2002-238 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: P20010238 Date Issued: Thursday,May.02,2002
This is to certify that work requested to be done as shown by Permit Number P20020238
has been completed;
Tax Map Number: 523400-302-014-0001.034-000.0000
Location:. 118 DIXON Rd
Owner: JOSEPH STANISLOWSKY
Applicant: JOSEPH ST.A.NISLOWSKY
This structure may be occupied as a:
By.Order of Town Board
Septic Alteration Residential TOWN of QUEEivAVRY
Director of Building&Code Enforcement
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TOWN OF QUEENSBUR.Y
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building& Codes (518).761-8256
: BUILDING PERMIT
Permit Number: P20020238 Application Number: A20020238
Tax Map No: 523400-302-014-0001-034-000-0000
Permission is hereby granted to: JOSEPH STANISLOWSKY
For property-located at: 118 DIXON 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 incompliance with the NYS Uniform Building Codes,and the Queensbury Zoning
Ordinance. Type of Construction Value
Owner Address: JOSEPH STANISLOWSKY Septic Alteration Residential
5"SPRINGDALE MANOR Dr Total Value
HAGUE,NY 12836-0000
Contractor or Builder`s Name Address Electrical Inspection Agency
JACOBIE EXCAVATING
NY 12804-0000
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Plans &Specifications
2002-238
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID- THIS PERMIT EXPIRES: Wednesday,April 09,2003-
(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 a e wn o u ns Tuesday,April 09,2002
SIGNED B for the Town of Queensbury.
ur3'•
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:
Office Use
Location of installation:
aa-2 I File Permit NoQ00 IV
Tax Map No.
I tee Paid
Owner,s Name:
..................................
Address: ry
2. INSTALLER'S NAME PHONE NO.
3. RESIDENCE INFORMATION: (circle year of dwelling,indicate 0 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 Flaw
980 or olde 3 x 150 gal/bdrm =
1980-1991 x 130 gaVbdrm
1991—present x 110gal/bdrm
EEO
Garbage Grinder Installed yes no
Spa or Whirlpool Installed yes_ no J\P�R,0 ZOPM2
OF QUEEN RY
4. PARCEL INFORMATION: (circle applicable information&indicate measureme gN DE
To o h Soil Nature Ground Water Bedrock or havervious Material Domestic Water Su
Flat sapat what depth at what depth
oiling
0 oam —feet feet well
Steep slope clay if well;water supply
_V6 slope other from any septic-system
depth: absorption is ft
other
Percolation Test- (To be completed by licensed professional engineer or architect)
Rate: i 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 for each Garbage Grinder,Spa or Whirlpool Tub.
Septic Tank: W> gallon(min. size 1,000 gal.)
Tile Field: each trench (0(/ ft Total System Length: Ai Z— —ft.
Seepage Pit(s): number of size ofeach: ft. by
Size of Stone tobe used: # t depth or thickness feet
Bed System Size: x
Alternative System: length andlor size
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: I 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 13629 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. -
-2
sigrifi-tur-e of responsible person Date
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