2012-477 TOWN OF QUEENSBURY
4j, 742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20120477 Date Issued: Tuesday, October 09, 2012
This is to certify that work requested to be done as shown by Permit Number P20120477
has been completed.
Tax Map Number: 523400-308-012-0002-065-000-0000
Location: 30 STEP1-IANIE Ln
Owner: DONALD & JAYME LORENTZ JR
Applicant: DONALD & JAYME LORENTZ JR
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 Cf
property owner of the responsibility for compliance with Site Plan, v�
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.
1
TOWN OF QUEENSBURY
742 Ray Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518)761-8256
BUILDING PERMIT
Permit Number: P20120477 Application Number: A20120477
Tax Map No: 523400-308-012-0002-065-000-0000
Permission is hereby granted to: DONALD &JAYME LORENTZ JR
For property located at: 30 STEPHANIE LII
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: DONALD& JAYME LORENTZ JR
Septic Alteration Residential
30 STEPHANIE Ln
QUEENSBURY,N.Y. 12804-0000 Total value
Contractor or Builder's Name/Address Electrical Inspection.agency
SANITARY SEWER
GEORGE DRELLOS 792-7257
PO BOX 224
GLENS FALLS NY
Plans&Specifications
2012-477
Residential Septic Alteration
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Tuesday,October 01,2013
(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 of Queensbury; Monday,October 01,2012
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
Sof: 2U12
Community Development Office
Town of Queensbury • 742 Bay Road • Queensbury, New York •12804
Office Use Only
TAX MAP NO. 30`? , a^�-(� PERMIT NO. 1.6)- 1 PERMIT FE 7c../
APPROVALS: ZONING TOWN CLERK
APPLICATION FOR SEPTIC DISPOSAL SYSTEM PERMIT: A PERMIT MUST BE OBTAINED
BEFO,RFVORK BEGINS. APPLICATION/� IS SUBJECT TO REVIEW ORE ISSUANCE q� A VALID PE MIT.
OWNERQN 4-L) /Mg.?' 2.- INSTALLER: "- j9ytl ,%09111 � � V/C Q�
S� k L,sADDRESS: 0 2u �i
ADDRESS: 3� 1 eac h /kJ" C� Ci P ` -1 6 ! _
PHONE NOS. '�/3 - v 2� b PHONE NOS. 7 g b - Q p `�J
LOCATION OF INSTALLATION:
RESIDENCE INFORMATION:
NO.OF COMPUTATION
YEAR BUILT X = TOTAL DAILY FLOW
BEDROOMS (Gallons per bedroom) GARBAGE GRINS FI
1980 or older X 150 = INSTALLED? '
1981 1991 X 130 = SPA OR HOT TUB
1992-present X 110 = INSTALLED? P
PARCEL INFORMATION: /
✓ TOPOGRAPHY: FLAT ROLLIN ""_ STEEP SLOPE %SLOPE
✓ SOIL NATURE: SAND . LOAM CLAY OTHER
✓ GROUNDWATER: AT WHAT DEPTH?
✓ BEDROCK/IMPERVIOUS MATERIAL: AT WH T DEPTH?
✓ DOMESTIC WATER SUPLY: MUNICIPAL WELL___(If well:water supply from any septic system absorption is: ft)
✓ PERCOLATION TEST: RATE ISPER MIINUTE 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: Lo d(3 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: p
.ABSORPTION FIELD(WITH NO.2 STONE) Total length I 0 ° ft. Each trench I- X Itc)
❑SEEPAGE PIT(S)(WITH NO.3 STONE) How many? Size?
❑ALTERNATIVE SYSTEM Bed or other type?
0 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 regula'• s with respect to this application and agree to
a.', - sy '1-se and al e. -meets of th- Town of Queensbury QUESTIONS? CALL 761-8256 OR EMAIL
a itary -wage Di ,,00 . I ,inan,/ i codes(o,queensbury.net
— (z? ( _ VISIT OUR WEBSITE FOR MORE INFORMATION
Si• .
ture of •erson R--ponsible Da e www.queensbury.net
LaVZL-- -11- -1,-)-6 I
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building &Code Enforcement Arrive: am/ m Depart: 4am/pm
742 Bay Rd., Queensbury, NY 12804 Inspector's Initials: '
NAME: k CA PERMIT NO.:
LOCATION: 30 INSPECT ON: /O --S-7,;\ RLI
RECHECK:
Comments and/or diagram
Soil Type: / Loam/ Clay
Type of Water: Municipal/ Well Water
Waterline separation 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 lengthft
j t .
Length of each trench ��ft.
Depth of trenches .. ft.
Size of Stone
Seepage Pits: Number
Size:
Stone Size:
Piping Size Type
Building to tank � ' `'
Tank to Distribution Box <
:' 1= r
Distribution Box to Field / Pit � A`
Y
Opening Sealed: r N
End Cap W— N
Inlet/Outlet Pipes&Baffles Y N
Manholes 12"or less below grade _Y_ N
[provide extension collar if Yes] _Y_ N
Location/ Separations
Foundation to tank -1
Foundation to absorption ft.
Separation of Pits .
Conforms as per Plot Plan a � N
Ergrreer,Report-and-As-Built _Y— N
ETU Maintenance Contract _Y_ N
provided
Location of System on Property:
Front Re r Left Side Right Side Middle Front Middle Rear
S stem Use Sta s:
\ Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
L:\Pam Whiting\2010\Building Codes Forms\Inspection Forms\Septic Inspection Report 03 29 10.doc
, ►2v
I �� ID
III
11114 III
0
1111 III vl
it
11111111
o 0
3
0 g
. „...
co
co "<
v
. o
N �
co r
ri.
a,
`` O
:, ,
111111111 I
III it
111111111111111111117111111 !
70 D0
-<
73
N
I-
-2 Z co�
C111:
rnaCLl 1-,� J
-414,1411, alr
'6
03
N1/4,
REAR PROPERTY LINE
C)
PM IT EVT PLAN
I HAVE PERSONALLY MEASURED THE DISTANCE
FROM THE PR•'ERTY LINES TO THE
'e'•OS At; TURE('' uR SIGN S)
i.. .v.r."11It"E DAT- 7/2_