SEP-000573-2017 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development- Building& Codes (518)761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: SEP-000573-2017 Date Issued: Friday, September 15, 2017
This is to certify that work requested to be done as shown by Permit Number SEP-000573-2017
has been completed.
Tax Map Number: 301.20-1-42
Location: 11 HERESFORD LN
Owner: ROBERT DICKINSON
Applicant: Sanitary Sewer Service
This structure may be occupied as a: Residential Septic Alteration
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,
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 12804-5904 (518)761-8201
Community Development-Building& Codes (518)761-8256
BUILDING PERMIT
Permit Number: SEP-000573-2017
Tax Map No: 301.20-1-42
Permission is hereby granted to: Sanitary Sewer Service
For property located at: 11 HERESFORD 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
Tvne of Construction
Owner Name: ROBERT DICKINSON Septic Disposal-Residential $0.00
Owner Address: 11 Heresford LN Total Value $0.00
Queensbury,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
Sanitary Sewer Service
PO Box 224
Glens Falls,NY 12801
Plans&Specifications
Residential Septic Alteration
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Tuesday,September 11,2018
(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 of eens / ton y Stfolrl
,2017
SIGNED BY: /vJ the Town of Queensbury.
Director of Building&Code Enforcement
SEp7le 025P®SAL Office Use Only
Reoeived ..
Tax Map ID
c . 2 - I -1t Z Permit No. Sep- 5,--3 201TAX f WA P Perm, Fee 4�
a eY�?re ►efPllvs';'a 'r��ni Approvals: I►,vn:,a 3 �Z Z
A�parc�►y� °r_� r✓� �i G l�-0 A--,j a PHoNEI E-J4G9ti..,. ---
ADDRESS / /1 el-ei 1 "- "
ICC PHONEI E-MAJL✓ `if`� �- �fJ
RDORESs:
PHONEIE-MAIL
Addreso � ��i✓S/ L.¢�e
GGIVTAGT PERSQIU FQt?Gf11L IALO 4111AiirGff:
F��e18�Ne�1NRA1�RRd fIBN
Year shit i;UT t}eiiioo= X 3allons per bedroom =Total Daily ROW
1980 or cider Garbage grinder installed _Y`,,,,_N
1981-1991 Spaor HotTub insulted _.Y U N
X992-Present
RaRCEL wl=QR(tl 7701U
Topography Plat roiling Steep slope %slope
Soil Nature Bend i_cam clay Other
Groundwater Atwha@afeptl2?
Bedrook I Impersrlout iY 161 At what d® �
Domlttic W alar Supply Municipal Weil Cif=U,water sapptyr from any septic system a=00n IS—ft.)
Pemolabon Test Rale: pe iTfmim per inch(test to be t:orrtpleted by lieerised engineering t archftect)
APROP0890 3MRiME FOR IIj W�4itFSt'i UC'nQAl
Tante eize G gallons(minimum size 1,000 gallons,add 250 gallons to size for each garbage grinder or spa or hottub)
System Typo Absorption field WM#2 stone Total lengttl _ ft;Each trench
awaga Frit VM 43 stone How many: size
Altetsa&O SWem Bed or other type?
Holding Tank SllMM Total required aapa&p- Tank size a ott Wm
Not= l)MGM system&asseciateti electrical work must be inspected by a Town approved electrical inspection agency;2)We will no longer
W ow systems to lze covered until such time as an As-BuIlt pian is Deceived&approved. The(Walled system must match the septic sysism
Layout Ontlte–no exceuttons-
,9wwA-e7g Any permit or approval granted which is based upon or is granted in reliance upon any mateft representation or
failure to psalm a Mateplat,alt or clrcumsfance know by or on behalf of an applicant, shall be void. i have read the regulations
and agree to abide bythesa andfl retiments ofthe Town of Qu�nsbuey 8enitaey Sewag leposal Qrdlnanee.
JJ Date: G //
Print llama ' . r
Sic�r,afure: Date: r
Town of Queensbury BuNng&Godes 3epticDispasal Pe tJpiy2lri�
gpTIC' PLL PLAN
I HAVE SEEN OR OBSERVED ALL OBJECTS
SUCH AS HOUSES, WELLS, TREES, FENCES, ETC
SHO HIS DOCUMENT.I HAVE PERSONALLY
ME URE FO HIS DIAGRAM.
SIGNAT E DATE - AcJO
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301.20-1-42 SEP-000573-2017
Dickinson, Robert k Revi : �r.
11 Heresford Lane [date:
Residential Septic Alteration
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