2007-737 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
4z Community Development- Building &Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number. P20070737 Date Issued: Tuesday, December 04, 2007
This is to certify that work requested to be done as shown by Permit Number P20070737
has been completed.
Tax Map Number. 523400-308-011-0001-036-000-0000
Location: 421 LUZERNE Rd
Owner. WILLIAM & CAROLYN HART
Applicant: WILLIAM & CAROLYN HART
This structure maybe occupied as a:
Septic Alteration Residential
By Older of Town Board
TOWN OF QUEENSBURY
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Issuance of this Certificate of Compliance DOES NOT relieve the
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.
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20070737 Application Number. A20070737
Tax Map No: 523400-308-011-0001-036-000-0000
Permission is hereby granted to: WILLIAM & CAROLYN HART
For property located at: 421 LUZERNE 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. Tie of Construction Value
Owner Address: WILLIAM &CAROLYN HART
Septic Alteration Residential
421 LUZERNE Rd
QUEENSBURY,NY 12804-0000 Total value
Contractor or Builder's Name/Address Electrical Inspection Agency
FRED SMITH
23 VERMONT Ave
QUEENSBURY,NY 12804
Plans&Specifications
2007-737
septic alteration residential
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Friday,November 28,2008
(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 of Que b itesday, November 28,2007
SIGNED BY ... for the Town of Queensbury.
Director of Building&Code Enforcement
=-___rrr-- - OFFICE USE ONLY r_____rr____rr___ '___ r_____r___.
TAX MAP NO.
PERMIT NO. PERMIT FEE ;
APPROVALS: ZONING TOWN CLERK
,__ rrr____r= r_ _r___________rrr___rrr____rrr_J /
PER _______rrr______-
APPLICATION FOR SEPTIC DISPOSAL SYSTEM MIT:
A PERMIT MUST BE OBTAINED BE ORE WORK BEGINS.APPLICATION IS SUBJECT TO REVIEW BEFORE ISSUANCE OF A VALID
PERMIT. /1 ,�y, ,��1 yJ,
OWNER: lli�m (j —e- J'� /, INSTALLER:
ADDRESS: �3 ! ADDRESS: d & 4 l ok
PHONE NOS._Wel &6 1/ PHONE NOS. W &( 93&
LOCATION OF INSTALLATION:
NO.OF RESIDENCE INFORMATION:
YEAR BUILT BEDROOMS X COMPUTATION= = TOTAL DAILY FLOW
1980 or older X 150 gallon per bedroom = GARBAGE GRIN ER
INSTALLED? _
1981 -1991 X 130 gallon per bedroom =
1992 SPA OR HOT Tpq present X 110 gallon per bedroom INSTALLED?
PARCEL INFORMATION:
✓ TOPOGRAPHY: Flat rolling V Steep slope %Slope
✓ SOIL NATURE: Sand Loam Clay Other
✓ GROUNDWATER: At what depth? L—
✓ BEDROCKAMPERVIOUS MATERIAL: At what depth? / 1/�
✓ 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: Me—)L GALLON (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: G�/ ¢
❑ ABSORPTION FIELD (WITH NO.2 STONE) Total length ft. Each trench J 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 c1uEST1oNs? CALL 761-82 - OR EMAIL
Queensbur Sanitary Sewa Disposal Ordinance. coaes�aueensburv.net
VISIT OUR WEBSITE FOR MORE INFORMATION
�� •+�� � www.aueensburv.net
Sign ure of Pers Responsible d tefl /
Town of Queensbury • Community Development Office • 742 Bay Road, Queensbury,NY 12804
B 5-LGL 6106
Septic Inspection Report
Office No. (518) 761-8256 Date Inspectigta req rec ' ah
Queensbury Building&Code Enforcement Arrive: pm
742 Bay Rd., Queensbury, NY 12804 Inspector's In�'
C.
NAME: �v�l PE NO.: _ -�3�
LOCATION: k-I JAI I PECT ON:
RECHECK:
Comments,and/or diagram
Sal T n Loam Clayf
Type of Wa . Municipal Well Water
Waterline separation distance
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length ft.
Length of each trench i ft.
Depth of trenches - ' ft.
Size of Stone
Seepage Pits: Number
-Size: x
Stone Size:
-Piping Size Tpe
Building to tank
Tank to Distribution Box
Distribution Box Pit
-Opening Sealedt XrNi Partial
End Ca
Inlet/Outlet Pipes&Baffles Y N
Location Se rations
Foundation to tank ft. '
Foundation to absorption
-Separation of Pits ft.
Conforms as r Plot Plan Y N
-Engineer Report and As-Bunt Y N
Location of System on Property:
Front Rear Left Side Right Side
Middle Fr nt Middle Rear
m s:
" Approved
Partial Approved and needs to be re-inspected, please call the Building &Cases Office
Disapproved
Last revised 021006
Last revised 1/6/05
PLOT PLAN
SEPTIC SYSTEM
,Notice: The following statement must be "stain ed" on your p o
plan. This sheet of paper mays d for purposes: of
drawing your plo p an. A terIV
�cyi plot plan,
ease read the toem nt nd sit�/. {off you choose to
u e other paper or o r p of pn, the office will stamp
t ose plans for ou s gna ure.
s
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R "I have seen or observed, or believe I saw evidence of,
all objects such as houses, welts, trees, fences, etc.,
TOWN OF QUEENSBURY shown on tI ' oc lent. I also represent that I have
BUILDING & GMTI
personall u dthe , Wances set forth on lh diagr 11."
Reviewed By:
Date: slcNnt ME un