2006-294 TOWN •
OF QUEENSBURY
c
sy
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20060294 Date Issued: Thursday, February 02, 2012
This is to certify that work requested to be done as shown by Permit Number P20060294
has been completed.
Tax Map Number: 523400-309-014-0001-080-000-0000
Location: 110 MAIN St
Owner: CUMBERLAND FARMS, INC.
Applicant: CUMBERLAND FARMS, INC.
This structure may be occupied as a:
Septic Alteration Commercial
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, YY 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: p20060294 Application Number: A20060294
Tax Map No: 523400-309-014-0001-080-000-0000
Permission is hereby granted to: CUMBERLAND FARMS. INC.
For property located at:
110 MAIN St
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: CUMBERLAND FARMS, 1NC
777 DEDHAM St
CANTON, MA 02021-0000
Contractor or Builder's Name /Address
1BS SEPTrc
IVAN BELL
2 LOWER WARREN STREET
OiJEENSBiTRY. NEW YORK
Septic Alteration Commercial
Total Value
Electrical Inspection Agency
Plans & Specifications
-294 Cumberland Farms 110 Main Street
Septic System
$25.00 PERMIT FEE PAID -THIS PERMIT EXPIRES: Saturday, May 12, 2007
(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 Town Que ~ ~)F4'i , 2006
SIGNED BY for the Town of Queensbury.
Director of Building & Code Enforcement
Application for Permit - Se
Town of Queensbury 742 Bay Road Qu
1. OWNER INFORMATION
Cumberland Farms
110 Main Street
Septic System Alteration
,Location of installation: /`"- u., ~~
- ( .- ~
Tax Map No. ~ y ~/` ~ /
Owner's Name• _l.. ~ ~'+ 6c t C a ~- ~ /mar ~. f .
2006-294
wince use// __ q
File Permit No. tP "" ~- /
Fee P '
/~'lo S,f a~ o~ l
2. 1NSTALLER'S NAME : ~ PHONE NO.
3. RESIDENCE INFORMATION: (circle year of dwel u-g, indicate # bedroom(s) and multiply # of
bedrooms with applicable gallons per bedroom to equal total datlyJlow)
Year of House: No of Bedrooms x Computation - Total Dail~Flow R ~'~ ~ ~~,~
1980 or older x 150 gaUbdrm = ~'~` ~ `~
1980 -1991 x 130 gal/bdrm = TOWS; ~,
i991-present x 110 gal/bdrm = UILDd~;L ,~ ~' ~uRY
CODE
Garbage Grinder Installed yes _ / no
Spa or Whirlpool Installed yes - / no
4. PARCEL INFORMATION: (circle applicable information & indicate measurements)
~_ ;~
a sin at w~~at~dep-h at what ~pth mru~icipal
ltng ~j~~eet y~'(i~eet well
Steep slope clay if well; water supply
_% slope other from any septic-system
depth: absorption is ft.
other
Percolation Test: (7'o be completed by licensed professional engineer or architect)
Rile: minute per Inch
5. PROPOSED SYSTEM: For New Construction: All individual sewage disposal systems must be designed by,a licensed
professional engineer or architect (unless installed in a Plam~ing Board approved subdivision). Add 25U gallons to the size
of the septic tank and leach field for each Garbage Grinder, Spa or Whirlpool Tub.
Septic Tank: gallon (mi». size 1, 000 ga1.J
Tile Field: each trench ,fit. Total System Length: fi'.
Seepage Pit(s): number of size of each: Jl. by Ji'.
Size of Stone to be used: # /depth or Thickness feet
Bad System Size:
z
Alternative System: ~ ~, length and/or size
6, HOLDIN~i TANK SYSTE : (if required)
Number of tanks: /Size of each: gallons /TOTAL Capacity: gallons
Note: Alarm System and associated electrical work must be inspected by a Town approved
electrical inspection agency.
7. SIGNATURE ~ INFORMATION FOR RESPONSIBLE PERSON (please read)
For your protection, please note that pursuant to Section 136-29 of the Coda 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 To f Queensbury Sanitary Sewage Disposal Ordinance.
gnature of responsible person Date
Septic Inspection Report
Office No. (518) 761-8256 Date Inspe
Queensbury Building & Code Enforr.ement Arrive: ~
742 Bay Rd., Queensbury, NY 12804 Inspect'or's
NAME:
LOCATION:
RECHECK:
~v~ s
Soil T :Sand - a
T o uniCa ater
Waterline se istanoe ft.
Well separation distance
Other wells: ft.
ft.
Abso tion Fiek1: Total fen ft.
Le of each trench ~ ft.
De of trenches ft•
Size of Stone
Pits: Number
size: x
Stone Size:
Pi i Size
Buildi to tank
Tank to Distribution ~
DisMbution Box ~~ ~
O ni Sea Partial
End Ca
Inl Outlet Pi & Baffles Y N
Location Se rations
Foundation to tank ft•
Foundation to abso on ft.
Se ration of Pits ft•
lot Pian
E ineer Re rt As-Built Y
Y N
Location of System on Property;
Front Rear Left Si ht Side
Middle Front Middle Rear
~~ ~ v
S 1'
part: m
i C/
NO.. Q I
' ON: Gj
~ R~7~--~~o~ Pt1, ~1 v~Lj
~~ 14c7` ~ ~F vJ ~Z ~
~ ~~'P-~
~~
g~Q~
~p ~~~~
- _ _--.
ystem Use Status:
proved
artial Approved and needs to be re-inspected, please calf the Building & Gocies Office
Disapproved
Last revised 021006
Last revised 1/6/05
,~ %%,~~ i
Septic Inspection Report
Ofiice No. (518) 761-8256 D~ Ins ~
Queensbury Bulkiing & Code Enforcement Arrive: g
742 Bay Rd., Queensbury, NY 12804 Inspector's Initial
NAME: c~ ~~-~'-f ` ~ y~,._~ F
LOCATION: ~ ,,,_ ~ I
RECHECK:
Soil T :Sand Loam
T of Wager: Munici I Well Water
Waterline ration distance ft,
Well separation dtstanoe
Other wells: ft,
~.
Weil Casing Length 50' + / -
150' tp well wired tf NO Y N N/A
Field: Total ~,
of each trench ft,
of trenches ft, ; "
Size of Stone
Pits: Number
Size: x
stone size:
Pi Size T
Buikli to tank
Tank to Distribution Box
Distributbn Box to-Field Pit
i Sealed: Y N
End Ca Y N
In Outlet Pi & Baffles Y N
Manholes 12" or less bekriv grade
extension aopar if Yes Y _ N
Y N
ram
Foundation to tank ft.
Foundatbn to a ft,
Se ration of Pits ft.
Plan . Y N
E Weer -Bur Y N
ETU Maintenance Contract _Y - N
vocation of System on Property:
/~~part. am/pm
NO.:
"ON: iZ- t. --ti's
Canments and/
E~/~
,~ ~ ~~
t~SP~c.~~~e~ ~~~~ :.~ 15-~
Er~`.~- t~E.EEZ_' S ~~~'o~T~
~~~ ~-~~~ E.~~~~ ~R~
Front Rear Left Side Right Side h area: Isla) ~s~-azss
FexC(5iB) 7d5-4-437. ~-742PayRoad
www.quee~uburp.net QuaensburYr,-lVY 12844
Approved
~~ and needs to be rr-tnspecbed, please call the Buikiirg ~ Codes Ofliae
\Pam wtannguoiong. codes wrmsunspacnon wrrnslsepac In~pectJon rt~on<_at3 291odoc
Septic Inspection
Office No. (518) 761-8256
Queensbury Building & Code Enforcement
742 Bay Rd., Queensbury, NY 12804
NAME:
LOCATION:
RECHECK:
Date Ii
Arrive:
~~~~_~ ~ ~ D ~~ eM~
1 ~ n M ~R ~ rJ ~,T~iEET
Soil T :Sand Loam Cla
T of Water: Munici I Weil Water
Waterline se ration distance ft.
Well separation distance
Other wells: ft.
ft.
Well Casing Length 50' + / -
150' to well wired if NO Y N N/A
Abso tion Field: Total len th ft.
Le th of each trench ft.
De h of trenches ft.
Size of Stone
See a Pits: Number
Size: x
Stone Size:
Pi in Size T
Buildin to tank
Tank to Distribution Box
Distribution Box to Field Pit
0 nin Sealed: Y N
End Ca Y N
Inl Outlet Pi & Baffles Y N
Manholes 12" or less below grade
rovide extension collar if Yes Y ,_ N
Y N
Location Se rations
Foundation to tank ft.
Foundation to absor ion ft.
Se ration of Pits
Conforms as r Plot Plan Y
En ineer Re rt and As-Built
ETU Maintenance Contract
rovided
Location of System on Property:
Front Rear Left Side Right Side
- a
NO.. tom-" Z°I ~
oN: ~ --mac -- \
C't$t~ 1J~ t~tJ ~~~~ ~ T~ E
1 tJ~C~ i''tvtJ\c~PaL. lv- ~v~~~.
T~ ~ M ~ >~TF~~ . Y" l~ L~
b~i~ ~ ~ ~ D ~ M ~~ \ b~ zn~ t
Middle Front Middle Rear
system Use Status:
pproved
Partial Approved and needs to be re-inspected, please call the Building & Codes Office
Disapproved
L:\Pam Whiting\2010\Building Codes Forms\Inspecaon Forms\Septlc Ir~spectfon RePa't-03 29 l0.doc