2009-091 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20090091 Application Number. A20090091
Tax Map No: 523400-301-012-0002-057-000-0000
Permission is hereby granted to: DENNIS J JACKSON
For property located at: 2 HEINRICK Cir
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. Tyne of Construction Value
Owner Address: DENNIS J JACKSON
2 HEINRICK Cir Septic Alteration Residential
QUEENSBURY, NY 12804 Total value
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans &Specifications
2009-091
SEPTIC ALTERATION RESIDENTIAL- TANK REPLACEMENT
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Saturday,March 27,2010
(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 th o of Qu b Iday, March 27, 2009
SIGNED BY for the Town of Queensbu
ry.
V
Director of Building&Code Enforcement
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
(zt Community Development- Building &Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number. P20090091 Date Issued: Thursday, August 26, 2010
This is to certify that work requested to be done as shown by Permit Number P20090091
has been completed.
Tax Map Number. 523400-301-012-0002-057-000-0000
Location: 2 HEINRICK Cir
Owner. DENNIS J JACKSON
Applicant: DENNIS J JACKSON
This structure maybe 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,
Variance, or other issues and conditions as a result of approvals by the Director of Building&Code Enforc ment
Planning Board or Zoning Board of Appeals.
__ OFFICE USE ONLYI __- %
r _ 0
TAX MAP NO. PE MIT NO. !� PERMIT FEE ' 1
`_ ' 0
APPROVALS: ZONING N 0 '
TOWN CLERK
-----------------
------------------------ --___!
APPLICATION FOR SEPTIC DISPOSAL SYSTEM PERMIT.
A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS.APPLICATION IS SUBJEC REVIEW BEFOZISSNCE OF A VALID
PERMIT
OWNER:- NiV t
INSTALLER:
ADDRESS: /t cC�L �ZG� ADDRESS:
PHONE NOS. PHONE NOS. 7 �
LOCATION OF INSTALLATION:
YEAR BUILT NO.OF X COMPUTATION= RESIDENCE INFORMATION:
BEDROOMS = TOTAL DAILY FLOW
1980 or older X 150 gallon per bedroom = GARBAGE GRINDER
1981 -1991 INSTALLED?
X 130 gallon per bedroom =
199 --present X 110 gallon per bedroom = SPA OR HOT TUB
INSTALLED?
PARCEL INFORMATION:
✓ TOPOGRAPHY: Flat rolling Steepslope_
%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
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 arc f�tect (unless installed in a Planning Board approved subdivision).
TANK SIZE: � � eppL Act �t'�"�„'�vN
GALLON (MIN. SIZE IS 1,000 GAL.)Add270 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?
❑ 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 4n m�I— 4—:-1 c....a -- _.__..____.-
L
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Septic Inspection Report t�
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building &Code Enforcement Arrive: am/pm Depart: m/pm
742 Bay Rd., Queensbury, NY 804 . Inspector's Initials:
NAME: PERMIT NO.:
LOCATION: INSPECT ON: 3a GS
RECHECK:
Comments and/or diagram
Soil Tyg Sand4 Loam Clay
Type of Water- unici Well Water
Water ration distance ft.
Well separation distance ft.
Other wells: ft.
Well Casing Length 50' + / - Y N N/A u7`
Absorption Field: Total length ft.
Length of each trench ft. -
Depth of trenches ft.
Size of Stone _
Seepage Pits: Number
Size: x
Stone Size:
Piping ize Type
Building to tank
Tank to Distribution Box r
Distribution Box to Field Pit
Opening Sealed: Y N
End Cap 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 V Y N
Engineer Report and As-Built Y N
Location of System on Property:
Front Rear Left Side Right Side Middle Front Middle Rear
Sy
s s:
Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
Last revised 06/18/07 U\Building&Codes Forms-01-1)\Building&Codes\Inspection Forms\Septic Inspection Report.doc
[
-71
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"I have seen or observed, or believe 1 saw evidence of, �►
all obiects such as ,houses, wells, trees, fences, etc.,
shown on this document. I also represent that 1 have 4FI,
persu' nee d the distan et f;,rth on the diagram:" Z
� t
3 Z 7
SIGNATURE DATE
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