2010-500 ��'` TOWN OFQ UEENSBURY
742 Ba Road eensb NY 12804-5902 (518) 761-8201
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Community Development- Building &Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20100500 Date Issued: Monday, October 25, 2010
This is to certify that work requested to be done as shown by Permit Number P20100500
has been completed.
Tax Map Number. 523400-308-018-0001-070-000-0000
Location: 57 NORTH CHURCH Ln
Owner. GERALD & STEPHANIE CARRUTHERS
Applicant GERALD & STEPHANIE CARRUTHERS
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, VI 4
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.
111b TOWN OF QUEENSBURY
woo 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20100500 Application Number. A20100500
Tax Map No: 523400-308-018-0001-070-000-0000
Permission is hereby granted to: GERALD & STEPHANIE CARRUTHERS
For property located at: 57 NORTH CHURCH Ln
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: GERALD & STEPHANIE CARRUTI
57 NORTH CHURCH Ln Septic Alteration Residential
QUEENSURY, 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
2010-500
septic alteration residential
$25.00 1'ERMTh FRE-PAID- THIS PERMIT EXPIRES: Wednesday, October 19, 2011
(If a longerpeniod 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 To7 .f. eensbny; 7 est ay, October 19,2010
f for the Town of Queensbury.
SIGNED BY �/)av � Qu ury.
Director of Building&Code Enforcement
A
Communitypb.) , :,74.3, En wi Ep
Development Office
, � P OCT 15 2010
Town of Queensbury • 742 Bay Road • Queensbury, New Yo k •12804 1
t571 0 QUEENSBI RY
Office U e Onl MNG & CODES
it
X M NO. PERMIT NO. I SID
PERMIT FEE �"_f ' O O
Ax
ZONING ____ TOWN CLER
APPLICATION FOR SEPTIC DISPOSAL SYSTEM PERMIT: A PERMIT MUST BE OBTAINED
BEFORE WORK BEGINS. APPLICATION IS SUBJECT TO REVIEW EFORE ISSUANCE OF A VALID PERMIT.
OWNER1 --C2--04-A-
- - - C 141Z -1z Q(S__ INSTALLER: L}_�/i_%�},ti fec,rw jf�.yJ_�
�/ n l j �- --- 0
ADDRESS:.- /" v fl- Glu r4. ( AN ADDRESS: r d v r 22`1> F
PHONE NOS. 7 9 3 '5' 7 -7 7 _ PHONE NOS. 7 g4, — 0 `�
LOCATION OF INSTALLATION: N• clot Li[C
RESIDENCE INFORMATION:
YEAR BUILT NO.OF X COMPUTATION = TOTAL DAILY FLOW
BEDROOMS (Gallons per bedroom) GARBAGE GRINDER
1980 or older j X 150 = i/6-73
L/`j j INSTALLED? _
1981 -1991 X 130 = SPA OR HOT TUB
1992-present X 110 = INSTALLED?
PARCEL INFORMATION: /
✓ TOPOGRAPHY: FLAT ROLLI ~' STEEP SLOPE %SLOPE
✓ SOIL NATURE: SAND V LOAM
CLAY OTHER
✓ GROUNDWATER: AT WHAT DEPTH?
✓ BEDROCK/IMPERVIOUS MATERIAL: AT WH/AT DEPTH?
✓ DOMESTIC WATER SUPLY: MUNICIPAL V WELL____(If well:water supply from any septic system absorption is:_ ft)
✓ 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: (COO 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:
❑ABSORPTION FIELD(WITH NO. 2 STONE) Total length ft. Each trench X
SEEPAGE PIT(S)(WITH NO. 3 STONE) How many? Size?_10', k s_
❑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.
I have read the re•ulations with respect to this application and agree to
e by these an. : requirements of the Town of Queensbury QUESTIONS? CALL 761-8256 OR EMAIL
Va./it-Lel
Sewa .,. s Or %' ce_— tocodesCa�ALL 7 1-8256O
41104) VISIT OUR WEBSITE FOR MORE INFORMATION
ture of Perso esponsible Date www.queensbury.net
, 2_ • 00 ) /0` i2- 1Jce-fw7�
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/ Depart: t am/pm
742 Bay Rd., Queensbury, NY 12804 Inspector's Initials: P
NAME: �w'f"tdiAers.5 PERMIT NO.: /0- S-00
LOCATION: 5-7-• (-)L. Ckocck 1_,, INSPECT ON: /0 -- /J-%O
RECHECK:
Comments and/or diagram
Soil Type: • i• oam/Clay
Type of Water: q[rr,« •. ► Well Water
Waterline separation distance ft.
Well separation distanceI
Other wells: `' a ft.
Well Casing Length 50'+/- r ` N N/A
[150'to well required if NO]._
Absorption Field: Total length ft.
Length of each trench ft. �
Depth of trenches ft. (7V ` 5
Size of St
Seepage Pits: Number /
Size: x _
Stone Size:
Piping Size Type
Building to tank ---I.— Z�Q� Cc>
Tank to Distribution :•. A
Distribution Box to Field 4 5-
Opening Sealed: I, N
End Cap Y_N
Inlet/Outlet Pipes&Baffles _N
j/
Manholes 12"or less below grade _N
[provide extension collar if Yes] //Y_N
Location/ Separations
Foundation to tank ft. 2 kc>k'
Foundation to absorption 'r", ft.
Separation of Pits ' r ft.
Conforms as per Plot Plan _Y
Engineer Report and As-Built Y NA-
ETU Maintenance Contract Y N
provided
Location tem on Property:
Fro R r Left Side Right Side Middle Front Middle Rear
stem •
Approved
Partial Approved and needs to be re-inspected, please call the Building&Codes Office
Disapproved
L:\Pam Whiting\2010\Building Codes Fom s\InspectIon Forms\Septic Inspection Report_03 29 10.doc
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