2002-251 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804.5902 (518)761-8201
Community Development-Building&Codes (518)761-8256
CER"I'IFICATE OF COMPLIANCE
Permit Number: P20020251 Date Issued: Wednesday,May 01,2002
This is to certify that work requested to be done as shown by Permit Number P20020251
has been completed.
Tax Map Number: 523400.289-011.0002-030-000.0000
Location: 69 COUNTRY COLONY Rd
Owner: LANCE&KAREN BRISTOL
Applicant: LANCE&KAREN BRISTOL
This structure may be occupied as a:
By Otder of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
Ditector of Buildi &Co 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: P20020251 Application Number: A20020251
Tax Map No: 523400-289-011-0002-030-000-0000
Permission is hereby granted to: LANCE&KAREN BRISTOL
For property located at: .69. COUNTRY COLONY Rd
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 m— compliance with the NYS Uniform Building Codes and the Queensbury Zoning
Ordinance. Type of Construction Value
Owner Address: LANCE k KAREN BRISTOL
Septic Alteration Residential
69 COUNTRY COLONY Rd
Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name Address Electrical Inspection Agency
SANITARY SEWER
DAN DRELLOS
PO BOX-224
GLENS FALLS NY
Plans &Specifications
2002-251
SEPTIC ALTERATION AS PER APPLICATION
$25.00 PERMIT FEE'PAID- THIS PERMIT EXPIRES- Tuesday,April 15,2003
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the Tovm of Queeppbury; Wnay,April 15,2002
_
SIGNED BY for the Town of Queensbury.
Director of Buildiny&�!AC'Ile Enforcement
-516 745 4437.
FILE No.638 04.,02 '02 AM,, i 1 25 j I D:TOWN- OF QUEENSQURY FAX,:518 745 4437, PAGE 1
Applicatiozx.for`Permit—Septio"Disposat system
Town of,Queensbury 742.Bay Road Queansbury,NY I?8o4.(378) 767-8?56, `
i. OWNER INFORMATION:, .__ Use
L,ocatiais'ofizrstallstioa' T -
v4c. G
File.Patxnit
Na.
Tax Map No, Fee Paid �a
Owner's Name: L 4AJ _ rsra L- __...................................
Address / tom✓ '. C a tZjG`ilC
PHONEI+tO. 7l- ,
> 9y.rJ]' r 7d'v,I' 72. INSTALLER'S NAME
3. Rg$IbENCE INFORMATION:=.(circle year-of dwelling,indicate#bedrooMA) and multiply# of
bedrooms with applicable gallons per bedroom to equal total dailyflow)
1980Ralaw
or older , x 150 gallbdrm
1980—�1991 x 130 gallbdrm
1991—present ._ x 110 gal/bdrm pi ` .
Garbage Grinder Installed yes / no `TG1WN O�Qus,6_ S3$J6�`�l
Spa or Whirlpool Installed yea ,; / no BgCa AND E
4. PARCEL INFORMATION:.;'Ccirole applicable information.&indicate measurements)., .
at and at what depth at what depth- al -
o ing loam ,feet feet all
Stee sloe ell;water. supply
P. p ,f>ern any septic-system
;rb slope other
depth: absorption is
other
Percolation Test (To be completed by licensed professional engineer or arphitect)
Raie: minute.per inch
3. PROPOSED SYSTEM; war' =Co131 lion: All individual sewage disposal systems must be designed by a licensed
pro*ssional cnalneei or arebicoct(unless installed fn a PlannWg Board approved subdivision). Add 250 'gallons to the size
of the septic tank and leach field for each Garbage Chinder,Spa or Whirlpool Tub.
ErS ,.16
Septic'Tank: �_O '-.=gallon.(min. size 1,000 gala
"Tile 7ield: each trench` .1i Total System Length; fr
Seepage Pit(s): - numberof N l' rise of each: -f1: by }t
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: gallon:
Note: Alarm System and associated electrical work must be inspected by a Town approved
! electrical inspection agency..•
7. SIGNATURE & FORMATION FOR RESPONSIBLE PERSON.(please read)
IN
For your proteotiot;please note that pursusnt to Section 136-29 ofthe Code ofthe Town
of Queenaburyi;any permit or approval granted-which is based'upon or is granted in,
reliance upon:any material misrepresentation or failure to make a material fhct 0z
oircurrsst erica knovm by or on behalf of an applicant; shall be,void.
I have read regulations with.rexpectto this"application and agree to abide bythese and all
re e_Town of Que ry Sanitary Sewage Disposal.Ordinan
pepersoniti suture of res�pons<tbi•
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C, PR 0 2002
TOWS!or QUEENsaURY �
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1 irojp seen or observed, or believe i saw evidence of,
;ts : such as houses, wells,trees, fences, etc.,
i : n document. I also epresent that I have
i3 :soI a I I y ured th s ces set forth on the iagram' .,
SIGNATURE DATE