2001-737 TOWN OF QUEENSBURY
Road,Queensbury,
��� 742 Bay Ro ,Q e sbury,NY 12804-5902 (518) 761-8201
)
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20010737 Date Issued: Wednesday, October 03, 2001
This is to certify that work requested to be done as shown by Permit Number P20010737
has been completed.
Tax Map Number: 523400-302-014-0003-073-000-0000
Location: 65 DIXON Rd
Owner: JOYCE LONG
Applicant: JOYCE LONG
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
(-DJ 4 4/411----
11
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: P20010737 Application Number: A20010737
Tax Map No: 523400-302-014-0003-073-000-0000
Permission is hereby granted to: JOYCE LONG
For property located at: 65 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 in compliance with the NYS Uniform Building Codes and the Queensbury Zoning
Ordinance. Type of Construction Value
Owner Address: JOYCE LONG Septic Alteration Residential
65 DIXON Rd Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name/ Address Electrical Inspection Agency
OUEENSBURY SEWER
JAY SWEET
Plans &Specifications
2001-737
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID - THIS PERMIT EXPIRES: Wednesday, October 02,2002
(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 Qu ensbury; Tuesday, October 02,2001
SIGNED B for the Town of Queensbury.
Director of Buil g& de Enforcement
•
Application for Permit—Septic Disposal System
Town of Qtteensbtny 742 Bay Road Queensbzny, NY 12804 (518) 761-8256
1. OWNER INFORMATION:
i Office Use
Location of installation:�6R• 1/ Y,() ✓ .)
• File Permit No t— 7`3 7
Tax Map No. / /
Owner's Name: Fee Paid
Address: lro t y. el zx.
•
2. INSTALLER'S NAME ,t P <k - PHONE NO. f 6. 4
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 o + ,t:Tf x 150 gal/bdrm =
t — 1991 x 130 gal/bdrm 8 QED
•
1991 —present x 110 gal/bdrm = u
• OCT 0 1 2001
Garbage Grinder Installed yes
Spa or Whirlpool Installed yes_ /
cy
P��1t tij i�;,.�,IG�� t;rOD�
4. PARCEL INFORMATION: (circle applicable information &indicate measurements)
To o>ra by Soil Nature Ground Water Bedrock or Impervious Material Dom stic Water Supply
iF.. • at what depth at what depth munict xc
?oiling loam feet feet - well
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: minute per inch •
•
5. PROPOSED SYSTEM: For New Constnnetion: 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: l,a a gallon (min. size 1,000 gal)
Tile Field: each trench ft. Total System Length: ft.
Seepage Pit(s): number of size of each: .ft. by
Size of Stone to be used: # / depth or thickness feet
Bed System Size: x
Alternative System: 7�`j e �c� length and/or size l v — ,2U
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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.
ign ur of responsible person Date
q
�9)
1 ✓ ed/11
TOWN OF QUEENSBURY
. BUILDING & C_ODE ENFORCEMENT6?
742 Bay Road
Queensbury NY 12804
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name /-�5., o 9..161K
Location (;P�).e4/" l 14. rs �; • i�4
Date A) 3 ,,t, P rmi t # Q/ ' 7 3 7
SOIL TYPE: San. Loam-Clay-
Results of 'ercolation Test-
(if applicable) Rate-Mi a/Inch
TYPE OF SYSTEM:
ABSORPTION FIELD: Total •th _
Length of each trench /
Depth of trenche /
Size of stone -' -J&,' ,`i
SEEPAGE PITS: Number-
Size - ft. x ft.
Stone size
PIPING: __ _— ' .ze Type
Bldg. to Tank 4=-e .Titi
Tank to Dist. Box n x)/e 55
Dist. Box to Field/' ' �, II
Openings Sealed? No . .Parta
LOCATION/SEPARATIO', .
Foundation to Tank feet
Foundation to Absorption •e.et .
Separation of Pits �'f et
Conforms as per Plot Plan Yes No
LOCATION OF SYSTEM ON PROPER :
(circle • -
Front - ' Left Side - Right Side
Middle F - Middle Rear
COMMENTS:
SYSTEM.USE APPROVED: YES NO
Arrived:
Departed: *, o )'re -
.
Building Inspector
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REVIEWED 7 .
DATE . .. ,:....i"41....: .., • ' 4:',,, •• . .
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: "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! have
u•rs-on• - measured the distan • set forth on tJdiagram."
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