2010-139 elak TOWN OFQ UEENSBURY
Fir* 742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20100139 Date Issued: Tuesday, December 11, 2012
This is to certify that work requested to be done as shown by Permit Number P20100139
has been completed.
Tax Map Number: 523400-309-007-0002-030-000-0000
Location: 26 MALLORY Ave
Owner: RALPH & DONNA PALMER
Applicant: RALPH & DONNA PALMER
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
property owner of the responsibility for compliance with Site Plan, if I
Variance, or other issues and conditions as a result of approvals by the i Xrrui g �' nforcement
Planning Board or Zoning Board of Appeals. \.
if TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20100139 Application Number. A20100139
Tax Map No: 523400-309-007-0002-030-000-0000
Permission is hereby granted to: RALPH &DONNA PALMER
For property located at: 26 MALLORY Ave
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: RALPH &DONNA PALMER
26 MALLORY Ave Septic Alteration Residential
QUEENSBURY,NY 12804 Total Value
Contractor or Builder's Name/Address Electrical Inspection Agency
QUEENSBURY SEWER
JAY SWEET
Plans &Specifications
2010-139
septic alterration residential
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Tuesday, April 12, 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 date.)
Dated at the Tor of eensb , , l Igti y, April 12, 2010
SIGNED BY l //: f for the Town of Queensbury.
Director of Building 8cCode Enforcement
r4r• �slr�i
7_2_370 OFFICE USE ONLY ; i';
TAX MAP NO. PERMIT NO. 10 PERMIT FEE I ,+
APPROVALS: ZONING TOWN CLERK
APPLICATION FOR SEPTIC DISPOSAL SYSTEM PERMIT:
A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS.APPLICATION IS SUBJECT TO REVIEW BEFORE ISSUANCE OF A VALID
PERMIT.
OWNER: . ' i /( ? / //cc" INSTALLER: CV) LLQ
ADDRESS: ` 1 l c %C ADDRESS: life-t- '
PHONE NOS. /
/ c `J f PHONE NOS. ��- / - / c_,.3
LOCATION OF INSTALLATION: , � . / %j z l,-'
NO. RESIDENCE INFORMATION:
YEAR BUILT X COMPUTATION= = TOTAL DAILY FLOW
BEDROOMS GARBAGE GF21NQ R
1980 or older X 150 gallon per bedroom = 3 INSTALLED? /C."
1981 -1991 X 130 gallon per bedroom =
SPA OR HOT TUB
1992-present X 110 gallon per bedroom = INSTALLED? /C-'
PARCEL INFORMATION:
✓ TOPOGRAPHY: Flat rolling/( Steep slope . %Slope
/ SOIL NATURE: Sand ,\ Loam Clay Other
✓ GROUNDWATER: At what depth?
✓ BEDROCK/IMPERVIOUS MATERIAL: At what depth?
✓ DOMESTIC WATER SUPLY: Municipal Well (If well: Water supply from any septic
system absorption is ft.)
✓ PERCOLATION TEST: Rate is minutes 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: le`- z. 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:
LA ABSORPTION FIELD (WITH NO. STONE) Total length
g /'� S ft. Each trench �f'S X
❑ 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
failure to make a material fact or circumstance known by or on behalf of an applicant, shall be void.
Septic Inspection Repo•
Office No. (518) 761-8256 Date Ins v- ion r-• - - - ., d:
Queensbury Building &Code Enforcement Arrive: °c-, et. ' - .epart: I Et ,/ 4,pm
742 Bay Rd., Queensbury, NY 12804 Inspector's Initials:
NAME: PA L ER � ERMIT NO.: 1C —1_?i�
Z
LOCATION: lo l\ R K
LLo 't A.3 E INSPECT ON: LA 1 LA —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. LE_BCA L\ *c Ti`s Co5E_
Well Casing Length 50'+/ - Y N N/A - - E kZ„
Absorption Field: Total length ft. LSAT E') QFC-OWL
Length of each trench ft. \ 002\
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
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
Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
Last revised 06/18/07 L:\Building&Codes Forms-OLD\Building&Codes\Inspection Forms\Septic Inspection Report.doc
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection r-• - - ted:
Queensbury Building&Code Enforcement Arrive: ilk' ••• Depa• . [WI a :m
742 Bay Rd., Quee• •ury, NY 12804 Inspector's Init. r �!
NAME: Ato. '. ,
I
7/3W
LOCATION: / h : �� INSPECT ON:
RECHECK:
Comments and/or diagram
SoilTy•- a. - ._m/ Clay
Type of Water: unicipal We_l Water
Waterli - _-_ . . ion 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 le.L ft.
Depth of trenches .ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank •,L, b
Tank to Distribution Box '-1" hp£_. 3 5
Distribution Box to Field/ Pit Lt" ACM- 3 t
Opening Sealed: 2/ N
End Cap vY N
Inlet/Outlet Pipes&Baffles _N
Manholes 12"or less below grade —N
[provide extension collar if rtt] Y N
Location/ Separations
Foundation to tank 1 ft. e-y--z�`cUS
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan N
Engineer Report and As-Built Y N
ETU Maintenance Contract _Y N
provided
Location of System on Prope •
Front 4k• . . - •- Right Side Middle Front Middle Rear
em Use Sta- s:
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 Report03 29 10.doc
Community Development Office
lbw ii* Town of Queensbury • 742 Bray Rd,
Queensbury, New York •12804 PLOT PLAN
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