2010-152 TOWN OF QUEENSBURY
0,0Bay Road,Queensbury,742 eensb ,NY 12804-5902 (518)761-8201
Community Development- Building &Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number. P20100152 Date Issued: Thursday, April 22, 2010
This is to certify that work requested to be done as shown by Permit Number P20100152
has been completed.
Tax Map Number: 523400-302-017-0001-024-000-0000
Location: 30 WINTERGREEN Rd
Owner. SHANNON & AUDREY TUCKER
Applicant: SHANNON & AUDREY TUCKER
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
`Dproperty 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.
4111111ATOWN OF QUEENSBURY
cosi 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20100152 Application Number. A20100152
Tax Map No: 523400-302-017-0001-024-000-0000
Permission is hereby granted to: SHANNON&AUDREY TUCKER
For property located at: 30 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: SHANNON&AUDREY TUCKER
30 WINTERGREEN Rd Septic Alteration Residential
QUEENSBURY,NY 12804 Total Value
Contractor or Builders Name/Address Electrical Inspection Agency
FRED SMITH
798-1836
QUEENSBURY, NY 12804-0000
Plans Sc Specifications
2010-152
SEPTIC ALTERATION RESIDENTIAL
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Friday,April 15, 2011
(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 own Que bry , 'fT rsday,April 15,2010
SIGNED BY ` ' for the Town of Queensbury.
Director of Building&Code Enforcement
oZ ./7 l/ 24
OFFICE USE ONLY r
9fr
TAX MAP NO. PERMIT NO. 6-6-2-PERMIT FEE___, -
' a /2010
APPROVALS: ZONING e TOWN CLERK r:
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.
OWNER: J//(��)f 64 1 /V`-f�'J INSTALLER: "'`�` ,)/1/14
ADDRESS: id (L11yii ADDRESS: le-Pla)///416.t'
PHONE NOS. 74/6- 56 4/51 PHONE NOS. 79 0 i G!.)
LOCATION OF INSTALLATION: 3d a)/n6V-7e -rj/r,1
NO.OF RESIDENCE INFORMATION:
YEAR BUILT BEDROOMS x COMPUTATION= = TOTAL DAILY FLOW
1980 or older ��,T. X 150 gallon per bedroom = GARBAGE GRI R
36 t) INSTALLED? At
1981 -1991 X 130 gallon per bedroom =
SPA OR HOT TAN,
1992-present X 110 gallon per bedroom = INSTALLED?
PARCEL INFORMATION:
✓ TOPOGRAPHY: Flat rolling Steep slope %Slope
✓ SOIL NATURE: Sand Loam Clay Other
✓ GROUNDWATER: At what depth? N
J ,
✓ BEDROCK/IMPERVIOUS MATERIAL: At what depth? #1/11
✓ DOMESTIC WATER SUPLY: Municipal t/ Well (If well: Water supply from any septic
system absorption is ft.)
,
✓ PERCOLATION TEST: Rate is /4" per minute per inch.
(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: ids-of 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: ,,II
kj ABSORPTION FIELD (WITH NO. 2 STONE) Total length 2Vd ft. Each trench 4'6/ X 2-
D
❑ SEEPAGE PITS) (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
1. 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.
/- 3 7:7L-A-,r,k)67_
Septic Inspection Report
Office No. (518) 761-8256 Date Inspectioyu--+..''iiir ed:
Queensbury Budding &Code Enforcement Arrive: 1 'y2-5 a ,j1 .;;•• -rt• I' a', j
742 Bay Rd., Queensbury, NY 12804 Inspector's Initials•"
NAME: /tar/. r UT NO.: 20/ a
LOCATION: 3C} tuitii ►P�T _� NSPECT ON:
RECHECK: !J
Comments and/or diagram
Soil Ty•: �`�►••m/ Clay
Type of Water:cia....T1411.W I Water
Wate •.ration distance FE.al- ft.
Well separation distance q eft.
Other wells: _ft.
Well Casing Length 50' +/ - Y N N/A
[150'to well required if NO]
Absorption Field: Total length 7-I--ID ft.
Length of each trench ''I ft.
Depth of trenches 'L,- ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank �•j i,c.,i{
Tank to Distribution Box -.3"
Distribution Box to Field/ Pit It 3 c-� �✓
Opening Sealed: /_N
End Cap
f
Inlet/Outlet Pipes&Baffles
Manholes 12"or less below grade _Y—
[provide extension collar if Y4] Y T N
Location/ Separations
Foundation to tank .
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Engineer Report and As-Built ^Y—N
ETU Maintenance Contract _Y_ N
provided
Location of System on Property:
Front ,( rO Side Rif Side Middle Front Middle Rear
System Use S .tus:
Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
L:\Pam Whiting\2010\Building Codes Forms\Inspecction Forms\Septic Inspection Report_03 29 10.doc
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