2009-573 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building&Codes (518) 761-8256
i
C�E R.TI F I CAT E OAF COM P L I XN C.'E
Permit Number: P20090573 Date Issued: Wednesday, December 01, 2010
This is to certify that work requested to be done as shown by Permit Number P20090573
has been completed.
Tax Map Number. 523400-240-005-0001-015-000-0000
Location: 102 CLEVERDALE Rd
Owner.. EVAN DONEGAN
Applicant: JANET AUSTIN
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 t IA—
property owner of the responsibility for compliance with Site Plan, (.�4 '�
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 12804-5902 (518)761-8201
Community Development- Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20090573 Application Number. A20090573
Tax Map No: 523400-240-005-0001-015-000-0000
Permission is hereby granted to: JANET AUSTIN
For property located at: 102 CLEVERDALE 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: JANET AUSTIN
Septic Alteration Residential
85 RIVER St
BELCHERTOWN, MA 01007 Total value
Contractor or Builders Name/Address Electrical Inspection Agency
IBS SEPTIC
IVAN BELL
2 LOWER WARREN STREET
QUEENSBURY,NEW YORK
Plans &Specifications
2009-573
SEPTIC ALTERATION RESIDENTIAL
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Saturday,November 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 T Quee uty� r' ay,November 20, 2009
SIGNED BY for the Town of Queensbury.
IV NZ,
Director of Building&Code Enforcement
OFFICE USE ONLY
W
TAX MAP NO. PERMIT NO. PERMIT FEE�L!�—
x"
0 A
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: INSTALLER:
DDRESS:
ADDRES
PHONE NOS. PHONE NOS. Z 09
LOCATION OF INSTALLATION:
RESIDENCE INFORMATION:
YEAR BUILT NO.OF x COMPUTATION= = TOTAL DAILY FLOW
B ROOMS GARBAGE GRINDER
1980 or older X 150 gallon per bedroom = INSTALLED?
1981 -1991 X 130 gallon per bedroom = SPA OR HOT TUB
---F -1992-present x 110 gallon per bedroom = INSTALLED?
PARCEL INFORMATION:
✓ TOPOGRAPHY: Flat rolling Steep slope— %Slope—
✓ SOIL NATURE: Sand—� Loam Clay— Other
✓ GROUNDWATER: At what depth?
✓ BEDROCK/IMPERVIOUS MATERIAL: At what depth
✓ DOMESTIC WATER SUPLY: Municipal— Welix (if well: Water Supply f any septic
system absorption is 3T 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: GALLON (MIN. SIZE IS 1,000 GAL.) Add 250 gallons to the size of the septic tank for
lbo�—each garbage grinder, spa or whirlpool tub.
SYSTEM TYPE:
D ABSORPTION FIELD (WITH NO. 2 STONE) Total length /Vn
ft Each trench
❑ SEEPAGE PIT(S) (WITH NO. 3 STONE) How many?wx Size? 111�7
❑ ALTERNATIVE SYSTEM Bed or other type?
❑ HOLDING TANK SYSTEM Total required capacity?
Tank size? -I�IA Number of tanks?
..........
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 misr9DrPqzntnfir%n
failure to make a material factor circumqtAnAM Un L— -- - ' '
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Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building &Code Enforcement Arrive: am/pm Depart: am/pm
742 Bay Rd., Queensbury,, NY 12804 Inspector's Initials: !�� ?
NAME: /��� PERMIT NO.: �J
LOCATION: ve f!::VINSPECT ON: / -
RECHECK:
Comments and/or diagram
Soil Type: Sand Loam/ Clay
Type of Water: Munici al Well Water
Waterline separation distance ft.
Well separation distance ft.
Ot Is: ft.
Well Casing Length ' + - Y N N/A
Absorption Field: Tota len th ft.
Length of each trench ft.
Depth of trenches It.
Size
of Stone 1 \
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 Cap N
Inlet/Outlet Pipes&Baffles Y N
Location Separations
Foundation to tank 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 Rear Left Sid Right Side Middle Front Middle Rear
System Use Status:
Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
Last revised 06/18/07 U\Building&Codes Forms-01-1)\Building&Codes\Inspection Forms\Septic Inspection Report.doc
Septic Inspection Report
Office No. (518)761-8256 Date Inspection request received:
Queensbury Building&Cale Enforcement Arrive: am/pm Depart:'72. am/pm
742 Bay Rd., Queensbury, NY 12804 Inspector's Initials:
NAME: ; ' ' 66C -'' :�' PERMIT NO.:
LOCATION: d /f��E',f�c� f�c ! �'`' +• NSPECT ON:
RECHECK:
Commcntsa
Soil T : Sand/ Loam Clay
Type of Water: Municipal Well Water
Waterline separation distance ft.
Well separation distance ft.
Other wells: I ft.
Well Casing Length 50'+ /- Y N N/A
150'to well r uired if NO
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenches ft.
Size of Stone d
Seepage Pits: Number C
Size: x
Stone Size: t
Piping Size Type_
Z \
Building to tank
Tank to Distribution Box
Distribution Box to Field Pit
Opening Sealed: Y N
End Cap N
Inlet
Outlet Pipes&Baffles Y N
Manholes 12"or less below grade Y N
[provide extension collar if Yes Y N
Location Separations
Foundation to tank ft.
Foundation to absoggon ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Engineer Report and As-Built _Y_N
ETU Maintenance Contract —Y N
rovided
Location of System on Property:
Front r Left Side Right Side Middle Front Middle Rear
stem S
Approved
Partial Approved and needs to be re-inspected, please tail the Building&Codes Office
Disapproved
L:\Pam Wh11Jng\2010\Bui1d1ng Codes Forms\Inspec Uon FWW\Septic Infection Report_03 2910.doc