2009-229 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development- Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20090229 Application Number. A20090229
Tax Map No: 523400-302-014-0002-012-000-0000
Permission is hereby granted to: MARY BRACKEN
For property located at: 15 DIXON Ct
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: MARY BRACKEN
15 DIXON Ct Septic Alteration Residential
QUEENSBURY, NY 12804-0000 Total value
Contractor or Builder's Name/Address Electrical Inspection Agency
QUEENSBURY SEWER
JAY SWEET
Plans &Specifications
2009-229
SEPTIC ALTERATION RESIDENTIAL
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Friday,June 04,2010
(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.)
J
Dated at the T CWntee ryt`' -,°�'>y'h�,June 04,2009
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
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. P20090229 Date Issued: Thursday, August 26, 2010
This is to certify that work requested to be done as shown by Permit Number P20090229
has been completed.
Tax Map Number. 523400-302-014-0002-012-000-0000
Location: 15 DIXON Ct
Owner. MARY BRACKEN
Applicant: MARY BRACKEN
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, z Jw
Variance, or other issues and conditions as a result of approvals by the Director of Building&Co(Ye Enfo ement
Planning Board or Zoning Board of Appeals.
------------------- --- --_ - ,
3o7 ./4-2—/ OFFICE USE ONLY
TAX MAP NO. PERMIT NO.O�2nPERMIT FEE JU ()
APPROVALS: ZONING TOWN CLERK %
%T WN OF UEENSBURY_-
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APPLICATION FOR SEPTIC DISPOSAL SYSTEM PERMIT:
A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS.APPLICATION IS SUBJECT TO REVIEW BEFORE ISSUANCE OF A VALID
PERMIT. G hh
OWNER: ". / 44 INSTALLER: (�` E'e C-iLs,
r
ADDRESS: ADDRESS:�( _ Axe n' �l
PHONE NOS. -7 1 PHONE NOS. 3
LOCATION OF INSTALLATION: ��� 1 yo tL C I
RESIDENCE INFORMATION:
YEAR BUILT NO.OF X COMPUTATION= = TOTAL DAILY FLOW
BEDROOMS 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: 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 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 2 6-v ft. Each trench ��~ X 611
❑ 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.
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection req r
Queensbury Building &Code Enforcement Arrive: t)-2cR--> D rt: fprr
742 Bay Rd., Queensbury, NY 12804 Inspector's Initia
NAME: P MIT NO.: - 7 7 C
LOCATION: 0 (',T I SPECT ON:
RECHECK:
Comments and/or diagram
Soil Type: Sand Loam/ Clay
Type of Water: Municipal Well Water
Waterline separation 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 ou MOE ft.
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: N
End Ca N
Inlet/Outlet Pipes &Baffles 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 Fr Middle Rear
System Use
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
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