2009-252 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20090252 Application Number. A20090252
Tax Map No: 523400-308-016-0001-038-000-0000
Permission is hereby granted to: JOHN& LISA WELLS
For property located at: 41 PINEWOOD 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: JOHN & LISA WELLS
41 PINEWOOD Rd Septic Alteration Residential
QUEENSBURY,NY 12804 Total value
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans &Specifications
2009-252
SEPTIC ALTERATION RESIDENTIAL
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Friday,June 11,2010
(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 T m aens lour day,June 11, 2009
SIGNED BY for the Town of Queensbury.
Director of Building&Code Code
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
4E Community Development- Building &Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number. P20090252 Date Issued: Friday, June 12, 2009
This is to certify that work requested to be done as shown by Permit Number P20090252
has been completed.
Tax Map Number. 523400-308-016-0001-038-000-0000
Location: 41 PINEWOOD Rd
Owner. JOHN & LISA WELLS
Applicant: JOHN & LISA WELLS
This structure maybe occupied as a:
Septic Alteration Residential
By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the /f
property owner of the responsibility for compliance with Site Plan, o°�
Variance, or other issues and conditions as a result of approvals by the Director of Building&Code E orcement
Planning Board or Zoning Board of Appeals.
.....-
% � OFFICE USE ONLY TE' �
TAX MAP NO. _PFFRMIT NO. ERMIT FEE— JUN 11 2009
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APPROVALS: ZONING TOWN CLERK ' ; �,__ =e
�4WN OF QUEENS
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______________________________________________________________ . , VWN Of�TG EENS _.
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APPLICATION FOR SEPTIC DISPOSAL SYSTEM P IT.
A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS.APPLICATION IS SUBJECT TO REVIEW BEFORE ISSUANCE OF A VALID
PERMIT. -�
OWNER: n INSTALLER:
ADDRESS: / //V f'C L�Jc�4� ADDRESS: 1
PHONE NOS. PHONE NOS. 79_ CT�
LOCATION OF INSTALLATION: / / / 2 ew o
YEAR BUILT NO.OF X COMPUTATION- = TOTAL DAILY FLOW RESIDENCE INFORMATION:
BEDROOMS GARBAGE GR
1980 or older X 150 gallon per bedroom d INSTALLED? U '�
1981 -1991 X 130 gallon per bedroom -
SPA OR HOT
1992-present X 110 gallon per bedroom - INSTALLED?
PARCEL INFORMATION:
✓ TOPOGRAPHY: Flat rollin Steep slope %Slope
✓ SOIL NATURE: Sand 7—Loam— Clay Other
✓ GROUNDWATER: At what depth?
✓ BEDROCK/]MPERVIOUS MATERIAL: At w at depth?
✓ DOMESTIC WATER SUPLY: Municipal Well (If well: Water supply from any septic
system absorption is ft.)
✓ PERCOLATION TEST: Rate is 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 be designed by
a licensed professional engineer or architect (unless installed in a Planning Board approved subdivision).
TANK SIZE: la2SVGALLON (MIN. SIZE IS 1,000 GAL.) Add 250 gallons to the size of the septic tank for
each garbage grinder, spa or whirlpool tub.
SYSTEM TYPE:
ABSORPTION FIELD (WITH NO. 2 STONE) Total IengthaZ:V) ft. Each trench 42, X �6
❑ 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.
f l2-
Septic Inspection Report
Office No. (518) 761-8256 Date Init
d:
Queensbury Building &Code Enforcement Arrive: art: = a
742 Bay Rd., Queens ury NY 12804 InspectoNAME:LOCATION: —
RECHECK:
Comments and/or diagram
Soil T oa Clay
Type of Water: uni ell Water
Wate in ration 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 tA It
Distribution Box to Field / Pit I
Opening Sealed: N
End Cap N
Inlet/Outlet Pipes &Baffles Y=N
Location Separations X'i
Foundation to tank 1' ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Y_ N
Engineer Report and As-Built Y N
Location of System on Property:
Front ear Left Side Right Side Middle Fro Middle Rear
System Use
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
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