2009-134 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20090134 Application Number. A20090134
Tax Map No: 523400-301-013-0002-03 1-000-0000
Permission is hereby granted to: JEREMY &MICHELE WILLIS
For property located at: 23 PEGGY ANN 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 Value
Owner Address: JEREMY&MICHELE WILLIS
23 PEGGY ANN Rd Septic Alteration Residential
QUEENSBURY, NY 12804-0000 Total value
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans &Specifications
2009-134
SEPTIC ALTERATION RESIDENTIAL
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Tuesday,April 20, 2010
(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¢41own'd Qteb , // y,April 20, 2009
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development- Building &Codes (518) 761-8256
CERTIFICATE C"" COMPLIAN't""k-or
Permit Number. P20090134 Date Issued: Thursday, August 26, 2010
This is to certify that work requested to be done as shown by Permit Number P20090134
has been completed.
Tax Map Number. 523400-301-013-0002-03 1-000-0000
Location: 23 PEGGY ANN Rd
Owner. JEREMY WILLIS
Applicant: JEREMY & MICHELE WILLIS
This structure may be occupied as a:
Septic Alteration Residential
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, d
Variance, or other issues and conditions as a result of approvals by the - j
Di ctor of Building& de E n:ement
Planning Board or Zoning Board of Appeals.
_ _ _-----------------------------
OFFIC
E USE ONLY -- -_
f l i 1
TAX MAP NO.
PERMIT NO, r PERMIT FE
E�;2SI
; 01
APPROVALS: ZONING ,
TOWN CLERK / '
/ 0
APPLICATION FOR SEPTIC DISPOSAL SYSTEM , / I -PERMIT:A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS.APPLICATION IS SUBJECT TO REVIEW BEFORE ISSUANCE OF A VALID
PERMIT.
-
OWNER: __; c i•-r- ,,� y i l �.`—/�
S INSTALLER:
ADDRESS: � C
ADDRESS: d
PHONE NOS. _��Q
- 7
LOCATION OF INSTALLATION: PHONE NOS. J p`
�vr N eci
v � t ' '2-
YEAR BUILT NR OF X COMPUTATION= RESIDENCE INFORMATION:
BEDROOMS = TOTAL DAILY FLOW
198- or older X 150 gallon per bedroom - GARBAGE GRIN 6R
1981 -1991 X 130 gallon per bedroom - INSTALLED? _
1992-present X 110 gallon per bedroom - SPA OR HOT TUB
- INSTALLED
PARCEL INFORMATION:
Vol TOPOGRAPHY: Flat rolling Steep sloe o
p Slope
✓ SOIL NATURE: Sand /o
Loam Clay Other_____
✓ GROUNDWATER: At what depth?
✓ BEDROCK/IMPERVIOUS MATERIAL: A4 �
At what depth?
✓ DOMESTIC WATER SUPLY: Municipal Well
(If well: Water supply from any septic
� system absorption is--.ft.)
PERCOLATION TEST: Rate is i �1
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
a licensed profession/'al engineer or architect (unless installed in a Planning Board approved subdivi io designed by
TANK SIZE. �•�� sion).
GALLON (MIN. SIZE IS 1,000 GAL.)Add 250 gallons to the size of the septic tank for
each garbage grinder, spa or whirlpool tub.
VABSOTIPTION
mo
PE: �FIELD
(WITH N0. 2 STONE) Total length
9
❑ SEEPAGE PIT(S) (WITH NO. 3 STONE Each trench X
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
:.................... .,..,.. ,,.,.,...........,.......,....,..,.,. ........ .......,....
. ...... .. .. .................................................................
LEA E REVIEW
MUST BE INSPECTED BY A TOWN
APPROVED ELECTRICAL INSPECTION AGENCY. P
•• ................................. VEW LIST PROVIDED.
For your protection, please note that pursuant to Section 136-29 of the Cod
e of Permit or approval granted which is based upon or is granted in reliance upon any material he Town of Queensbury, any
failure to make a material fact or circumstance known by or on behalf of an applicant, shall be voidresentation or.
I have read the regulations with respect to this application and
QueAbagree to abide by these and all requirements of the Town of QUESTIONS? CALL 761-8256 OR EMAIL
nitary Sewer isposal Ordinance. oodesfelaueensburvnet
VISIT OUR WEBSITE FOR MORE INFORMATION
Sigate
on es onsible / '"`"�"—•gueensburv.net
P
QTown of Queensbury ■ Community Development Office - 742 BayRoad,
ad, Queensbury, NY 12804
Pic
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection requ iv
Queensbury Building &Code Enforcement Arrive: kl-�2k-)-a art: an pm
742 Bay Rd., Queensbury, NY 12804 Inspector's Initials:
NAME: 1 E IT NO.:
LOCATION: I PECT ON:
RECHECK:
Comments and/or diagram
Soil T n oam/ Clay
Type of Water• al/Well Water
Waterline separation distance ft.
Well separation distance ft.
Other wells: ft.
Well Casing Length 50' + / - Y N N/A
Absorption Field: Total length a ft.
Length of each trench a ft. i
Depth of trenches ft. —"�? CD Q ' W
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box F%
Distribution Box to Field/ PitOpening Sealed: N
End Cap N
Inlet/Outlet Pipes &Baffles Y N
Location/ Separations
Foundation to tank . ft.
Foundation to absorption ft. � �
Separation of Pits ft.
r Plot Plan _Y N
En ineer RepoO and As-Built Y
Location of System on Prope
Q�ronj�areft Side Right Side Middle Front Middle Rear
System Use Status:
pproved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
Last revised 06/18/07 L:\Building&Codes Forms-OLD\Building&Codes\Inspection Forms\Septic Inspection Report.doc
Septic Inspection Report
Office No. (518) 761-8256 Date Ins ion r iv d:
Queensbury Building &Code Enforcement Arrive: m epart: am/pm
742 Bay Rd., Queensbury, NY 12804 Inspector's Initial .
NAME: !L�1 P IT NO.: _
LOCATION: A IVPECT ON: -` -7_
RECHECK:
Comments and/or diagram
Soil Type: Sand Loam/ Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft.
Well separation distance ft.
Other wells: ft.
Well Casing Length 50' + / - Y N N/A
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenches ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box
Distribution Box to Field Pit
Opening Sealed: Y N
End Ca _Y_N
Inlet/Outlet Pipes&Baffles _Y_N
Location Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits
5" _ N
Engineer Re rt and As-Built Y N
Location of System on Property:
Front Rea Left Side Right Side Middle Front Middle Rear
System e t
Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
Last revised 06/18/07 L:\Building&Codes Forms-OLD\Building&Codes\Inspection Forms\Septic Inspection Report.doc
ALENGINEERING, PLLC
Civil Engineering . Structural Design . Structural Inspection
RECORD PLAN DRAWING SUBMISSION
FOR
SEPTIC SYSTEM REPLACEMENT
Date: April 27,2009
To: Town of Queensbury
Building Department
742 Bay Road
Queensbury,NY 12804
Re: Willis Residence
23 Peggy Ann Road
Queensbury,NY 12804
To Whom It May Concern:
Find enclosed an 11 x 17 record drawing depicting the replacement septic system as it was
constructed at the above noted address.
If you have any questions please call.
Sincerely,
Ryan K. Riper, P.E.
Encl.
225 Ruggles Road
Saratoga Springs,New York 12866
Cell:518.817.0099 Office:518.581.3893
e-mail:RyanRiper@RKengineering.us