SEP-000628-2017 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-000628-2017 Date Issued: Friday, October 6, 2017
This is to certify that work requested to be done as shown by Permit Number SEP-000628-2017
has been completed.
Tax Map Number: 302.5-1-16
Location: 4 VISTA CT
Owner: Jeffrey Selditz
Applicant: IBS Septic
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,
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.
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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-000628-2017
Tax Map No: 302.5-1-16
Permission is hereby granted to: IBS Septic
For property located at: 4 VISTA CT
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
Tvoe of Construction
Owner Name: Jeffrey Selditz Septic Disposal-Residential $0.00
Owner Address: 4 Vista CT Total Value $0.00
Queensbury,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
IBS Septic
2 WARREN ST
Glens Falls,NY 12801
Plans&Specifications
Residential Septic Alteration
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Monday,October 8,2018
(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 ex iration date.)
Dated at the Town Queens dft;�KO 017
SIGNED BY: for the Town of Queensbury.
Director of Building&Code Enforcement
0
SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 12804 y�
IoHn nftZicrit.hun �-P �/
P: 518-761-8256 www.gueensbury.net Permit#:
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Tax Map ID#: 1- 1('57 Permit Fee: $ ; Invoice#: -3
Project Location' vi5tcA[ Septic Variance? Yes No
Primary Owner(s) :YQ
Mailing Address LiT4
Phone & Email
Installer/Builder e
Mailing Address Low
Phone & Email
Engineer
Mailing Address �I i�7 5�' 1 C fJ,r s
Phone & Email
Contact Person for Building&Code Compliance: hit Phone: 0—ILt
RESIDENCE INFORMATION:
Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yes Nq!
1980 or older Q Installed? (circle one)
1981-1991
Spa or Hot Tub Yes pw
Installed? (circle one)
1992-Present
PARCEL INFORMATION:
Topography lat Rolling Steep Slope %Slope
Soil Nature V Sand Loam Clay Other
Groundwater At hat depth?
Bedrock/Impervious material At hat 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 q5tL)JLrhgallons (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 1
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NAME. t �C 1'� V DATE: I 1,J Ell
PRINT
SIGNATURE: DATE: 0—
VIJ
Town of Queensbury Building&Code En r ement Revised February 2017
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302.5-1-16 SEP-000628-2017
Selditz, Jeff
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I Residential Septic Alteration ; n E
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