98-711 CERTIFICATE Oj ' COMPLIANCE
TOWN 0F= QUEENSBURY
WARREN C0UN1'Y, NEW YORK
IF
Elate Novembe2r 12 19 98
98711
to certify that work requested to be done as shown by Permit No .
completed . µ
SE-PTIC ALTERATION
. This structure may be used as a
Location 44 LUZERNE RD .
Owner DEAN , LARRY & DEBORAH
TAX MAP Nov 1300 - 1 - 5 By Order of Town Board
TOWN OF
OF Q E BURY
Director of Building & Code Enforcement
_ _ __ Lii1i1�"' THY f ■'IIY `II{f fY1MY1i3111iY1 iiYi1
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Application for SEPTIC DISPOS E PERMIT
Town of Queeasbury
Dept of Community Development EPerTm't . � /Building & Codes Office742 Bay Road $ b�
Queensbury. NY izsoa f, /
Location of property for installation: A*Z T l.` y 7z
Property Owner's Name: t , * . _
Property Owner's Mailing Address: 7S Cr
Installer's Name: 'L-k Q -' t3--.5 t.,r r 1 A- •.- Phone # 07f- _�g
Number of bedrooms (if residential): -�' Total daily flow:
(residential - compute 0 150 gal./bdrrn.)
Topography: flat, rolling: steep slope % of slope
Soil Nature: _ sand, loam, clay, other / depth:
Ground water: at what depth? feet / Bedrock or Impervious Material.: at what depth? . feet
Percolation test: not required, required f rate min. per inch ]
Domestic water supply: - Y municipal, well, other
If domestic water supply is a WELL, water supply from any septic absorption is feet.
PROPOSED SYSTEM
Septic tank,/_ d gallon (rnir�imum Size: LOW .)
Tile field: each trench 5 v feet 1 Total system length: � � �r feet
Seepage pit(s): number of I size each.: ft. by ft.
Size of stone to be used: # 7- I depth or thickness dF ` / �' r feet
\ 4
HOLDING TANK. SYSTEM: fif required)
Number of tanks: Size of eachw gallons
Alarra eystgm and associated electrical work to be baspec+ed by a certified agency.
For your protection, please note that pursuant to Section. 136-29 of the Coda of the Town of Queensbury, any permit or
approval granted which is based upon or is granted in reliance upon any material misrepresenudion or fulura to rusks a
materW fact or circuzastance known by or on behalf of an applicswtt, 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
Queansbury Sanitary Sewage D
' J y'
Signature of responsible person:
TOM OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804
(518) 761-8256
SEPTIC DISPOSAL 'SYSTEM I"SPECTION
Name
Location
Date 11 , Z--� Permi t
SOIL TYPE an__ am-Clay_
Results of Percp l ati on Test-
( if applicable ) Rate-Minutefl
TYPE OF SYSTEM=
ABSORPTION FIELD : Total L gth
Length of each tre h +
Depth of trenches
Size of stone
SEEPAGE PITS : er-
Size - t . x f t .
Stone size Size �yPe
PIPING:
Bldg . to nk
L
Tank to isto Box .*
Dist . Box to Field/Pit artia
Openings Sealed? Yes o
LOCATJOK/SEPA'RATIONS : feet
Foundation to Tank — '-- feet
Foundation to Absorption ^ram___
feet
Separation of Pits Yes No
Conforms as per Plot Plan
LOCATION OF SYSTEM ON PROPERTY:
( circle one )
Front - Rear - Left Side - Right Side
Middle Front
SYSTEM USE APPROVED : C -NO
Arrived:
Depa
U 01 di n pect r
"I have seen or observed, w believe # saw wMe nce of.
ail objects such as houses, wells, trees. fencees. etc.
shown on this document. I also represent that I have
per nally measured4e dista es set forth on the diagram."
SIGNATURE DATE
sow
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