2001-177 TOWN OF QUEENSBURY
BayRoad, en b NY 12804-5902 (518) 761-8201
��� 742 Que s ury,
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20010177 Date Issued: Tuesday, May 08, 2001
This is to certify that work requested to be done as shown by Permit Number. P20010177
has been completed.
Tax Map Number: 523400-301-012-0002-051-000-0000
Location: 14 HEINRICK Cir
Owner: ROBERT &DAWN KEENAN
Applicant: ROBERT &DAWN KEENAN
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN 0,F QUEENSBURY
c/1a2 A
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
BUILDING PERMIT
Permit Number: P20010177 Application Number: A20010177
Tax Map No: 523400-090-000-0004-125-000-0000
Permission is hereby granted to: ROBERT&DAWN KEENAN
For property located at: 14 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: ROBERT&DAWN KEENAN Septic Alteration Residential
14 HEINRICK Cir TotalValue
QUEENSBURY,NY 12804
Contractor or Builder's Name/ Address Electrical Inspection Agency
CONDONS SEPTIC &DRAIN SERVICE
Plans &Specifications
2001-177
SEPTIC ALTERATION AS PER APPLICATION
$25.00 PERMIT FEE PAID - THIS PERMIT EXPIRES: Sunday,April 20,2003
(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 Queensbury; Friday,April 20,2001
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
` Application for Permit—Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury, NY 12804 (518) 761-8256
1. OWNER INFORMATION:
p //�,`�,/C I C(,q /� Office Use
Location of installation:/ )'-J j C f ��f
File Permit No /
Tax Map No.
' :Po gfkf 11 �� ���
Owner s Name• � C/.+� F�/l/ • -�-� '��- ! �
Address:/1f //e/'/tltktc l r Ci, c/€ APR 1 82001
CoOAN�t: -e
27d F I
G1fl/c/ j s ���G% /!
2. INSTALLER'S NAME ��jC?i��ONE NO.
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate#bedroom(s) and multiply# of
bedrooms with applicable gallons per bedroom to equal total daily flow)
Year of House: No. of Bedrooms x Computation = Total Daily Flow
•80 or old: x 150 gal/bdrm = /) 6
1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm =
Garbage Grinder Installed yes / no X'
Spa or Whirlpool Installed yes / no
4. PARCEL INFORMATION: (circle applicable information &indicate measurements)
To o r it Na ure Gr and Water' Bedrock or Im ervious Material Dom stic Water Supply
,lat and at what depth at whgt depth inunici al
Rolling oam feet /V feet we 1
Steep slope clay if well; water supply
%slope other from any septic-system
depth: absorption is ft.
other
Percolation Test: (To be completed by licensed professional engineer or architect)
Rate: 0 minute per inch
5. 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 f each Garbage Grinder, Spa or Whirlpool Tub.
ONC��F i=
Septic Tank: Fp g1/17allon (min. size 1,000 gal) d
Tile Field: each trench t ft. Total System Length: O ft. j��r��"`jJ 714�
Seepage Pit(s): number of size of each: ft. by ft.
Size of Stone to be used: # / depth or thickness feet
Bed System Size: x
Alternative System: length and/or size
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: / Size of each: gallons /TOTAL Capacity: gallons
Note: Alarm System and associated electrical work must be inspected by a Town approved
electrical inspection agency.
7. SIGNATURE &INFORMATION FOR RESPONSIBLE PERSON(please read)
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 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 Queensbury Sanitary Sewage Disposal Ordinance.
/
Signature of responsible person ( Date
iliwt:.
NOMTOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name 1(eer\a,Y\ cl),AQs2/1„.._
Locatiod N A( o:
Date c— K- p )Permit # ` 77
SOIL TYPE• and oam-Clay-
Results of Percolation Test-
(if applicable) Rate-Minute/Inch
TYPE OF SYSTL�: ,
ABSORPTION 'iE k: Total Length
Length of e.ch ench )-1 -J --_
Depth of tre• che• -2_ i-r,
Size of ston: t 0 .A ZD(a
SEEPAGE PITS: Nu ber-
Size - ft. x ft.
Stone size
PIPING: Size Type
Bldg. to Tank % • % --
Tank to Dist. Box **
Dist. Box to Fiel • Pit 0 ,c, 1-0 OFaiwn
Openings Sealed? Yes o Partial
LOCATION/SEPAR, ON :
Foundation to Tank Kfeet
Foundation to Absorption . -7 D feet
Separation of Pits __ et
Conforms as per Plot "Ian Yes o
LOCATICM OF SYSTEM ON PROPER
(circle one)
Fr - Left Side - ` 4 4.,' '
fiddle Front Middle Rear
•
SYSTEM USE APPROVED: 40 NO
Arrived: 'f
Depart •
it ing n e t r
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TOWN OF OUEENSBURY
BU!LDING AND COnF:.
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"I have seen or observed,or believe I saw evidence of, ,... t -I- 6
,all obiects such as houses,,wells,trees,fences, etc., . lo A5 1 1
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Ishown on this document. I also represent that I have . 0 ,
ii personally measured the distances set forth on the diadam.' ito :(5
SIGNATURE DATE P.:- IS) ;72, ,,,M
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