2011-405 TOWN OFQ UEENSBURY
wig 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building& Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20110405 Date Issued: Tuesday, August 23, 2011
This is to certify that work requested to be done as shown by Permit Number P20110405
has been completed.
Tax Map Number: 523400-295-014-0002-073-000-0000
Location: 16 DORSET P1
Owner: JEREMIE & KRISTEN MAC EWAN
Applicant: JEREMIE & KRISTEN MAC EWAN
This structure may be occupied as a:
Septic Alteration Residential
By Order of Town Board
TOWN OF QUEENSBURY
A f ., JW
Issuance of this Certificate of Compliance DOES NOT relieve the
property owner of the responsibility for compliance with Site Plan, vr�
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.
1
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
FON
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20110405 Application Number: A20110405
Tax Map No: 523400-295-014-0002-073-000-0000
Permission is hereby granted to: JEREMIE&KRISTEN MAC EWAN
For property located at 16 DORSET P1
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: JEREMIE &KRISTEN MAC EWAN Septic Alteration Residential
16 DORSET P1 Total Value
QUEENSBURY,NY 12804-0000
Contractor or Builder's Name/Address Electrical Inspection Agency
IBS SEPTIC&DRAIN
ATTN: WAN BELL
2 LOWER WARREN St
OUEENSBURY,NY 12804
Plans&Specifications
2011-405
septic alteration residential
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Sunday,August 12,2012
(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 o1QQueenslOjY,/ i id y august 12,2011
SIGNED BY `vi .� for the Town of Queensbury.
Director of Building&Code Enforcement
n � � � � . E, .I10
OFFICE USE ONLY �, m 3 ' i- _ U
j —Z-) - 7 _-� I '`"'S- `` _ 'i AUG 1 1 2011
TAX MAP NO. . i ,,F, PERMIT NO. PERMIT FEE
APPROVALS:
ZONING TOWN CLERK TOWN OF QUEENSBURY
APPLICATION FOR SEPTIC DISPOSAL SYSTEM PE" I i •13UrLDING & CODES
A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS. APPLICATION IS SUBJECT TO REVIEW BEFORE
ISSUANCE OF A VALID PERMIT. 2
OWNER: -3(.1. h. wa�INSTALLER: L 1. 0. J S
ADDRESS: ft(0 air r S t/ ADDRESS: #Gil (10 LC r- Imo, U r f C't 5
PHONE NOS. )a (— S f % 6 PHONE NOS. 7n D ' ( / ? f
LOCATION OF INSTALLATION:
RESIDENCE INFORMATION:
NO. COMPUTATION
YEAR BUILT BEDROOMS X (Gallons per bedroom) = TOTAL DAILY FLOW • GARBAGE GRINDA
1980 or older 3 X 150 = Q INSTALLED?
A
1981-1991 14 X 130 = VA SPA OR HOT TU /ffJ
1992-present A /� X 110 = /f / INSTALLED? !BA�/�`
PARCEL INFORMATION: /`/ v
✓ TOPOGRAPHY: FLAT ROLLING STEEP SLOPLVA %SLOP
✓ SOIL NATURE: SAND LOAM CLAY A OTHEVIA
✓ GROUNDWATER: AT WHAT DEPTH? 0
✓ BEDROCK/IMPERVIOUS MATERIAL AT WHAT DEPTH? /44
✓ DOMESTIC WATER SUPLY: MUNICIPAL WELL �M"(If well:water supply from any septic system absorption is: Ifti
✓ PERCOLATION TEST: RATE IS PER MIINUTE PER INCH[mpi]
(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: /C)Dd GALLON(MIN.SIZE IS 1,000 GAL.)Add 250 gallons to the size of the septic tank for
111 each garbage grinder,spa or whirlpool tub.
SYSTEM TYPE:
0 ABSORPTION FIELD(WITH NO.2 STONE) Total lengthU ft. Each trench i X O
0 SEEPAGE PIT(S)(WITH NO.3 STONE) How many?Afr Size?
0 ALTERNATIVE SYSTEM Bed or other type?
0 HOLDING TANK SYSTEM Total required capacity? Tank sizeVA// — Number of tanks?,(
A i moi/
NOTE: ALARM SYSTEM AND ASSOCIATED ELECTRIC•L 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 Que nsbury QUESTIONS? CALL 761-8256 OR EMAIL
Sanitary Sewage posal Ordinance. / codes(t?Queensburv.net
`/A$ 1/ VISIT OUR WEBSITE FOR MORE INFORMATION
Signa ure of Person Responsible Date www.uueensburv.net
Town of Queensbury*Community Development Office*742 Bay Road, Queensbury NY 12804
2 Weah
7----
Septic Inspection Report �,-
Office No. (518)761-8256 Date Ins request received:
Queensbury Building&Code Enforcement Arrive: ,U 0 am/pm �e art: am/pm
742 Bay Rd., Queensbury, NY 12804 Inspector's I itials: 4
NAME: fric &SvkJ _ PERMIT NO.:
LOCATION: /6 Ly`s . INSPECT ON: >r�i .
RECHECK: /
Comments and/or diagram
Soil Type= Loam/Clay
Type of Water: «•••. /Well Water
Wate'i - •••.ration 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 1--10 ft.
Length of each trench ft.
Depth of trenches ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping 2fizev Type
Building to tank '/
Tank to Distribution Box l `61 ?�
Distribution Box to Field/ Pit
Opening Sealed: i N
End Cap ____N
Inlet/Outlet Pipes&Baffles Y_N
Manholes 12"or less below grade Y_N
[provide extension collar if Yes] Y N
Location/ Separations
Foundation to tank A/ ft.
Foundation to absorption ft.
Separation of Pits 71' ft.
Conforms as per Plot Plan —N
Engineer Report and As-Built Y_N
ETU Maintenance Contract _Y N
provided
Location of System on Property:
Front Left Side Right Side Middle Front Middle Rear
stem ,t .
Approved
Partial Approved and needs to be re-inspected, please call the Building&Codes Office
Disapproved
L:\Pam Whiting\2010\Building Codes Forms\InspecUon Forms\Septic Inspection Report_03 29 10.doc
'r ( /'l �l
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:
II_/, 1
NAME: � .' ��C- PERMIT t- PERMIT NO.: a
LOCATION: s =- INSPECTON: Y 1 —/
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. -r�t� VtC`�- -1. t 1401
Well Casing Length 50'+/- Y N N/A
[150'to well required if NO] C� - �.-�� �
Absorption Field: Total length ft. pi
Length of each trench
Depth of trenches ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size: evy(„jt,_
Piping Size Type F ,
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_N
Manholes 12"or less below grade Y_N
[provide extension collar if Yes] Y N
Location/ Separations
Foundation to tank ft.
Foundation to absorption ft
Separation of Pits
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
stem t�
A •proved
_ r- pp •'-• and needs to be re-inspected, please call the Building&Codes Office
V/ Disapp • -
L:\Pam Whiiting\2010\Building Codes Forms on Fonns\Septic Inspection Report_03 29 10.doc
/ • 1
"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 also represent that I have
personally measured the distances set fcrth on he iagram."
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Septic Inspection Report
Office No. (518)761-8256 Date Inspeogon equest received:
Queensbury Building&Code Enforcement Arrive: /U/( am/ /Depart: am/pm
742 Bay Rd., Queensbury, NY 12804 Inspector's Initials: IP
!'' ___-
NAME: i n �'r;"Ct - PERMIT NO.: , '_. / ''-�
-�_
LOCATION: ,_, .�., j == ./- INSPECT ON: / /V
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.
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 T N
End Cap Y N
Inlet/Outlet Pipes&Baffles Y—N
Manholes 12"or less below grade Y N
[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 J'
provided Oh- 1� CO-)-e- 1"r4 L ��
Location of System on Property:
Front Rear Left Side Right Side Middle Front Middle Rear
System Use Status:
Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
L:\Pam Whiting\2010\Building Codes Foims\Inspectlon Forms\Septic Inspection Repat_03 29 10.doc
Septic Inspection Report
Office No. (518) 761-8256 Date Inspen req L C
Queensbury Building&Cock Enforcement Arrive: .2-= 'Da• • /A - •.rt: am/pm
742 Bay Rd., Queensbury, N$-•12804 Inspector's Initials: .�• �-
NAME: Z \AC
C \ Rd�IrT NO.: C\7�=1::;S7
LOCATION: 27.-[?ERR VRik! tt. itISPECT ON: –(--\t-t --\
RECHECK:
Comments and/or diagram
Soil Type: Sand/ Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance _ft. ._4.. –
Well separation distance ft.
Other wells: ft. c� q
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 N
Manholes 12"or less below grade Y N
[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 Status:
Approved
Partial Approved and needs to be re-inspected, please call the Building&Codes Office
Disapproved
L:\Pam Whiting\2010\Building Codes Forms\Inspectlon Forms\Septic Inspection Report_03 29 10.doc
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TOWN OF QUEENSBURY
BUILDING & C. . ..:.PT.
Reviewed By: At(
Date: .
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