SEP-000223-2017 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-000223-2017 Date Issued: Friday, May 12, 2017
This is to certify that work requested to be done as shown by Permit Number SEP-000223-2017
has been completed.
Tax Map Number: 308.12-1-16
Location: 5 EAST DR
Owner: Harold Hermance
Applicant: Harold Hermance
This structure may be occupied as a: Residential Septic Alteration
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, 4!
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.
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development-Building&Codes (518)761-8256
BUILDING PERMIT
Permit Number: SEP-000223-2017
Tax Map No: 308.12-1-16
Permission is hereby granted to: Joe Maille
For property located at: 5 EAST DR
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
Tyne of Construction
Owner Name: Harold Hermance Septic Disposal-Residential $0.00
Owner Address: 5 East DR Total Value $0.00
Queensbury,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
Joe Maille
1322 Mahaffy RD
Fort Edward,NY 12828
Plans&Specifications
Residential Septic Alteration
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday,May 10,2018
(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 expiration date.)
Dated at the Town of Bens /ted s a ,2017
1)SIGNED BY: for the Town of Queensbury.
Director of Building&Code Enforcement
SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 12804
"il``` "',h`11, P: 518-761-8256 www.gueensbury.net Permit#:
Tax Map ID#: �ia _1 — —� Permit Fee: $ / , Invoice#:
Project Location:
Septic Variance? Yes No
Primary Owner(s) ;'ff
Mailing Address
Phone & Email
Installer/Builder ��
Mailing Address J
Phone & Email
Engineer TOWN OF QUEENSBU
Mailing Address OPMENT
Phone & Email
Contact Person for Building&Code Compliance: ,.��_'�1r1f 1.L� Phone:
RESIDENCE INFORMATION:
Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yes No
1980 or older Installed? (circle one)
1981-1991 Spa or Hot Tub Yes o
�7 Installed? (circle one)
1992-Present
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature �� Sand Loam Clay Other
Groundwater At what depth?
Bedrock/Impervious material At what depth? /
Domestic Water Supply Municipal _Well (if well, water supply from any septic system absorption is_ft.)
Percolation Test Rate: per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size /4'6b gallons(min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone Total length Jho 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.
2% 4"
PRINT NAME DATE:
SIGNATURE: ` l�l� ,4i�'GC� ''✓ /, �� DATE:
Town of Queensbury Building&Code Enforcement Revised February 2017
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