2001-116 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: P20010116 Date Issued: Wednesday, March 22, 2006
This is to certify that work requested to be done as shown by Permit Number P20010116 =
has been completed.
Tax Map Number: 523400-295-014-0001-067-000-0000
Location: 22 WHIPPOORWILL Rd
Owner: JAMES &DONT DICKINSON
Applicant: JULI FISHER
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, x
Variance, or other issues and conditions as a result of approvals by the + '
Director of Building&Code Enforcement
Planning Board or Zoning Board of Appeals.
1 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
top es
Community Development- Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20010116 Application Number: A20010116
Tax Map No: 523400-082-000-0005-023-006-0000
Permission is hereby granted to: JULIE FISHER
For property located at: 22 WHIPPOORWILL 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 in compliance with the NYS Uniform Building Codes and the Queensbury Zoning
Ordinance. Type of Construction Value
Owner Address: JULIE FISHER Septic Alteration Residential
22 WHIPPORWILL Rd Total Value
QUEENSBURY,NY 12804-1017
Contractor or Builder's Name/ Address Electrical Inspection Agency
I.B.S. SEPTIC
2 LOWER WARREN STREET
OUEENSBURY,NY
Plans &Specifications.
2001-116
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID - THIS PERMIT EXPIRES: Friday,March 21,2003
(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 o ueensb ; Wedn sday,March 21,2001
SIGNED BY a„ 4 / for the Town of Queensbury.
Director of Building& de E•orcement
•
Application for Permit-Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 128.04 (518) 761-8256
1. OWNER INFORMATION:
Location of installation: e) ) r.�.�i�' d'r- c , C � Orrice Use
(,,
Tax Map No, / / File Permit No
O '_ g
Owner's Name: At^rtt A. ,I G (-( C r .Tc-(•e-'C(r fee Paid
• Address: 719o) t;- 4.'l`("er CA--1 CC
2, •'INSTALLER'S NAME : T, L. .c S� 1,"G PHONE NO. r 2i' - �/
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate #bedroom(s) and multiply II of
bedrooms with applicable gallons per bedroom to equal total daily flow)
Year of House: No. of Bedrooms x Computation = Total Daily Flow
•
• 1980 or older , . 3 • . . x ISO gAVbdrm = l s 0 ,
• 1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm =
Garbage Grinder Installed yes / no . —v MAR 2 d 200�
•
Spa or Whirlpool Installed • yes / no-. r
13t111-DING,gND
ED ED.
'' 4. PARCEL INFORMATION: (circle applicable information &indicate measurements) e _ 0
TOWN OF QUEENSSURY
_
Mute .Q.t<vuuct Water_._D.0r.ock.or_Imporxious_ 1çriJDomestic Wator.StIpply
tat sand al whcN /ep11r ir! !w v crplh nur,r c l/,crl)
I a Ing clam fee! �/l// f�'e! well
•
Sleep slope clay if well; water supply'
%slope other from any septic-system
depth: - absorption is • ft.
Other .
-Percolation Test: (To be completed by licensed pro fessional engineer or architect)
• . Rate: minute per inch
S. 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 Io the size
of the septic tank and leach field for each Garbage Grinder, Spa or.Whirlpool Tub.
Septic Tank: ("p 1606 gallon (min. size 1,000 gal) G ri S y
J
Tile Field::each trench ft.. • Total System Length: ft.
Seepage Pit(s): number of4._ size of each: r .fl. by V f?.
Size of Stone to be used: N 3 / depth or thickness. _ /r__ftet
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'ofthe 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.cr
e____
— 3 0 �o , •
Ignature of respo s ble person Date
TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name \ S
Location cgOtO )\ WON) \ \
I �
Date Permit #000 i '-/i( P
SOIL TYPE: San oam-Clay-
Results of Percolation Test-
(if applicable) Rate-Minute/Inch
TYPE OF SYSTEM:
ABSORPTION FIELD: Total Length
Length of each trench
Depth of trenches
Size of stone
SEEPAGE P 'S: Number-
Size - r x f ft.
Stone size _
PIPING: Size TAyP e
Bldg. to Tank
Tank to Dist. Box SQ/Z ;,•5
Dist. Box to Field/P' • d
Openings Sealed? Yes No Partia
LOCATION/SEPARATION •
Foundation to Tank . feet
Foundation to Absorption . eet
Separation of Pits f et
Conforms as per Plot Plan Yes No
ON OF SYSTEM ON PROPER •
(circl'- one)
Front - Rear - Left Side - Right Side
• e Front - Middle Rear
COMMENTS:
•
SYSTEM USE APPROVED: I NO
Arrived: -
Departed: AN
Jrc
Building Inspector
TOWN OF QUEE E3URY
BUILDING - ,, D.:yL
REVIEWED BY . ." :..:!eo.,:_, . / di
DATE
"I have seen or observed,or believe I saw evidence of,
all objects such as houses, wells,trees, fences, etc.,
shown on this document. I also represent that I have
personally asured th distances set forth on the diagram."
SIGNATURE DATE
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