SEP-000440-2017 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development-Building& Codes (518)761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: SEP-000440-2017 Date Issued: Friday, August 4, 2017
This is to certify that work requested to be done as shown by Permit Number SEP-000440-2017
has been completed.
Tax Map Number: 309.9-1-65
Location: 67 OHIO AVE
Owner: EDWARD TESSIER
Applicant: Smith's Excavating
This structure may be occupied as a: Residential Septic Alteration
By Order of Town Board
TOWN
^OFFQQUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the
property owner of the responsibility for compliance with Site Plan,
Variance,or other issues and conditions as a result of approvals by the
Planning Board or Zoning Board of Appeals. Director of Building&Code Enforcement
TOWN OF QUEENSBURY
742 Bay Road Queensbury,NY 12804-5904 (518)761-8201
qL Community Development-Building& Codes (518)761-8256
BUILDING PERMIT
Permit Number: SEP-000440-2017
Tax Map No: 309.9-1-65
Permission is hereby granted to: Smith's Excavating
For property located at: 67 OHIO 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
Tvce of Construction
Owner Name: EDWARD TESSIER Septic Disposal-Residential $0.00
Owner Address: 67 Ohio Total Value $0.00
Queensbury,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
Smith's Excavating
23 Vermont AVE
Queensbury,NY 12803
Plans&Specifications
Residential Septic Alteration
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday,July 26,2018
(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 e date.
Dated at the Town o ueens f/ /J W e July 261 2017
SIGNED BY: ayy� V for the Town of Queensbury.
Director of Building&Code Enforcement
SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury, NY 12804
P: 518-761-8256 www.gueensbury.net Permit#: 5E:-P'44k43 •-2.1004
Tax Map ID#: '3c)t3. !�- l-11 & 5 Permit Fee: $ 0 ; Invoice#: 240
Project Location: (0-� ni11e) Ayc- Septic Variance? Yes ✓ No
Primary Owner(s) � Do re;�_(ee eSS'e r
Mailing Address -74 15Yeee f ('�;JCn1 -:280
Phone & Email
Installer/Builder �' q
Mailing Address
Phone & Email (�
Engineer
Mailing Address ✓
Phone & Email
J
Contact Person for Building&Code Compliance: Ci '1 U II Phone: 't cl J JU
RESIDENCE INFORMATION: ( C_N11'F! 1U��"}�'
Year Built #of be rooms X gallons per bedroom =total d it fly_. 0' `- ageGrincte Yes No/
1980 or older Installed? (circle one) V
1981-1991 Spa or Hot Tub Yes Noi
Installed? (circle one) �/
1992-Present
PARCEL INFORMATION:
Topography lat Rolling _Steep Slope _%Slope
Soil Nature V Sand _Loam _Clay _Other
Groundwater At what depth?
Bedrock/Impervious material At hat depth? 1v4
Domestic Water Supply _Municipal _Well (if well,water supply from any septic system absorption is_ft.)
Percolation Test Rate:AM per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size allons(min. size 1,000 gallons,add 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone Total length ft.; Each Trench�—ft.
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 and approved.
The installed system must match the septic 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 known by or on behalf of an applicant,shall be void. I
have read the regulations and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage
Disposal Ordinance. �
PRINT NAME:_ '�� 54-76 DATE:
SIGNATURE: DATE:
i
Town of Queensbury Building&Code Enforcement Revised February 2017
FILE Fo SEPTIC PLOT PLAN ll lJUL 4 Zpa�
I HAVE SEEN OR OBSERVED ALL OBJECTS �"
TOWN O OUELNSn7n't'
SUCH SES,WELLS,TREES, FENCES, ETC Sl11LDiNG
THIS CUMENT.I HAVE PERSONALLY — --
M TH ANCE SET FORTH ON AG P� qa
I N TURE DATE Vix
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VC
TOWN OF Q*F �51j !DING &
Revie&Jved P
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309.9-1-65 SEP-000440-2017
Tessier, Edward
67 Ohio Avenue
Residential Septic Alteration �1
i