2009-170 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20090170 Application Number. A20090170
Tax Map No: 523400-308-019-0001-062-000-0000
Percussion is hereby granted to: MARY VANNESS, LE
For property located at: 16 PINELLO 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. Tyne of Construction Value
Owner Address: MARY VANNESS, LE
GAIL& ROGER MOREHOUSE Septic Alteration Residential
52 PINELLO Rd Total value
QUEENSBURY,NY 12804-0000
Contractor or Builders Name/Address Electrical Inspection Agency
Plans &Specifications
2009-170
septic alteration
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Friday,May 07, 2010
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of ensbury bef re the expiration date.)
/
Dated at a To (VF en�ury� day,May 07,2009
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 OF COMPLIANCE
Pen-nit Number. P20090170 Date Issued: Thursday, May 07, 2009
This is to certify that work requested to be done as shown by Permit Number P20090170
has been completed.
Tax Map Number. 523400-308-019-0001-062-000-0000
Location: 16 PINELLO Rd
Owner. MARY VANNESS, LE
Applicant: MARY VANNESS, LE
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 �, p
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.
%__..__----__................ ""FFICE USE ONLY......... -------- -------
TAX MAP NO. PERMIT NO. �— P MIT FEE ' 9 W E
o o
APPROVALS: ZONING '
TOWN CLERK '
;MAY 0 5 2009
APPLICATION FOR SEPTIC DISPOSAL SYSTE Pt WG&CODES '
G CODES
A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS.APPLICATION IS SUBJECT TO REVIEW BEFORE ISSUANCE OF A VALID
PERMIT.OWNER: od Mpreko,ks-c INSTALL S
f ( ER:
ADDRESS: L 11� 'e l 16 (�d - ADDRESS:
vie WQ41( ffr\Sf- M�
PHONE NOS._ _(J o Q 4 PHONE NOS. v I I
LOCATION OF INSTALLATION:
1�
YEAR BUILT NO.OF X COMPUTATION= RESIDENCE INFORMATION:
BEDROOMS = TOTAL DAILY FLOW
1980 or older X 150 gallon per bedroom = GARBAGE GRINDER
1981 -1991 INSTALLED?
X 130 gallon per bedroom =
1992-present X 110 gallon per bedroom = SPA OR HOT TUB
INSTALLED?
PARCEL INFORMATION:
✓ ;�TOPOGRAPHY: Flat rolling Steep
slope_ %Slope
✓ SOIL NATURE: Sand LT—Loam
Clay Other
✓ GROUNDWATER: At what depth?
✓ BEDROCK/IMPERVIOUS MATERIAL: At what depth?
✓ DO_MESTIC WATER SUPLY: Municipal Well
(If well: Water Supply from any septic
system absorption is ft.)
✓ PER TEST: Rate is inutes per inch [MPI]
(Test to be completed by a licensed professional engineer or architect.)
PROPOSED SYSTEM FOR NEW CONSTRUCTION: All individual sewage disposal systems must be designed by
a licensed professiona
l engineer or architect(unless installed in a Planning Board approved subdivision).
TANK SI ZE: GALLON (MIN. SIZE IS 1,000 GAL.)Add 250 gallons to the size of the each garbage grinder, spa or whirlpool tub. septic tank for
SYSTEM TYPE:
ABSORPTION FIELD(WITH NO. 2 STONE Total len thlq (�
) 9 ,J� 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, any
permit 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 and all requirements of the Town of QUESTIONS? CALL 761-8256 OR EMAIL
Queens r Sanitary Sewage Disposal Ordinance. codes D-gueensbury net
VISIT OUR WEBSITE FOR MORE INFORMATION
i1� w_ww.aueensbury net
Signature er n Responsible Date
aTown of Queensbury - Community Development Office • 742 Bay Road, Queensbur , NY 1280 y 4
B 5-LGL 6i06
Sd
Septic Inspection Rep
Office No. (518) 761-8256 Date Ins Jior�n.� r e e Iv
Queensbury Building &Code Enforcement Arrive: T part: =a
742 Bay Rd., Queensbury, NY 12804 Inspector's Initi s:
NAME: � Ir I L) P MIT NO.: /
LOCATION: SPECT ON: ` T
RECHECK:
Comments and/or diagram
Soil Type: oam Clay
Type of Water: unici II Water
Waterline separation distance
Well separation distance ft.
Other wells: ft.
Well Casing Length 50' + / - Y N N/A
Absorption Field: Total length 'Z CX> ft.
Length of each trench eft.
Depth of trenches
Size of Stone '._
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank F
Tank to Distribution Box
Distribution Box to Field / Pit
Opening Sealed: Y N
End CapY N
Inlet/Outlet Pipes &Baffler N
Location Separations 1
Foundation to tank tft.
Foundation to absorption ft.
Separation of Pits ft
Conforms as per Plot P Y N
Engineer Report and -Buil N
Location of System on Property:
Front Rea Left Side Right Side Middle Front dIe Re
S Us S
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-01-1)\Building&Codes\Inspection Forms\Septic Inspection Report.doc
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