Gallons per bedroom) GARBAGE GRINDER
1980 or older ) X 150 = -- r° INSTALLED? A.,/JQ
1981 -1991 X 130 = SPA OR HOT TUB ,
1992-present X 110 = INSTALLED? �L
PARCEL INFORMATION:
✓ TOPOGRAPHY: FLAT 'OLLI 4 STEEP SLOPE %SLOPE
✓ SOIL NATURE: /LOAM CLAY OTHER
✓ GROUNDWATER: AT WHAT DEPTH? /t/ �Q
/79
✓ BEDROCK/IMPERVIOUS MATERIAL: AT WHAT DEPTH? r 1
✓ DOMESTIC WATER SUPLY: MUNICIPA
L WELL (If well:water supply from any septic system absorption is: ft)
✓ PERCOLATION TEST: RATE IS �( / - PER MIINUTE PER INCH Empi]
(Test to be omp eted 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).
TANK SIZE: /4,0 ) GALLON(MIN.SIZE IS 1,000 GAL.)Add 250 gallons to the size of the septic tank for
each garbage grinder,spa or whirlpool tub.
SYSTEM TYPE: (--- I
ABSORPTION FIELD(WITH NO.2 STONE) Total length-0( ft. Each trench X �d
❑SEEPAGE PIT(S)(WITH NO.3 STONE) How many? Size?
❑ALTERNATIVE SYSTEM Bed or other type?
❑ HOLDING TANK SYSTEM Total required capacity? Tank size? Number of tanks?
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.
I have read the regulations with respect to this application and agree
to abide by t se and all requirements of the Town of Queensbury QUESTIONS? CALL 761-8256 OR EMAIL
Sanitary S age Disposal Ordi nce. codes(@oueensburv.net
// / 7/ VISIT OUR WEBSITE FOR MORE INFORMATION
Signature of Person Responsible/ Date wvvw.aueensburV.net
Town of Queensbury* Community Development Office *742 Bay Road, Queensbury NY 12804
Z : 3o
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection requ-: ;•-i -•:
Queensbury Building &Code Enforcement Arrive: 2. ';'era :e : = Jib ar(LP-
742 Bay Rd., Queensbury, NY 12804 Inspector's Initial •
NAME: 66r P MIT NO.: /l I
-0 CF.
LOCATION: L�J 7 �41 'q����� (-INSPECT ON: 2°.-//
RECHECK: �l
Comments and/or diagram
Soil Ty oam/ Clay
Type of Water: ell Water
Waterline, ration distance ft.
Well separation distance ft.
Other wells: ft.
Well Casing Length 50' + /- Y N N/A
[150'to well required if NO]
Absorption Field: Total length 7_. : ft.
Length of each trench ( ft.
Depth of trenches Z ft.
Size of Stone a--
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank kA"
Tank to Distribution Box th'' 9 •d'
Distribution Box to Field/ Pit Lt
Px pEe�
Opening Sealed: N; ,Y—N
End Cap _%Y N
Inlet/Outlet Pipes&Baffles u'Y„_•�N
Manholes 12"or less below grade Y_N
[provide extension eollarifYesi , Y N !74I 13 I ,,T
Location/ Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits / ft.
Conforms as per Plot Plan tr• f N
Engineer Report and As-Built` Y Y—N
ETU Maintenance Contract YN
provided
Location of System on Property:
Front Rear Left Side Right Side Middle Front Middle Rear
System Use Status:
1. Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
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Septic Inspection Report
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Office No. (518) 761-8256 Date Ins ction uest received: 1//0/
Queensbury Building &Code Enforcement Arrive: 2 am Depart' / am/pm
��' �� Jp
742 Bay Rd., Queensbury, NY 12804 Inspector's Initials: c
NAME: tore._5 7 ,--1-65 /
pf-, C PERMIT NO.: 1 I — 6 d
LOCATION: Li( Lt1 (Ny-<)p--.Q-e,J INSPECT ON: // 0/
RECHECK:
• entsa • o oi.•r-
Soil T and oam / Clay •
•
Type of Wat M icipal Well Water pfl`r f i n L —
Waterline s_ ation distance ft. /
Well separation distance ft. IIN ."C- ri/ C6f7.
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 Siz /./ Ty /
Building to tank Tank to Distribution Box K a
Distribution Box to Field / Pit
Opening Sealed: j4 N
End Cap _ _N
Inlet/Outlet Pipes&Baffles VY— 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 Sys Property:
Front Rear Left Side Right Side Middle Front Middle Rear
System Use Status:
proved
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