2015-195 TOWN OF QUEENSBURY
vro y742 Ba Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20150195 Date Issued: Wednesday, August 19, 2015
This is to certify that work requested to be done as shown by Permit Number P20150195
has been completed.
Tax Map Number: 523400-308-014-0001-052-000-0000
Location: 183 PITCHER Rd
Owner: FOREST PARK -- 65 GREGWOOD CIRCLE
Applicant: FOREST PARK -- 65 GREGWOOD CIRCLE
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 ( ag,P 4
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 QUEENSBURY
coro 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20150195 Application Number: A20150195
Tax Map No: 523400-308-014-0001-052-000-0000
Permission is hereby granted to: FOREST PARK MHC. LLC
For property located at: 183 PITCHER 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: FOREST PARK MHC, LLC Septic Alteration Residential
31200 NORTHWESTERN Hwy Total Value
FARMINGTON HILLS MI 48834-00
Contractor or Builder's Name /Address Electrical Inspection Agency
Plans&Specifications
2015-195
Septic Alteration
67 Gregwood Circle
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday, May 26,2016
(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 T n of eens ry� • : ., ay 26,2015
4
SIGNED BY � \ for the Town of Queensbury.
Director of Building&Code Enforcement
SEPTIC DISPOSAL PERMIT
/ Office Use Only
DATE I I 1 \ ' 'v 3 Received
'n1111� MAY 2 2015 Tax Map,I D
TAX MAP ID Perr> it;Ne. 1_0 I`J— 1ei5
P..etmit Fee 10 td.
7��t � 1e r P QJFENSELOCATION OF INSTALLATION
rova` :
,1$4.`Pur. 'NG f-
APPLICANT gored :Oak MH- at LLC PHONE/E-MA1L1y5'I1'I(P 7 j}
�-r�st crk
rhp-pryer-tie-3 torn
ADDRESS )83 O lifYe'ir Z. l S1 1 N 7 I g (J`1
c'� (5i E3
INSTALLER/BUILDER: �.J �i1.Z 1-1`��itt`I� C%G'L S PHONE/E-MAIL :5rat-"I c-8
ADDRESS: A ` J5b -a.4-iLiuy( pnYt.5c Ny 19 'tc>f el
OWNER PCir 9t Th-ICK ir-Pc LL(i_ PHONE/E-MAIL, ltk Li.6 0.406 1/6=
c=
Address klarUgNoG(.I CIr is `'k'1-te nskjL-t-v-T NV 1 ,9dtL
Ica))
CONTACT PERSON FOR BUILDING&CODES COMPLIANCE: MC(05(i fa iii (,1 (71/1 PHONE1,45,--r-r7 ,c
jr
RESIDENCE INFORMATION
Year Built #of bedrooms X Gallons per bedroom =Total Pally Flow
1980 or older .5 3 ci® Garbage grinder installed _Y bra
1981-1991 Spa or Hot Tub installed _Y
1992-Present
i
PARCEL INFORMATION
Topography /Flat rolling Steep slope %slope
/Sand Nature Loam Clay Other
Groundwater At what depth? /lf//I 7 Z`i
Bedrock/Impervious Material At what depth? 4//r -tl 72-"1
Domestic Water Supply /Municipal dell(if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: ., 7 per minute per inch(test to be completed by licensed engineering/architect)
�
PROPOSED SYSTEM FOR NEW CONSTRUCTION P Z7,",fe-//* 4,,-.-4-4,"/
Tank Size I()CO, gallons(minimum size 1,000 gallons,add 250 gallons to size for each garbage grinder or spa or hot tub)
System Type Absorption field with#2 stone Total length L D 4-2 ft.; Each trench 2' x 5-2)
Seepage Pit with#3 stone How many: ;size
Alternative System Bed or other type?
Holding Tank System Total required capacity? Tank size #of tanks
Notes: 1)Alarm system&associated electrical work must be inspected by a Town approved electrical inspection agency;2)We will no longer
allow systems to be covered until such time as an As-Built plan is received & approved. The installed system must match the septic system
layout on file—no exceptions.
DECLARATION: Any permit or approval granted which is based upon or is granted in reliance upon any material representation or
failure to make a material fact or circumstance know by or on behalf of an applicant,shall be void. I have read the regulations and
agree to abide by hese and all requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance.
Print Name: f C/L�9 Q-t'{?.t' 'LGVI, Date: ,,1 a2 f j
Signature: L(..�'lC,%i.'l.1 A"l[�1/� Date: 5I c?I IIS
Town of Queensbury Building&Codes Septic Disposal Permit July 2014
Town of Queensbury Building & Code Enforcement
Office No. (518) 761-8256
Septic Inspection Repot
Inspection request received:
Namea '� Inspected ono ..r ( '
Location: L� t I. � a Arrived - A, a.m.I p.m.
Permit No.: t 5 "' tt /) — /ctL Inspector's Initials:
r‘ Comments and/or diagram
Soil Type: Sand/Loam I CI ,
Type of Water: Municipal I WI Water
Waterline separation distance ft.
Well separation distance ft.
Other wells: \ ft. 1
Well Casing Length 50' /- \ Y N_LN/A
[150'to well required if NO] 'i
Absorption Field: Total length \ ft.
Length of each trench i ft.
Depth of trenches ft.
0-0.,
16j
Size of Stone "`!
Seepage Pits: Number ,;�
kr—L
�
Size: x N- e �!`yJ'�_,
Stone Size: , (�
,
t---
Piping •ize Type r �
Building to tank
Tank to Distribution Box .% Zt)
''' '
Distribution Box to Field/Pit `�r '
Opening Sealed: _Y N
End Cap _Y N
Inlet/Outlet Pipes&Baffles _Y N
Manholes 12"or less below grade Y N �)
[provide extension collar if Yes] YJ N
I
Location/Separations ji
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits .,-"----. ft.
Conforms as per Plot Plan �_ N
Engineer Report and As-Built ( Y N
ETU Maintenance Contract provided N
Location of System on Property:
Front Rear Left Side Right Side Middle Front Middle Rear
S stem Use Statu . -.
A pprov
'a ial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
Septic Inspection Report
G. Peter Jensen
17 West Road
South Glens Falls
New York 12803
(518) 798—3859 J�°'i 2 8 205
June 05, 2015
To Whom It May Concern:
I have designed(plan 14-1103)and observed the installation of the septic system
at lot 65 &67 Gregwood Circle, Forest Park MHC, Town of Queensbury, Warren
County,New York. It would appear that the installation is within the intent of the design
documents. To the best of my knowledge and belief, no field conditions were
encountered that would require a re-design of the septic system. Hancor ARC 24
chambers, with a 25%reduction,have been substituted for the stone and pipe system.
To the best of my knowledge and belief all of the distance separation requirements
have been met.
Sincerely,
G. Peter Jensen
0,E0 Apt,
e- Isshie "A496°
cr cf, s
���010
Town of Queensbury Building & Code Enforcement I 0— [a-
Office No. (518) 761-8256
cilareisizi
Septic Inspection Report
Inspection request received: 1 AA - 15
Name: ✓` I.
Inspected on: £ ,a 1 `1! _LU'lP I, 01- /5
Location: Cal a t ))d d CvzL . Arrive: . 4 .40 a.m.I p.m.
Permit No.: ( 0r/C-1615 Inspector's Initials:
Comments and/or diagram
Soil Type: Loam/Clay
Type of Water: Municipal I Well Water
Waterline separation distance ft.
Weil separation distance ft.
Other wells: ft.
Well Casing Length 50'+/- Y N_N/A
[150'to well required if NO] ))te-64-
1
Absorption Field: Total length __ ft. di
Length of each trench ft. � '� ���a C` `�
Depth of trenches gr IA— ft. m
Size of Stone `v " r 3D, -Lor-70 7
1
Seepage Pits: Number1
Size: x
Stone Size: L„— (4..t........\ c."Piping Size Type ,t �,(.
Building to tank V't._ � V �'
V)/47----?)C-zti
Tank to Distribution Box
Distribution Box to Field/Pit 2.cc-
Distribution V r�'-
Opening Sealed: _N
End Cap V N
Inlet/Outlet Pipes&Baffles t ' N
Manholes 12"or less below grade _Y N
[provide extension collar if Yes] _Y_N
Location I Separations
Foundation to tank ft.
Foundation to absorption ft. < rrea—
Separation of Pits ft.
Conforms as per Plot Plan _Y_N �,(
Engineer Report and As Built _Y__N ef �(I" LWi' 1 i`r `7grz-1/�
`rIj'
ETU Maintenance Contract provided _Y_N
Location of System on Property;
Front Rear L ft Side Right Side Middle Front Middle Rear
1
S stem Use Status.
A
P rtial Approv and needs to be re-inspected, please call the Building&Codes Office
DeSeptic Inspection Report 0
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