2004-485 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. P20040485 Date Issued: Monday, December 11, 2006
This is to certify that work requested to be done as shown by Permit Number P20040485
has been completed.
Tax Map Number. 523400-296-007-0001-018-000-0000
Location: 107 COUNTRY CLUB Rd
Owner. JAMES & CHRISTINE MARSHALL TRUSTEES
Applicant: JAMES & CHRISTINE MARSHALL TRUSTEES
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
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: P20040485 Application Number: A20040485
Tax Map No: 523400-296-007-0001-018-000-0000
Permission is hereby granted to: JAMBS & C',HRTSTU%TF MARSHAT,T,TRTTSTF,F,S
For property located at: 107 COUNTRY CLUB 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: JAMES & CHRISTINE MARSHALL
107 COUNTRY CLUB Rd Septic Alteration Residential
Total Value
QUEENSBURY,NY 12804
Contractor or Builders Name /Address Electrical Inspection Agency
T.B.S. SEPTIC
2 LOWER WARREN STREET
OTJEENSBTTRY_ NY
is
Plans&Specifications
2004-485
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID -THIS PERMIT EXPIRES: Tuesday, June 28, 2005
(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 of Queensbury; Monday, June 28, 2004
SIGNED BY for the Town of Queensbury.
Director of Building diaiforcement
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am Depart: am/pm
742 Bay Rd., Queensbury, NY (12804 Inspector's Initials: ,�-
NAME: �aY^S`'lC��►'( ) PERMIT NO.: 2�z/ �,S—
LOCATION: �C7 ��7l�on �.1 JY� RJ INSPECT ON:
RECHECK:
Comments and/or diagram
Soil Type: Sand/ Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft.
Well separation distance ft.
Other wells: ft.
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 Fieldl Pit
Opening Sealed: Y N Partial
End Ca
Inlet/Outlet Pipes&Baffles Y N
Location/ Se rations
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 Side Right Side
Middle Front Middle Rear
System Use us:
Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
Last revised 021006
Last revised 1/6/05
Application for Permit—Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
L OWNER INFORMATION:
Office Use
Location of installation: 4f ® CQ 1j,A, (`
w fj l� File Permit No. •'.
Tax Map No. j
� I Fee Paid
Owner's Name: .^'4C S� (1` �0
Address: C��y� r Cv�
3 � s a 2. INSTALLER'S NAME r ✓ � PHONE NO.
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate 4 bedroom(s) and multiply# of
bedrooms with applicable gallons per bedroom to equal total daily flow)
Year of House: No of Bedrooms x Computation = Total Daily Flow
1980 or older x 150 gal/bdrm =
1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm =
Garbage Grinder Installed yes, / no
Spa or Whirlpool Installed yes_ / noKit
4. PARCEL INFORMATION: (circle applicable information&indicate measureme&fl 2004
Togi�araDhv SoiWature Ground Water Bedrock or Impervious Ater Supply
Flat sand at ha depth at w t depth
ing feet feet well
Steep slope clay if well;water supply
_%slope other from any septic-system
depth: absorption is ft.
other
Percolation Test: (To be completed by licensed professional engineer or architect)
Rate: 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 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.
,�,� C- kI S/, -
Septic Tank: 1 gallon (min. size P,00.0 gal)
Tile Field: each trench ft. Total System Length: ® ft
Seepage Pit(s): number of' size of each: ft. by ft.
Size of Stone to be used: #_ l depth or thickness U(A feet
Bed System Size: x
Alternative System: length andlor size
6. HOLDING TANK SYSTEM: (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 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 Queensbury Sanitary Sewage Disposal Ordinance.
l> / P` �d
Signature of resp n 1e p on Date
�df
L `N�
Ak
Olt .�..
IV
0 pM
Cc
"I have seen or observed, or believe I saw evidence of,
all objects such as houses, wells, trees, fences, etc.,
shown on this document. I a?so repres-I nt th t ! have
" h on the diagram."
personal{1 ~e � i
SIGNATURE DATE
13UILDI id
REVIEWED
CDATE ,.,,�••
� brd
, 330 9
Septic Inspection Report
1>
p p
Office No.(518)761-8256 Date Inspection red est r c 1v d:
Queensbury Building&Code Enforcement Arrive: am/p epar
m/
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initi Is:
NAME: �CAmQ � _ PE IT NO.:
o 4-q&S
LOCATION: ECT ON:
RECHECK:
Comments a=1�diaram
Soil Type: Sand/Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft.
Well separation distance ft.
Other wells: ft.
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/Partial
End Caps
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 Side Right Side
Middle Front Middle Rear
System Use Statu
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
Last revised 116105
Septic Inspection Report
f
Office No. (518)761-8256 Date InspectiIreest r cc' cd)Queensbury Building&Code Enforcement Arrive: /p �e art: S�'+ am/pm742 Bay Rd., Queensbuly,NY l2804 Inspector's In (`(`NAME: (1� Y IT NO.: ��7-4
S
LOCATION: /Q v� �oECT ON:
RECHECK:
Comments and/or diagram
Soil Tyg. Sand IkAdm/Clay
Type o W unicipal/Well Water
Waterline separation distance ft.
Well separation distance ft.
Other,wells: ft,
Absorption Field: Total length
Length of each trench
Depth of trenches
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
pipina Size Type
Building to tank
Tank to Distribution Box i Ian
Distribution Box to-13ielp Pit
Opening Sealed: Y/ /Partial
Location/Separations
i
Foundation to tank
Foundation to absorption ft.
Separation of Pits ft
Conforms as per Plot Plan Y VN
Location of System on Property:
����
Front Rear Left Sidee Right Side
Middle Front Middle Rear
System Use Statu
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:\SueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
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:
L
NAME: 1 PERMIT NO.: Q O0 -
LOCATION: -- � INSPECT ON:
RECHECK:
Comments and/or diagram
Soil Type: Sand/Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance
Well separation distance ft.
Other wells: $.
Absorption Field: Total length ft.
Length of each trench ft.Depth of trenches $.
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/Partial
End Caps
Location/Separations
Foundation to tank
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 Side Right Side
Middle Front Middle Rear
System Use Status:
a / Approved
�—Partial Approved and needs to be re-inspected,please call the Building& Codes Office
Disapproved
Last revised 1/6/05