2010-169 TOWN OFQ UEENSBURY
742 Bay Road Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building &Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20100169 Date Issued: Friday, May 21, 2010
This is to certify that work requested to be done as shown by Permit Number P20100169
has been completed.
Tax Map Number. 523400-301-007-0001-009-000-0000
Location: 9 CENTENNIAL Dr
Owner. EDWARD & JOAN HARSEN
Applicant: EDWARD & JOAN HARSEN
This structure may be occupied as a:
Septic Alteration Residential
By Omer of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the -4/
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&Co.e Enfo ement
Planning Board or Zoning Board of Appeals.
1�\ TOWN OF QUEENSBURY
limi
cos 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20100169 Application Number. A20100169
Tax Map No: 523400-301-007-0001-009-000-0000
Permission is hereby granted to: EDWARD &JOAN HARSEN
For property located at: 9 CENTENNIAL Dr
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: EDWARD &JOAN HARSEN
9 CENTENNIAL Dr Septic Alteration Residential
QUEENSBURY, NY 12804 Total Value
Contractor or Builder's Name/Address Electrical Inspection Agency
SANITARY SEWER
DAN DRELLOS
PO BOX 224
GLENS FALLS NY
Plans &Specifications
2010-169
SEPTIC ALTERATION RESIDENTIAL
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Wednesday,April 20,2011
(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 dat .)
Dated at the Ton of ens4 .,; ay,April 20, 2010
av
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
/ >/ OFFICE USE ONLY "
TAX MAP NO. PE '1..-
RMIT NO. i PERMIT FEE
pR n, 2010
APPROVALS: ZONING TOWN CLERK
APPLICATION FOR SEPTIC DISPOSArr`'""
L SYSTEM PERMIT:
A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS.APPLICATION IS SUBJECT TO REVIEW BEFORE ISSUANCE OF A VALID
PERMIT.
OWNER: 41Cs-)MIL IIIA � SR
INSTALLER: i
ADDRESS: e2,0RN , ADDRESS: P O l9. Zzyi G F
q
PHONE NOS. -7 /3 - 73 5 --
/y PHONE NOS. 7 5%e- is 6.-3
LOCATION OF INSTALLATION: 9 C. 1 @p..; "—
YEAR BUILT NO.OF X COMPUTATION- RESIDENCE INFORMATION:
BEDROOMS = TOTAL DAILY FLOW
1980 or older X 150 gallon per bedroom = GARBAGE GRINDER
INSTALLED? ND
1981 -1991
X 130 gallon per bedroom =
1992-present X 110 gallon per bedroom = SPA OR HOT TUB ,t rO
INSTALLED? '"
PARCEL INFORMATION:
✓ TOPOGRAPHY: Flat rolling Steepslope p %Slope
✓ SOIL NATURE: Sand t oam Clay Other
✓ GROUNDWATER: At what depth?
✓ BEDROCK/IMPERVIOUS MATERIAL:
/t wat depth?
✓ DOMESTIC WATER SUPLY: MunicipalY
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: I QC 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:
�vb
<ABSORPTION FIELD (WITH NO. 2 STONE) Total length ft. Each trench � X �f
❑ 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
fails irc+n m.nL.s ., .«.+ .: i t _i _- .
ti
li" -
Septic Inspection Repo
Office No. (518) 761-8256 Date Inspection request received: li i o
Queensbury Building &Code Enforcement Arrive: am/pm Depart: /2 e am/pm
742 Bay Rd., Queensbury, NY 12 Inspeector's Initials; f
NAME: t.�-- LSJ PERMIT NO.. j-010 - 01C99
LOCATION: 1.P �.t��'��C r(A—INSPECT ON: c( i t )_v i 6
RECHECK:
Comments and/or diagram
Soil Type: / Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft.
Well separation distance ft.
Other wells:
Well Casing Length 50' +/ - ( Y N
[150'to well required if NO]
Absorption Field: Total length "'.z ft.
Length of each trench _L ft.
Depth of trenches "' ft.
Size of Stone Z.--
Seepage Pits: Number
Size:
Stone Size:
Piping Size Type CK- -L 6. 'cz
Building to tank
Tank to Distribution Box `Y �� f
Distribution Box to Field/ Pit '
; 21�,—
Opening Sealed: ; y' N
End Cap �/ N
Inlet/Outlet Pipes&Baffles ,/Y N
Manholes 12"or less below grade V —N
[provide extension collar if Yes] VY—N
Location/ Separations
Foundation to tank / 4' ft.
Foundation to absorption '- ft.
Separation of Pits J(If' ft.
Conforms as per Plot Plan
Engineer Report and As-Built —Y N
ETU Maintenance Contract _Y_N
provided
Location of Sys - - Property:
Front •ear Left Side Right Side Middle Front Middle Rear
stem U - S.tus:
1 Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
L:\Pam Whiting\2010\Building Codes Forms\Inspection Forms\Septic Inspection Report 03 29 10.doc
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