2013-018 411_114•14. 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: P20130018 Date Issued: Wednesday, January 23, 2013
This is to certify that work requested to be done as shown by Permit Number P20130018
has been completed.
Tax Map Number: 523400-309-011-0001-009-001-0000
Location: 112 FOURTH St EXT
Owner: CHARLES & CONNIE NORMAN
Applicant: CHARLES & CONNIE NORMAN
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 csDavo04 f1
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.
064 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building&Codes (518)761-8256
BUILDING PERMIT
Permit Number: P20130018 Application Number: A20130018
Tax Map No: 523400-309-011-0001-009-001-0000
Permission is hereby granted to: CHARLES & CONNIE NORMAN
For property located at: 112 FOURTH St EXT
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: CHARLES & CONNIE NORMAN
112 FOURTH ST. EXT Septic Alteration Residential
QUEENSBURY,NY 12804 Total Value
Contractor or Builder's Name/Address Electrical Inspection Agency
IBS SEPTIC & DRAIN
ATTN: IVAN BELL
2 LOWER WARREN St
OUEENSBURY.NY 12804
Plans&Specifications
2013-018
Residential Septic Alteration
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday,January 16, 2014
(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 ue sbury• "*/We s.:y,January 16, 2013
C-4SIGNED BY `- a, 'V for the Town of Queensbury.
Director of Building&Code Enforcement
\� Community Development Office
Town of Queensbury • 742 Bay Road • Queensbury, New York •12804 JAN 1 (✓
' 2813
Office Use Only r o
TAX MAP NO. 3 D r 4 s ti I -/J r q• / PERMIT NO. if 3 r6 I 0 PERMIT FEE KId
APPROVALS: ZONING TOWN CLERK
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: COVn� i �Cf�(V"'0I\ INSTALLER: Z\ �� C) e.s r' '(
I
ADDRESS: 11. }���iJ�• ADDRESS:) LQ VJ e r(wJ!(Pts.C)A -
PHONE NOS. 7_ �f (1( PHONE NOS.c \
\
LOCATION OF INSTALLATION: - LH-LN 5
RESIDENCE INFORMATION:
NO.OF COMPUTATION
YEAR BUILT X = TOTAL DAILY FLOW
BEDROOMS (Gallons per bedroom) GARBAGE GRIN R
1980 or older Th) X 150 = I J n INSTALLED?WL
1981 -1991 X 130 = I SPA OR HOT TUB
1992-present X 110 = INSTALLED?
PARCEL INFORMATION: `r
✓ TOPOGRAPHY: FLAT ROLLING V! STEEP SLOPE, %SLOPE'V I\
✓ SOIL NATURE: SAND LOAM/ar CLAY`V OTHER N
1
✓ GROUNDWATER: AT WHAT DEPTH? 1\I
✓ BEDROCK/IMPERVIOUS MATERIAL: AT W T DEPTH? IV I�
I DOMESTIC WATER SUPLY: MUNICIPAL I WELL\V 6 (If well:water supply from any septic system absorption is: !v ft)
✓ PERCOLATION TEST: RATE IS I V I PER 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: tn(Y) 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: () e IS 1 "e
dABSORPTION FIELD (WITH NO. 2 STONE) Total length �\ .1 ft. Each trench T X X1(1
0 SEEPAGE PIT(S)(WITH NO. 3 STONE) How many?_ `vV
� Size? I
0 ALTERNATIVE SYSTEM Bed or other type? \ I IV 1\
CI HOLDING TANK SYSTEM Total required capacity? `V N Tank size? iv N Number of tanks?N 11-
NOTE:
fNOTE: 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 Queensbury QUESTIONS? CALL 761-8256 OR EMAIL
Sanita is osal Ordinance. codes(tqueensburv.net
ry� g p t—I�—I�
Signature of Pe on Responsible Date VISIT OUR WEBSITE FOR MORE INFORMATION
www.queensbury.net
(10 ,e -ro OA_
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received: 14-7//
Queensbury Building &Code Enforcement Arrive: am/pm Depart: i 2i" am/pm
742 Bay Rd., Queensbury, NY 12804 Inspector's Initials: ;!. : '
NAME: 1 .,1)0Ai��Y1 4 Iv -(55 PERMIT NO..
LOCATION: I I Z i 0,-1z-T 14 , E i. INSPECT ON: 1W
RECHECK:
Comments and/or diagram
Soil Type: Sand/ Loam/ Clay
Type of Water:, Munic l/Well Water
Waterline separation distance
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 n
Seepage Pits: Number
Size: rc
Stone Size: ,
Piping Size Type
Building to tank
Tank to Distribution Box
Distribution Box to Field/ Pit
Opening Sealed: V N
End Cap \' _ N,
Inlet/Outlet Pipes&Baffles v N
Manholes 12"or less below grade _Y_:'N;� —
[provide extension collar if Yes] Y_,L. N,l
Location/ Separations
Foundation to tank ; ft.
Foundation to absorption !~_- i _ft.
Separation of Pits \. ft.
•
Conforms as per Plot PlaQ _,Y 1 ' N
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 Stak{s:
`�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
.\ VOU A\, OT _.--- ---..----}"-.---
wC\R1 I'4(
1 -
rr99�
VS
I oG
Or 4!
f
r '-.'4'
Nq /
L -,c o o 10or
\ c)CN \&(\, F�\\� '' _V
`~ (c,, \<A,'±s.. C-r11`", Co'`.neC -R
16
Et_____
s
) )
I:1I r: y)PYlit!3 IA
•
IC c)k
\_A' 35
t--) I� m%'-.
1 ptie
,..../
oew i4
TOWN OF QU U •Y 1oa '� +s
BUILDING & 'Opt'. a : . ' ��
Reviewed By. /'f,A
Date:
smarm
11,
u. --vi, 54.-
J,�;� i f; X013
Go ru ye
0rr, se No1Mo►r.
79c6-°1+ 1-1-C6
uEP7 b.,. ' 1A
I HAVE SEEN ----�N
SUCH SEEN OR.a OBSERVED ALL OBJECTS
SUCH � SELLS, TREES FENCES,
O'"THIS DOCUMENT I HAVE PONETC
vfEAS ift �.E'DISTANCE SET FORTH ON THfS PERSONALLY
SIGNQTUJ2E /i��
SATE
Woit e(
liCs
I+ -"Fk 5 i .
ve