2012-501 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20120501 Date Issued: Tuesday, November 05, 2013
This is to certify that work requested to be done as shown by Permit Number P20120501
has been completed.
Tax Map Number: 523400-308-018-0001-071-000-0000
Location: 87 REVERE Rd
Owner: DANIEL & CYNTHIA VACHON
Applicant: DANIEL & CYNTHIA VACHON
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 � �
property owner of the responsibility for compliance with Site Plan, avP 1
Variance, or other issues and conditions as a result of approvals by the Director of Building& Code Enforc mens
Planning Board or Zoning Board of Appeals.
TOWN OF QUE,ENSBURY
742 Bay R(ud,Quccn,4)urY,NY 12904-5902 (5'18)761-8201
Cornivinnity Developtnent- Building& Codes (518) 761-8256
BUILDING PERMIT
Peri it Nuniber: 1120120501 Application Number: A20120501
Tax ,\Iap No: 523400-308-018-0001-071-000-0000
1'ertiii,,,sic,)tiislicrcl)ygi-;intcdtor: DANIEL & CYNTHIA VACHON
For property located.at: 87 REVERE Rd
in the Town of Queensbury, to construct or place
at the above location In accordance with ;application together with plot plans and other itiforillatioll hereto filed
and approved and in compliance with the NYS Uniforin BUildilIg and the Qltcerisbury Zoning
Ordinance. Type of Constrtiction Valiae
Owner Address: DANIEL & CYNTHIA VACHON Septic Alteration Residentia8
87 REVERE Rd N"'
QUEENSTotal ante.
NY 12804
C',ontractor or Iiiii1der's Nainc / Address t,"Iectrical Inspection Agency
Plans&Specifications
2012-501
IRes, Septic Alteration
$40.00 PERMIT FEE PAID -THIS PERMIT EXPIRES., Wednesday, October 23, 2013
(If a Jortger period is reqoired,an application for an extension must be ruade to the code L11forct'.111cnt Officer
of diel'o%vn of Queensbury before the expiration date.)
Dated at the Town of Queensbury; Tuesday, October 23, 2012
S 1IGNE -"I)BY for thc'Fo\vn of Queensbury.
Director of Building& Code I.�'nfi',ircerricnt
OFFICE USE ONLY
TAX MAP NO.3 0 S.lS ��1 PERMIT NO. )a `SO) PERMIT FEE 1D OPT
APPROVALS: ZONING TOWN CLERK 2012
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: Ultotrd l6( V>�� ectN G 1 AL ,1.1
ADDRESS: � 11�- J ��C. AM./Kt-1s' S-.
•J�
PHONE NOS.(-5 -7S � %Cj S h- L
LOCATION OF INSTALLATION: S r� h, �� A S LA (p c `.
NO.OF RESIDENCE INFORMATION:
YEAR BUILT BEDROOMS X COMPUTATION= = TOTAL DAILY FLOW
1980 or older X 150 gallon per bedroom Q GARBAGE GRINDER
HCl INSTALLED? /4—'67
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
e p
✓ SOIL NATURE: Sand Loam Clay Other
✓ GROUNDWATER: At what depth? r /.
✓ BEDROCK/IMPERVIOUS MATERIAL: At what depth? ~/
✓ DOMESTIC WATER SUPLY: Municipal r/ Well (If well: Water supply from any septic
system absorption is ft.)
✓ PERCOLATION TEST: Rate is i' .4" minutes per inch [MPI]
(Test to be competed 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: /e-'('(-7 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: .� r\,? ( -f-F,
g'.. SORPTION FIELD (WITH NO. 2 STONE) Total length 66 ft. Each trench 2 x Sd
❑ SEEPAGE PIT(S) (WITH NO. 3 STONE) How many? Size? ��rJ /i/y�� et
�JQn PC
❑ ALTERNATIVE SYSTEM Bed or other type?
❑ HOLDING TANK SYSTEM Total required capacity?
Tank size?/Gv"' 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 these and all requirements of the Town of QUESTIONS? CALL 761-8256 OR EMAIL
Queensbury Sanitary Sewage Disposal Ordinance. codes(aqueensburv.net
VISIT OUR WEBSITE FOR MORE INFORMATION
Z www.queensbury.net
Signature of Person Responsible Date
"nY Town of Queensbury • Community Development Office • 742 Bay Road, Queensbury, NY 12804
B 5-LGL 6/06
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection req - - •iv-•.
Queensbury Building &Code Enforcement Arrive: \ -?j i` ' a 101� •.rt:
742 Bay Rd., Queensbury, NY 12804 Inspector's Initial • —
NAME: V oYr., f? IT NO.:
LOCATION: �1 �V ,r-'F RA INSPECT ON: 11.- 1-1-
RECHECK:
Comments and/or diagram
Soil Type: Sand/ Loam / Clay
Type of Water: Municipal/ Well Water c_
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 length ft.
Length of each trench ft.
Depth of trenches _ ft.
Size of Stone {f
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box
Distribution Box to Field/ Pit
Opening Sealed: _Y— N
End Cap ,Y N
Inlet/Outlet Pipes&Baffles Y N
Manholes 12"or less below grade _ N
[provide extension collar if Yes] Y T N
Location/ Separations
Foundation to tank ft.
Foundation to absorption a 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 •-.r Left Side Right Side Middle Front Middle Rear
S stem Use S . s: 6t L r-�
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
1' u.e� d us q -- I1
Septic Inspection Report
Office No. (518) 761-8256 Date Ins.- ion r:-, 6:::•
rece'.ed•
Queensbury Building &Code Enforcement Arrive: le,- :r . ,-r,.- • ll
742 Bay Rd., Queensbury, NY 12804 Inspector's Initials: '
i
NAME: \) C LS'V Q 4 'ERS NO.: i `)- �U I
LOCATION: 1 K e Q F re• Rd I► PECT ON: /b --:-..W2--rx
RECHECK:
Comments and/or diagram
Soil Type- m/ Clay
Type of Wa ell 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 length ft.
Length of each trench trench _52E-4.-i..6-0 ft.
Depth of trenches ft.
Size of Stone z _
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank 1-1` (..11- 640 �zc.I1,e
Tank to Distribution Box '` J`v�'
Distribution Box to Field/ Pit p ,i L_ it, Li c t Pu C_''C
Opening Sealed:
End Cap N ---> L—p ��
Inlet/Outlet Pipes&Baffles _ N /
Manholes 12"or less below grade _Y ✓r�
[provide extension collar if Yes] _Y N t•._ ��-> Tt) 1,13' V 1_ tkPkt3 : __5_
Location/ Separations �X—Tt= �
Foundation to tank Exp-7"7—ft.
Foundation to absorption 7 [) ft.
Separation of Pits ft.
Conforms as per Plot Plan V Y_ N
Engineer Report and As-Built _Y N
ETU Maintenance Contract _Y_ N
provided i C' \"-,AP-C--
z A LL___ LL
Location of System on Property: E� /5— E `c ` ��
Front Rem Left Side Right Side Middle Front iddUe Rear' 1 Sj E_
System Use Status:
pproved
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
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building &Code Enforcement Arrive: am/ m Depart:G� ' ' am/pm
742 Bay Rd., Queensbury, NY 12804 Inspector's Initials: -
NAME: S\\ j) PERMIT NO.: D` 50
LOCATION: p €1- Pal INSPECT ON: /0 aq-/-)
RECHECK:
Comments and/or diagram
Soil Type: 47/ Loam/ Clay
Type of Water: Municipal/ Well Water I
Waterline separation distance ft. Co5�
Well separation distance ft.
Other wells: _ ft.
Well Casing Length 50' + / - Y N N/A
[150'to well required if NO]
length Field: Total
Absorption ,bk ft. Yolk- ---1,4is-4/-P 9 �
Length of each trench c> ft. n
Depth of trenches _7'1_4- ft.
Size of Stone (_ E
Seepage Pits: Number
Size: x
Stone Size: `� l
�r2v
Piping Size Type 1(
Building to tank (1 C1(-= C� f �. 1R$ \T c3-C-C
Tank to Distribution Box Nt-
Distribution Box to Field/ Pit ¶ �I - VL?.
Opening Sealed: Y N
End Cap Y N
Inlet/Outlet Pipes& Baffles TY N
Manholes 12"or less below grade _Y_ N
[provide extension collar if Yes] _Y_ N
Location / Separations
Foundation to tank ft.
Foundation to absorption 4- ft.
Separation of Pits ( ft.
Conforms as per Plot Plan
Engineer Report and As-Built _Y �' N
ETU Maintenance Contract _Y —N
provided
Location of System on Property:
Front Rear Left Side Right Side Middle Front Middle Rear
System Use Status:
Partial Approv-• and needs to be re-inspected, please call the Building &Codes Office
11 - •• .•-•
L:\Pam Whiting\2010\Building Codes Forms\Inspection Forms\Septic Inspection Report_03 29 10.doc
MCommunity Development Office
` Town of Queensbury • 742 Bay Rd. /I (
/•
Queensbury, New York .12804 PLOT PLAN i 5 �l
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