2011-164 .4111111fti TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building& Codes (518) 761-8256
CERTIFICATEF
O COMPLIANCE
Permit Number: P20110164 Date Issued: Monday, May 09, 2011
This is to certify that work requested to be done as shown by Permit Number P20110164
has been completed.
Tax Map Number: 523400-289-007-0001-004-000-0000
Location: 111 TEE HILL Rd
Owner: JOHN& GEORGENE ANDERSON
Applicant: JOHN& GEORGENE ANDERSON
This structure may be occupied as a:
Septic Alteration Residential
By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the /1
property owner of the responsibility for compliance with Site Plan, div
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
F
Community Development-Building&Codes (518)761-8256
BUILDING PERMIT
Permit Number: P20110164 Application Number: A20110164
Tax Map No: 523400-289-007-0001-004-000-0000
Permission is hereby granted to: JOHN&GEORGENE ANDERSON
For property located at 111 TEE HILL 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: JOHN&GEORGENE ANDERSON Septic Alteration Residential
31 YORKSHIRE Dr Total Value
QUEENSBURY,NY 12804-0000
Contractor or Builder's Name/Address Electrical Inspection Agency
MORNING STAR SEPTIC
Plans&Specifications
2011-164
septic alteration residential
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday,May 03,2012
(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 To of eens e , ay 03,2011
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
05/02/2011 15:05 5187932116 MORNING STAR SEPTIC PAGE 01/02
Revised 4/14/2010
W:OFFIC
ll5f=ONLY .
/-1
NO, f PERMIT NO- I' PERMIT Fi=E
APPRaVALS: ZONING TOWN CLERK
APPLICATION FOR SEPTIC DISPOSAL SYSTEM PERMIT:
A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS. APPLICATION IS SUBJ CT TO REVIEW BEFORE
ISSUANCE OF A VALID PERMIT. r,
OWNER: INSTALLER:
ADDRESS: f�7
ADDRESS:
PHONE NOS._ �I�' `�O Q PHONE NOS
LOCATION OF INSTALLATION: RESIDENCE INVORMATiON-
NO.OF COMPUTATION TOTAL DAILY FLOW GARBAGE GRINDER
YEAR BUILT BEDROOMS X Gallons per bedroom INSTALLED?
198o or older X 150
X 130 SPAORHOTTUB
1931-1991 INSTALLED?
1992-Present X 110 -
PARCEL,INFORMATION: ! .
TOPOSRAI?HY: ROLLING STEEP SLOPE—
SOIL °/aSLOPE
./ NATi I F.: SAND
LOAM CLAY OTHER
✓ nOU DW TER: AT WHAT DEPTH?
✓ ED Call PERVIOUS MA RI L• AT WHAT DEPTH?
✓ g IESTIc'WATERS PLY: MUNICIPAL_, W E�U�(If well:
i water supply from any septic system absorption is:_�fiZ
✓ P RCO TIO TEST: RATE IS PER MIINUTE PER INCH[MR1
(rest to be completed by a licensed Professional engineer or archtteGt)
PROPOSED SYSTEM FOR NEW CONSTRUCTION: Au individual sewage disposal systems must bo desigrue<t by a licensed professional engineer
or arclfdact(unless installed in a Planning Board approved subdivision).
TANK SiZe- •Q�ltla1D GALLON(MIN.SIZE 1S 1,000 GAL.)Add 250 gallons to the size of the septic tank for
each garbage grinder,spa or whirlpool tub.
SYS_ E TYM, 2'SO x
❑ASSORPTiON FIELD WITH NO.2 STONE) Total length
ft- Each trench
p SEr�PAGE PIT(S)WITH N0.3 STONE)
How many? Size?
❑ALTERNATIVE SYSTEM Bed or other type?
� Tank size?��Number of tanks?
❑HOLDING TANK SYSTEM Total required capacity-
NOTE: ALARM SYSTEM AND ASSOCIATED p EA S R�/IEWtIVORLI3T PROUiDED.ST BE NSPECTED BY A TOWN
APPROVED ELECTRICAL INSPECTION AGE
For your protection,please note that pursuant to Section 136-29 of the Code of the Town of Queensbury,any permit or approval
grayed 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 appilcant,shall be void•
I have read the regulations with respect to this application and agree
C(QIUE-STIONS? CALL 761.8256 OR 1JMAIL
to abide by these and all requirements of the Town of Queensburyes sue sbitnr•n tSanitary Sewage Disposal Ordinance-
SITF FOR MORE INFORMATION
, W pu�sburv.net
Signature of Pers n Responslb[e Date Queen
sbury NY 12804
Town of Queensbury' Commun'itjr Development Office'"742 Bay Road,
lo-lz- -71
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:&12:�9
NAME: AR -e PERMIT NO.:
LOCATION: 4L�7.-Ee &izz 1<f0f INSPECT ON:
RECHECK:
Comments and/or diagram
Soil T Sa /
Type of Water: Munici al ell
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
Absor ption Field: Total length ft.
Length of each trench fit,.
Depth of trenches L
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 Ca N
InletjOutlet Pipes&Baffles N
Manholes 12"or less below grade
[provide extension collar if Yes
Location Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits V-,\-
Conforms as per Plot Piao N
E ' r As=Bu' Y
_..-' AS B'U' " I OLIV
ETU Maintenance Contract Y_N
provided
Location of System on Props
Front ear USideRight Side Middle Front Middle Rear
System Use S
Approved
Partial Approved and needs to be re-inspected, please call the Building&Codes Office
Disapproved
L:\Pam Whiting\2010\8ullding Codes Forms\Inspecgon Forms\Septic Inspection Report-03 2910.doc
05/02/2011 15:05 5187932115 MORNING STAR SEPTIC PAGE 02/02
518493-2290
• FaX#$18-793-2115
E-mail.momingstarsepticfhotmail.com
N2 443 www.morningstarseptic.com
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Date: _ / - 107 Jewel Road,Gansevoort,NY 12831
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