2008-488 Septic Inspection Report
Office No. (518) 761-8256 Date Inspection
Queensbury Building &Code Enforcement Arrive: a rtTa am �
742 Bay Rd., Queensbury, NY 12804 Inspector's Initials.
NAME: S�& + 0 G�r� t��i�p� IT NO.:
LOCATION: Vt ON e TM E t _K0 F SPECT ON: 1 I-7 --i7
RECHECK:
Comments and/or diggram
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
150'to well required if NO
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 Cap Y N
Inlet/Outlet Pipes&Baffles Y
Manholes 12"or less below grade _Y_ _N L—O 1
[provide extension collar if Yes 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
ETU Maintenance Contract Y_N
provided
Location of System on Property:
Front Rear Left Side Right Side Middle Front Middle Rear
System Use S to
Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
L:\Pam Whiting\2010\Building Codes Forms\Inspeccbon Forms\Septic Inspection Report 03 2910.doc
Town of Queensbury■ Building&Codes Enforcement Office.742 Bay Road• Queensbury,NY 12804
DEEP HOLE/PERC TEST
Reques for Town E 'neer Review
Property
Lf`t Phone:
Owner: J 1
Property Owner's
Address:
Location of Test: Tax ID#: i to
`TT
*Applicant's Engineer: tAd„ ,��-�.� 1.,,1 Elie2 hone: 72 e --0 ( -Ls-
Applicant's Agent: c Phone:
Additional Notes:
lk
1. Reason for Request? ),New Septic System D Replacement Septic System El Failed Septic System
0 Subdivision Ksite Plan Review
2.Are Wetlands present? X YES 1-1 NO El UNKNOWN
*Note: Applicant is required to engage an engineer for design and testing of the system The Town
Engineer's responsibility is to witness system testing only.
PLOT PLAN: Plot plan, to scale, to be submitted with application
FEE SCHEDULE:
a. $ 200 Flat Fee Date Paid:
Check No.:
b. OR Fee to be determined during To Be Determined:
Site Plan / Subdivision review process
SIGNATURE:
In carrying out the provisions of Article IV, the Local Board of Health or the enforcement officer may
engage the services of a qualified professional consultant for expert review and recommendation arising
from the carrying out of the provisions of Art. IV, including but not limited to the review of plans,
specifications and reports, attendance at inspections, dye tests, deep hole test pits, septic related deep
hole and percolation tests, system installations, and any other aspect of any matter contained in this Art.
IV, and any costs incurred in such review shall be paid to the Town by the owner of the property before
any approval can be granted under this Art. IV shall become effective within 30 days of presentment of an
invoice for same, whichever is sooner. Such costs shall not exceed $1,500 without prior written notice to
the party to be charged with same.
My signature below indicates I have thoroughly read and understand the instructions, agree to the
submission requirements and have completed the applicatia . I also fully understand that additional
engineering fees may be necessary per Town of Queensbury L cal Law 136-14D.
SIGNATURE OF APPLICANT: L Lf' te: ��
SIGNATURE OF AGENT: Date:
Original (B&C File) Canary (Planning) Pink(Applicant) Gold (Town Clerk)