2008-420 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: P20080420 Date Issued: Wednesday, August 13, 2008
This is to certify that work requested to be done as shown by Permit Number P20080420
has been completed.
Tax Map Number: 523400-301-008-0002-048-000-0000
Location: 22 PROSPECT Dr
Owner: ROSCOE & LORRAINE JACKSON JR
Applicant: ROSCOE & LORRAINE JACKSON JR
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,
1 11 A -0 /1
Variance, or other issues and conditions as a result of approvals by the Director of B Ong Code of e
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20080420 Application Number. A20080420
Tax Map No: 523400-301-008-0002-048-000-0000
Permission is hereby granted to: ROSCOE & LORRAINE JACKSON JR
For property located at: 22 PROSPECT Dr
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: ROSCOE &LORRAINE JACKSON
22 PROSPECT Dr Septic Alteration Residential
QUEENSBURY,NY 12804 Total Value
Contractor or Builders Name/ Address Electrical Inspection Agency
Plans &Specifications
2008-420
septic alteration residential
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Thursday,August 13, 2009
(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 of Qu e /b ry; sday,August 13, 2008
SIGNED BY " for the Town of Queensbury.
m'Y
Director of Building&Code Enforcement
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FICE USE ONLY �
TAX MAP NO. PERMIT NO. " ERMIT FEE
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APPROVALS: ZONING TOWN CLERK ;
i
..................
APPLICATION FOR SEPTIC DISPOSAL SYSTEM PERMIT;
A PERMIT MUST BE OBTAINED BEFOREILPRK INS.APPLICATION IS SUBJECT TO REVIEW BEFORE ISSUANCE OF A VALID
PERMIT. V__
OWNER: il Ck- T INSTALLER: �`�(;ti g w,j �,�,� (_�� e-_L/—
l C..S ADDRESS: . ES
ADDRESS: �P�V � .��� � "Y
PHONE NOS. PHONE NOS.
LOCATION OF INSTALLATION: rCSti' -� '
«. .....«.......«.....«....................i..................... �.................«.....�.........,...............,................«...................................................;...,...................................................................... RESIDENCE INFORMATION.
N0.OF '
YEAR BUILT BEDROOMS X COMPUTATION= { _ '1 TOTAL DAILY FLOW GARBAGE GRIN ER
«µ1980 or older
„« j X 150 gallon per bedroom f =. .« , . . « . INSTALLED? f _
».. ... .. ;
1981 -1991 X 130 gallon per bedroom I SPA OR HOT TUB/
,
1992 present ; X 110 gallon per bedroom E = 1 # INSTALLED?
««...««..«.........._...«...........,%...................................................................................................................I.............,s...........E..................................................................
........
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 PER MIINUTE 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 architect(unless installed in a Planning Board approved subdivision).Add 250
gallons to the size of the septic tank and leach field for each garbage grinder, spa or whirlpool tub.
✓ PT IC TANK: s GALLON (MIN. SIZE IS 1,000 GAL.) TILE FIELD: EACH TRENCH FT.
✓ TOTAL SYSTEM LENGTH: FT. SEEPAGE PIT(S): HOW MANY? 1
✓ SIZE OF EACH __FT. X /t-) FT.
✓ SIZE OF ST NE TO BEUSED: # /DEPTH OR THICKNESS �FT.
✓ BED SYSTEM SIZE: X
✓ ALTERNATIVE SYSTEM: LENGTH AND/OR SIZE
✓ HOLDING TANK SYSTEM:(If required) NO. OF TANKS: /SIZE OF EACH
✓ GALLONS.!TOTAL CAPACITY: GAL.
�....N......................................:.:...............:.................,.:....«.:.,...................,.,«.....,.......,.;.............,.. «..,.:.,.,.:.:.,.,...,...:.:.,...,,..............,.,.,.,.,.,.,.....................:.:.:.:.....,...................P...............«.............................................
1
NOTE: ALARM SYSTEM AND ASSOCIATED ELECTRICAL WORK MUST BE INSPECTED BY A TOWN
APPROVED ELECTRICAL INSPECTION AGENCY. PLEASE REVIEW LIST PROVIDED.
i..........................................:.,.,,,, ,....,.:.:.:.....:.................:.....................:.:.:.:.........:.,.........,.......,.,.,.:.:.:.:.,.:.:.:.:.,.„,.:.:.,.:.,.,.:.:.,.;.,...:.,.,.,.:.,,,.,,:.,.,.,.,.,.,., «.,.,.,.,.:.,.:.,.:.,.:. :.„,,.:.....:,:..... ...........:...............................
,.,.,.,
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
fallure to make a material fact or circumstance known by.or on behalf of an applicant, shall be void.
1 have read the regulations with respect to this application and QUESTIONS? CALL 761-8256 OR EMAIL
agree to abide by these and all requirements of the Town of codes 0aueensburv.net
Queensbury Sanitary Sewage Disposal Ordinance.
VISIT OUR WEBSITE FOR MORE INFORMATION
v_4rww:aueensburv.not
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Signature o .P r on Responsible Date
Town of Queensbury • Community Development Office • 742 Bay Road, Queensbury,NY 12804
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evidence of
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NFices, etc.,
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DATE
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Septic Inspection Report
Office No. (518) 761-8256 Date Inspection r t r eive .
Queensbury Building &Code Enforcement Arrive: a part: '
742 Bay Rd., Queensbury, NY 12804 Inspector's Initia
NAME: cTAC �j ai� ERMIT NO.: — _
LOCATION: Z Z Y�O'�Fc r _ INSPECT ON: — —
RECHECK:
Comments and/or diagram
Soil T m / Cla
Type of Water• unicl Well Water
Wat 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: 91 x
Stone Size:
--o,-
Piping Size T e
Building to tank ,
Tank to ' W
DieWbutmo Pit
),-
Opening Sea Y
End Ca Y N
Inlet/Outlet Pipes&Baffles Y N
Location Separations 1 h ��
Foundation to tank ft.
Foundation to absorption > t> L_ At 1�5
Separation of Pits ft.
Conforms as per Plot Plan VY N
Engineer Report and As-Built Y N
Location of System on Property:
Fron Rear Le Right Side Middle Front Middle Rear
t m 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