SEP-000418-2017 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-000418-2017 Date Issued: Thursday, July 20, 2017
This is to certify that work requested to be done as shown by Permit Number SEP-000418-2017
has been completed.
Tax Map Number: 290.-1-44
Location: 267 CHESTNUT RIDGE RD
Owner: Adam Gray
Applicant: IBS Septic
This structure may be occupied as a: Residential Septic Alteration
Replacing last 10 feet of lateral only By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the bjW 4 t
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.
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-000418-2017
Tax Map No: 290.-1-44
Permission is hereby granted to: IBS Septic
For property located at: 267 CHESTNUT RIDGE RD
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
Owner Name: Adam Gray Septic Disposal-Residential $0.00
Owner Address: 226 Chestnut Ridge RD 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
Replacing last 10 feet of lateral only
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Tuesday,July 17,2018
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury beforethe exp'ation date.)
Dated at the Town of ueensb / ton y 17,201 7
SIGNED BY: for the Town of Queensbury.
Director of Building&Code Enforcement
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.4 Community Development Office
Town of Queensbury - 742 Bay,RQa� 2Q-2QNew York -12804
Office Use Oniy tUJLL 11 7
TAX MAP NO. d�l'U �'�`l PERMIT NO. " bCx l9-'ZFEE U� U(?
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: OPM (T /-r INSTALLER: �i J�
ADDRESS: ADDRESS: t,..>.Q�(W�i r (� 6c('i
PHONE NOS. "— PHONE NOS.
LOCATION OF INSTALLATION:�O V L l��—rs
RESIDENCE INFORMATION:
YEAR BUILT NO.OF X COMPUTATION = TOTAL DAILY FLOW
BEDROOMS Gallons er bedroom GARBAGE GRINDER
1980 or older X 150 = INSTALLED?
1981 -1991 X 130 = SPA OR HOT TUB
1992-present X 110 = INSTALLED?
PARCEL INFORMATION:
✓ TOPOGRAPHY: FLAT ROLLI STEEP SLOP %SLOPE
✓ SOIL NATURE: SAND LOAM CLAY OTHER
✓ GROUNDWATER: AT WHAT DEPTH?
✓ BEDROCMMPERVIOUS MATERIAL: AT WHAT DEPTH?
✓ ,_
DOMESTIC WATER SUPLY: MUNICIPAL WELL (If well:water supply from any septic system absorption is:
✓ PERCOLATION TEST: RATE IS PER MIINUTE PER INCH[mpil (Test to be completed by a licensed professional
engineer or architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION: All it d:vidual sewage disposal systems must be designed by a licensed professional engineer or
architect(unless installed in a Planning Board approved subdivision).
TANK SIZE: `-1-'�`f }GALLON (MIN. SIZE IS 1,000 GAL.)Add 250 gallons to the size of the septic tank for each garage grinder,
spa or whirlpool tub.
SYSTEM T PE:
ABSORPTION FIELD(WITH NO. 2 STONE) Total length-�O(� ft. Each trench X
❑ SEEPAGE PIT(S)(WITH NO. 3 STONE) How many? Size?
❑ALTERNATIVE SYSTEM Bed or other type?
❑ 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.
For your protection, please note that pursuant to Section 136-29 of the Code of the Town of Queensbury, an;ypermit 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 an all requirements of the Town of Queensbury QUESTIONS? CALL 761-8256 OR EMAIL
Sanitary S a isposal Ordinance. codesO aueensbury.net
VISIT OUR WEBSITE FOR MORE INFORMATION
Signature of son Responsible Date www.gueensbury.net
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