2011-364 TOWN OF QUEENSBURY
742 Bay Road,,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building& Codes (518) 761-8256
CE RTIFICATE OF COMPLIANCE
Permit Number: P20110364 Date Issued: . Tuesday, August 23, 2011
This is to certify that work requested to be done as shown by Permit Number P20110364
has been completed.
Tax Map Number: 523400-308-005-0001-002=000-0000
Location: .399 WEST MT. Rd
Owner: GREGORY & LINDA FULLER
Applicant: GREGORY& LINDA FULLER
This structure maybe occupied as a:
Septic Alteration'Residential
By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the
property owner of the responsibility for compliance with Site Plan,
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 QUEENSB_URY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518).761-8256
BUILDING PERMIT
Permit Number: P20110364 Application Number: A20110364
Tax Map No: 523400-308-005-0001-002-000-0000
Permission is hereby granted to: GREGORY&LINDA FULLER
For property located at: 399. WEST MT. 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 Qpeensbury Zoning
Ordinance. Type of Construction Value
Owner Address: GREGORY&LINDA FULLER Septic Alteration Residential
399 WEST MT. Rd Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
BRADLEY'S SEPTIC SERVICE
654-6318
47 HACK Rd
CORINTH NY 12822-0000
Plans&Specifications
2011-364
septic alteration residential
$40.00. PERMIT FEE PAID-THIS PERMIT EXPIRES: Saturday,July 28,2012
(If a'longer period is required,an application for an extension mustbe made to the code Enforcement Officer
of the Town of Queensbury before the"expiration date.)
Dated at the Town of QueensbuAy; Thursday,July 28,2011
SIGNED BY 0 r le for the Town of Queensbury
.- -
Director of Building&V de Enforcement
__ ____OFFICE USE ONLY___."..:.
,
TAX MAP NO. PERMIT NO. PERMIT FEE D
APPROVALS: ZONING TOWN CLERK JUL 2 6 2011
?OWN OF-QUEEIVSBUR�
APPLICATION-FOR SEPTIC DISPOSAL SYSTEM P ILDING& CODES
A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS.APPLICATION IS SUBJECT TO REVIEW BEFORE ISSUANCE OF A VALID
PERMIT.
OWNER: INSTALLER:
ADDRESS:__ 3 ( 9 W � ADDRESS: "7 O
PHONE NOS. PHONE Nos. S"I 3 i p
LOCATION OF INSTALLATION:
NO.OF RESIDENCE INFORMATION:
YEAR BUILT BEDROOMS X COMPUTATION= = TOTAL DAILY FLOW
1980 or older X 150 gallon per bedroom = GARBAGE GRINDER
INSTALLED?
1981 -1991 X 130 gallon per bedroom =
SPA OR HOT TUB
1992—present X 110 gallon per bedroom = INSTALLED?
PARCEL INFORMATION:
✓ TOPOGRAPHY: Flat rolling Steep slope %Slope
✓ SOIL NATURE: Sand_ Loam Clay OtherLL.
✓ GROUNDWATER: At what depth?
✓ BEDROCK/IMPERVIOUS MATERIAL: At what depth?
✓ DOMESTIC WATER SUPLY: Municipal ✓wh Well. (If well: Water supply from any septic
system absorption is ft.)
✓ PERCOLATION TEST: Rate is minutes per inch [MPI]
(Test to be completed 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: 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:
❑ ABSORPTION FIELD (WITH NO. 2 STONE) Total length' ft. Each•trench X
❑ SEEPAGE PIT(S) (WITH NO. 3 STONE) How many? Size?
❑ ALTERNATIVE SYSTEM_ �qe or other type? --ZJ \
❑ HOLDING TANK SYSTEM Total required capacity?
Tank size? Number of tanks?
NOTE: ALARM SYSTEM AND ASSOCIATED ELECTRICAL WORK MUST BE INSPECTED BY A TOWN i
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 these and all requirements of the Town of - QUESTIONS? CALL 761-8256 OR EMAIL
Queensbury Sanitary Sewage Disposal Ordinance. codesCa�Queensburv.net
VISIT OUR WEBSITE FOR MORE INFORMATION
www.aueensbury.net
Signature of Person Responsible Date
rr Town of Queensbury.- Community Development Office ■ 742 Bay Road, Queensbury, NY 12804
B 5-LGL 6/06
(3:00 )
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/pm Depart-7-i. am/pm
742 Bay Rd., Queensbury, NY 12804 Inspector's Initials: n "I1 )•�;
NAME: Fuller PERMIT NO.:
LOCATION: INSPECT ON: --
RECHECK:
Comments and/or diagram
Soil T Loam/Clay
Type of Water• t Well Water
Water a aration 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 ft.
Length of each trench 42 ft.
Depth of trenches ft.
Size of Stone —4 win
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box
Distribution Box to Field Pit ('rz' Ftv
Opening Sealed: _ N � L,
End Cap N
Inle Outlet Pipes&Baffles Y N
Manholes 12"or less below grade N
rovide adenslon collar if Yes N
Location I Separations
Foundation to tank ft.
Foundation to absorption
Separation of Pits
it r4t—
Conforms as per Plot Plan FN
Engineer Report and As-Built _Y N
ETU Maintenance Contract Y_N
provided
Location of Syste erty:
Front Rear Left Side Right Side Middle Front Middle Rear
stem Use S
Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
L:\Pam Whiling\2010\Building Codes Forms\Inspection Forms\Septic Inspection Report-03 2910.doc
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