2013-340 TOWN OF QUEENSBURY
wow742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20130340 Date Issued: Wednesday, July 31, 2013
This is to certify that work requested to be done as shown by Permit Number P20130340
has been completed.
Tax Map Number: 523400-309-009-0003-063-000-0000
Location: 58 MASSACHUSETTS Ave
Owner: LEWIS SMITH
Applicant: LEWIS SMITH
This structure may be occupied as a:
Septic Alteration Residential
By Order of Town Board
TOWN OF Q/UjEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the _Ctif/ /it
owner of the responsibility for compliance with Site Plan, vz�
Variance, or other issues and conditions as a result of approvals by the Director of Building&Code Enforcement
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Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20130340 Application Number. A20130340
Tax Map No: 523400-309-009-0003-063-000-0000
Permission is hereby granted to: LEWIS SMITH
For property located at 58 MASSACHUSETTS Ave
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: LEWIS SMITH
58 MASS. Ave Total agueAltetion Residential
QUEENSBURY,NY 12804 Total value
Contractor or Builder's Name /Address Electrical Inspection Agency
Plans&Specifications
2013-340
Res. Septic Alteration
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Tuesday,July 29,2014
(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 f Queer sb 7 A Mo: i y`,July 29,2013
SIGNED BY t for the Town of Queensbury.
Director of Building&Code Enforcement
OFFICE USE ONLY j
TAX MAP NO.304,9-,3- .03ERMIT NO. /3'3jo PERMIT FEE y0 Ai 2 6 203 ISI
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: J /F 5////ryye1
/n/',J, { L/�I INSTALLER: �rJ2'� r/�/� jrnl��
ADDRESS:/ 22ChO0tJ /4S ADDRESS: 04J &to f 26/;-6
PHONE NOS. PHONE NOS./3;7V 79 841126/L%/ d95-6/
LOCATION OF INSTALLATION:
YEAR BUILT Na OF X COMPUTATION= = TOTAL DAILY FLOW RESIDENCE INFORMATION:
BEDROOMS
1980 or older X 150 gallon per bedroomGAINSTRBAAGLLEED?GRINDER
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1981 -1991 X 130 gallon per bedroom =
1992-present X , 110 gallon per bedroom = I SPA EDT TUB
INSTAALL LED?
PARCEL INFORMATION:
✓ TOPOGRAPHY: Flat rolling Steep slope %Slope
✓ SOIL NATURE: Sand II Loam Clay Other
✓ GROUNDWATER: At what depth?
✓ BEDROCK/IMPERVIOUS MATERIAL: At what depth?
if DOMESTIC WATER SUPLY: Municipal Well (If well: Water supply from any septic
system absorption is ft.)
✓ PERCOLATION TEST: Rate is 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: `(,t'{�O GALLON (MIN. SIZE IS 1,000 GAL.)Add 250 gallons td the size of the septic tank for
each garbage grinder, spa or whirlpool tub.
SYSTEM TYPE:
ABSORPTION FIELD (WITH NO. 2 STONE) Total length AO ft. Each trench 02 x 35
❑ SEEPAGE PIT(S) (WITH NO. 3 STONE) How many? Size?
0 ALTERNATIVE SYSTEM Bed or other type?
O 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.
Septic Inspection Report �,/� ,R
Office No. (518) 761-8256 Date Inspection req„ ,'�' . • l vL f I )
Queensbury Building &Code Enforcement Arrive: 1-70 a ur,� t.-..rt: \^•-30 amtpim�
742 Bay Rd., Queensbury, NY 12$04 Inspector's Initials: �
NAME: 4j M . I frNO.: ; > -3�O
LOCATION: 5$ !b t1-5 5 A-61/1/4.v se-Ter? � SPECT ON: `7/10 3
RECHECK:
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Comments and/or diagram
Soil Type m/ Clay
Type of Water: unid ater
Waterline separation distance kr) ft. -l- FeotS- Pc�y
�
Well separation distance fL
Other wells: ft.
Well Casing Length 50' +/ - Y_N_N/A
[150'to well required if NO]
Absorption Field: Total length 1 LW) ft.
Length of each trench N P ft.
Depth of trenches 9-1, ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank 41 ” 5c2H y fl
Tank to Distribution Box J-1"
Distribution Box to Feld/ Pit > " �c 2 15 c 7 t '�bVc-175-
Opening
1j5Opening Sealed: Y N
End Cap f N
Inlet/Outlet Pipes&Baffles ,/
Manholes 12"or less below grade -s/ Y
[provide extension collar if Yes] _Y_N
Location/ Separations
Foundation to tank \ID ft.
Foundation to absorption ZUft.
Separation of Pits r 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 a -ft Side Ri.ht Side Middle Front Middle Rear
System 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 Foms\Inspection Forms\Septic Inspection Report03 29 10.doc
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