1122 BUILDING PERMIT
TOWN OF QUEENSBURY
No. 001122
(� ` ( WARREN COUNTY, NEW YORK cn
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PERMISSION is hereby gra ted to h rles Stewart w
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OWNER of property to a Dixon Road Street,Road or Ave.
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in the Town of Queensbury,To Construct or place a Sewer System PI
at the above location in accordance to application together with plot plans and other information hereto filed and 1-1
approved and in compliance with the Town of Queensbury Building and Zoning Ordinance. m
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1. OWNE R'S Address is
77 Dixion Road
Glens Falls, New York
2. CONTRACTOR or BUILDER'S Name
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3. CONTRACTOR or BUILDER'S Address
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4. ARCHITECT'S Name
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5. ARCHITECT'S Address v
6. TYPE of Construction— (Please indicate by X)
( )Wood Frame ( ) Masonry ( 1 Steel ( )
7. PLANS and Specifications
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8. Proposed Use
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Sewer System /,/f46,,,,,F.,.jee.v hi
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$ 5 .00 PERMIT FEE PAID —THIS PERMIT EXPIRES 5-13- 19 71
(If a longer period is required an application for an extension must be made to the Building and Zoning inspector of the
town of Queensbury before the expiration date.)
Dated at the Town of Queensbury this 16 ay of April 19 71
SIGNED BY for the Town of Queensbury
, Building and Zo ng Inspector
SEWAGE DISPOSAL APPLICATION
APPLICATION FOR A PERMIT TO CONSTRUCT, ALTER OR ENLARGE A
SEWAGE DISPOSAL SYSTEM FOR A PRIVATE RESIDENCE WITHIN THE
§ TOWN OF QUEENSBURY
1. Name a mailing address of applicant:
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2. Specific location- of property: _ --
3. Application is for:
New construction of private dwelling.
Alteration or enlargement of existing sewage disposal system.
4. Description of building:
a. number of bedrooms
b. garbage grinder
(yes or no)
5. Property line dimensions, or total area of property:
6. . Topography:
(flat, rolling, steep slope, gentle slope, etc.
7. a. Nature of soil. (Describe to a depth of 5 feet if tile
field is to be used or 10 feet if leaching pits are
proposed, zj.ving thickness of various strata such as
top soil, clay, loam, nand, gravel, rock„ etc. )
b. How determined?
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8. a. Soil percolation test made by
(Refer to Part III, Bulletin 1, N. Y. S. Department of Health)
b. Percolation test notes submitted?
(yes or no)
9. Proposed sewage disposal system indicated on attached plan or
sketch? -
yes or no)
10. Date when construction will commence
It is hereby agreed that if this application and attached plans
dated or any amendment or revision thereof,
are approved, installation of sewage disposal facilities will be
made in accordance with the details thereof as shown on such
approved plans.
_0_ N OF QUEENSBURY
Dat: E fn� p 7isyie of applicant
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