8622 •
BUILDING PERMIT
TOWN OF QUEENSBURY • No. 8622
WARREN COUNTY, NEWYORK
PERMISSION is hereby granted to John Polk
OWNER of property located at Assembly Point Road Street, Road or Ave.
ro
Sewage Alteration x
g in the Town of Queensbury,To Construct or place a
at the above location in accordance to application together with plot plans and other information hereto filed and
approved and in compliance with the Town of Queensbury Building and Zoning Ordinance.
1. OWNER'S Address is 12 Carrie Court
Schenectady, New York
•
2. CONTRACTOR or BUILDER'S Name
Percy Denton ui
3. CONTRACTOR or BUILDER'S Address
Star Route kc
Glens Falls, New York 'b
4. ARCHITECT'S Name
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5. ARCHITECT'S Address
•
6. TYPE of Construction— (Please indicate by X)
( ) Wood Frame ( ) Masonry ( )Steel ( )
7. PLANS and Specifications CA
ID
No.
ID
8. Proposed Use
Sewage system for dwelling
P.)
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$ 10. 00 PERMIT FEE PAID —THIS PERMIT EXPIRES July 9 19 86
(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 9th Day of July 19 84
SIGNED BY —74q ^"— 'L for the Town of Queensbury
Building and Zoning Inspector �<?
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TOWN OF QUEENSBURY
> TOWN OF QUBENSBURY
- S / BUILDING & ZONING DEPARTMENT
SEWAGE .DISPOSAL PERN!IT APPLICATIONREGINVE
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1. Owner ' s Name .J) /10 / fri e
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Address a �i� / G -� ���/�`�Y/ C�.1' 3✓�0 � i:aa �
Telephone No.
2. Property location 453 / 0 / I R r4 a-4 /717
see
3 . Name of person or firm responsible for installing system \ r�—^-
• Telephone No. 4 j 6 7 n 7
Address /. G /�Il�-�� � i / /� so
4. Number of bedrooms (residential buildings only) c9 G 1- c)
5. Daily flow gallons/day
6. Septic tank capacity - . / /� 00, ;et
. gallons
7. Topography: flat, rolling, steep
% of slope •
8. Nature of soil and depth •
9. If ground water, bedrock or impervious material is apparent at what
depth does it begin? ft.
10. Percolation test: A is required
B is not required
C If required• what is the rate minutes/inch
11. Water supply:- municipal, well, other gAv4__
12. Type of system proposed: drywell, tile field, other
Any contractor,. corporation, individual, etc. engaged in• the /construction
of a sanitary sewage disposal system who covers the same before inspection,
does not have an approved permit, or varies from the approved application
will be subject to a penalty. of $250 as provided for in Section 6 .010 of the
Queensbury Sanitary Sewage Ordinance.
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Date //�i q ,q2,71,(>,3
t jsighature of applicant
On separate sheet of paper submit a' diagram of the proposed septic system
with all dimensions, including distance. from any structure, distance from
property line and domestic water supply, etc. Include all dimensions of
the system itself.
Form 3-82 '
S CPT d C— F2 /4) L—/�
Sam
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