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2009-199 OFFICE USE ONLY 10 TAX MAP NO. PERMIT NO. PERMIT FEES 0 L5 APPROVALS: ZONING TOWN CLERK MAY 19 2009 ' / .. APPLICATION FOR SEPTIC DISPOSAL SYSTEM I�IG G & CODES A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS.APPLICATION IS SUBJECT TO REVIEW BEFORE ISSUANCE OF A VALID PERMIT. (�1 OWNER: �,) INSTALLER: ADDRESS: II ADDRESS: -7 /�- y G- � PHONE NOS. �f PHONE NOS. / 7 t✓`� /� � LOCATION OF INSTALLATION: NO.OF RESIDENCE INFORMATION: YEAR BUILT BEDROOMS X COMPUTATION= = TOTAL DAILY FLOW GARBAGE GRINDER 1980 or older X 150 gallon per bedroom = INSTALLED? 1981 -1991 X 130 gallon per bedroom = SPA OR HOT TUB 1992-present X 110 gallon per bedroom = INSTALLED? PARCEL INFORMATION: ✓ TOPOGRAPHY: Fiat rolling Steep slope %Slope ✓ SOIL NATURE: Sand 1/ Loam Clay Other ✓ GROUNDWATER: At what depth? ✓ BEDROCK/IMPERVIOUS MATERIAL: At what depth? ✓ DOMESTIC WATER SUPLY: Municipal V 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: 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 ff SEEPAGE PIT(S) (WITH NO. 3 STONE) How many? Size?r(A! ❑ 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, anyf 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 regulations with respect to this application and agree to abide by these and all requirements of the Town of QUESTIONS? CALL 761-8256 OR EMAIL Queen ury Sanitary Sewa a Disposal Ordinance, codes mueensbury net VISIT OUR WEBSITE FOR MORE INFORMATION " /d r a www.pueensburv.net gnature ofAerson Responsible Date :n Town of Qiteensbury - Community Development Office - 742 Bay Road, Qteensbury, NY 12804 B 5-LGL 6/06 TOWN OF QUEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201 Community Development- Building&Codes (518) 761-8256 BUILDING PERMIT Permit Number: P20090199 Application Number. A20090199 Tax Map No: 523400-301-012-0001-007-000-0000 Permission is hereby granted to: LOUIS &FAITH BELISLE For property located at: 9 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. Type of Construction Value Owner Address: LOUIS &FAITH BELISLE 9 HEINRICK Cir Septic Alteration Residential QUEENSBURY, NY 12804 Total value Contractor or Builder's Name/Address Electrical Inspection Agency Plans &Specifications 2009-199 septic alteration residential $25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Thursday, May 20, 2010 (If a longer period is required,an application for an extension mmst be made to the code Enforcement Officer of the Town of Queensbury before the expiration date.) Dated at the To(6 o eens Wed 'esday, May 20, 2009 SIGNED BY for the Town of Queensbury. Director of Building&Code Enforcerncr�a TOWN OF QUEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201 Community Development - Building & Codes (518) 761-8256 CERTIFICATE OF COMPLIANCE Permit Number: P20090199 Date Issued: Tuesday, May 26, 2009 This is to certify that work requested to be done as shown by Permit Number P20090199 has been completed. Tax Map Number: 523400-301-012-0001-007-000-0000 Location: 9 HEINRICK Cir Owner: LOUIS & FAITH BELISLE Applicant: LOUIS & FAITH BELISLE 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 f� 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. Septic Inspection Report Office No. (518) 761-8256 Date Ins7r'sn io st a e' ed: Queensbury Building &Code Enforcement Arrive: a / . epart: am/pm 742 Bay Rd., Queensbury, NY 12804 Inspectoitials NAME: P NO.: LOCATION: �, I ECT ON: RECHECK: Comments and/or diagram Soil Ty oam JClay Type of Water: nici l Water Wa aration distance ft. Well separation distance ft. Other wells: ft. Well Casing Length 50' + / - Y N N/A 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 Size Type Building to tank Tank to x � . utio d i CiDeninq Sealed: Y N End Cap N Inlet/Outlet Pipes&Baffles _Y N Location/ Separations Foundation to tank C Foundation to absorption 70 Separation of Pits ft. Conforms as per Plot Plan Y N Engineer Report and As-Built Y N Location of System on Property: r Left Sid Right Side M' dle Front Middle Rear Use 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 ,..._ - - _ ti. _ _ _ .r� �.. �, .._ l ! �'� � ^-• r �L Septic Inspection f%: Office No. (518) 761-8256 Date Inspection re Queensbury Building &Code Enforcement Arrive: o art: a pm 742 Bay Rd., Queensbury, NY 12804 Inspector's Initials: NAME: �.f�l - PEV� ><t) LOCATION: or �C-1 j 1 t S°' � IN RECHECK: Comments and/or diagram Soil Type: Sand Loam/ Clay Type of Water: Municipal/ Well Water Waterline separation distance ft. 6 C) Well separation distance ft. Other wells: ft. Well Casing Length 50' + / - Y N N/A VA01 oG Absorption Field: Total length ft. -t-0 n \ Z2 5L 1(> 6F-&L'V Length of each trench ft. pV e C�HA �► 6 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 System Use Status: Approved Aartial Approved and needs to be re-inspected, please call the Building &Codes Office isapproved Last revised 06/18/07 L:\Building&Codes Forms-OLD\Building&Codes\Inspection Forms\Septic Inspection Report.doc