2008-212 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development- Building &Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number. P20080212 Date Issued: Monday, May 19, 2008
This is to certify that work requested to be done as shown by Permit Number P20080212
has been completed.
Tax Map Number. 523400-295-018-0002-022-000-0000
Location: 12 DORSET PI
Owner. LISA STEVENS
Applicant: LISA STEVENS
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, VVV
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: P20080212 Application Number. A20080212
Tax Map No: 523400-295-018-0002-022-000-0000
Permission is hereby granted to: LISA STEVENS
For property located at: 12 DORSET Pl
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: LISA STEVENS
12 DORSET PI Septic Alteration Residential
QUEENSBURY,NY 12804-0000 Total value
Contractor or Builder's Name/ Address Electrical Inspection Agency
Plans &Specifications
2008-212
septic alteration residential
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Thursday, May 14, 2009
(If a longerperiod 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 To o eens d sday, May 14, 2008
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
or
OFFICE USE ONLY
o TAX IV�AP NO. PERMIT NO./^ / PERMIT FEE
APPROVALS: ZONING TOWN CLERK
0 DES,
............ff _j
APPLICATION FOR SEPTIC DISPOSAL SYSTEM PERMIT:
A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS.APPLICATION IS SUBJECT O REVIEW BEFORE ISSUANCE OF A VALID
PERMIT.
OWNER: 41'ria INSTALLER:
ADDRESS: v ��� P 4,4C.� ADDRESS: ey
J
PHONE NOS. PHONE NOS. 7 96
LOCATION OF INSTALLATION:
................................................................................................:........................................................................................ .........................................................................; RESIDENCE INFORMATION.
i NO.OF
YEAR BUILT � X COMPUTATION= I = ; TOTAL DAILY FLOW ':,
BEDROOMS
...............................................a. a.....................................................................;...........t..................... ............................................1 GARBAGE GR{Nt)DER
1980 or older X 150 gallon per bedroom € _ INSTALLED? /�
M._..._................................:..,....................................... .... ........................................ .... .........1_....:..................................................{
1981 -1991 X i 130 gallon per bedroom = PA OR HOT TUB
..........................................;..............................................<...........a.........................................................................;...........i..........................................
................................£ INSTALLED?
1992-present X 110 gallon per bedroom =
..............................................................................................1............t....................................................................................1..........................................................................a
PARCEL INFORMATION:
✓ TOPOGRAPHY: FLAT ROLLING `/ STEEP SLOPE %SLOPE
✓ SOIL NATURE:SAND 6"O� LOAM CLAY OTHER
✓ GROUNDWATER: AT WHAT DEPTH? BEDROCK/IMPERVIOUS MATERIAL: 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 MIINUTE 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).Add 250
gallons to the size of the septic tank and leach field for each garbage grinder, spa or whirlpool tub.
�
06g,*SST/.u6 5
✓ SEPTIC TANK: GALLON (MIN. SIZE IS 1,000 GAL.) TILE FIELD: EACH TRENCH FT.
✓ TOTAL SYSTEM LENGTH: .2-D J FT. SEEPAGE PIT(Sl: HOW MANY?
✓ SIZE OF EACH FT. X FT.
✓ SIZE OF STONE TO BE USED: # /DEPTH OR THICKNESS FT.
✓ BED SYSTEM SIZE: X
✓ ALTERNATIVE SYSTEM: LENGTH AND/OR SIZE
✓ HOLDING TANK SYSTEM:(If required) NO. OF TANKS: /SIZE OF EACH
✓ GALLONS./TOTAL CAPACITY. GAL.
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
Queensbury San' a Disposal Ordinance. codes®aueensburv.net
(::VISIT OUR WEBSITE FOR MORE INFORMATION
www.aueensbury.net
170
SIjinaiGre o Person es onslble Date
Town of Queensbury - Community Development Office - 742 Bay Road, Queensbury,NY 12804
Community Development O ice
TC4own of Queensbury • 742 Bay Rd.
Y
Queensbury, New York •12804 PLOP PLAN
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Shbw all existing and proposed structures. Indicate the setbacks of all structures and buildings from all property lines.
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1 SQUARE = FT.
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Septic Inspection Report
Office No. (518) 761-8256 Date Ins uest received:
Queensbury Building&Code Enforcement Arrive: �m/lam „Depart: am/pm
742 Bay Rd., Queensbury, NY 12804 Inspecto s Initials: yY�
NAME: PERMIT NO.: —�
LOCATION: f INSPECT ON: �'—l��,
RECHECK:
mmen and/or diagram
Soil T Loam !a
T of a r: unici I Well Water
Waterline se ra ' n di nce ft.
Well separation distance ft.
Other wells: ft,
Absorption Field: Total length 2=10 ft.
Length of each trench ft.
Depth of trenches ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping ze Type
-Building to tank T
Tank to Distribution Box �Ro 2--�
Distribution Box to Field Pit
Opening Sealed: Y I N Partial
End Cap 177'
Inlet/Outlet Pipes&Baffles Y N
Location Separations
Foundation to tank ft.
Foundation to absorption 2 ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Engineer Report and As-Built Y N
Location of Sy n Property:
Front Rear Left Side Right Side
Middle Front fiddle Rear
s
Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
Last revised 021006
Last revised 1/6/05