2005-675 TOWN OF QUEENSBURY
742 Bay Road,Queensburp,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20050675 Date Issued: Wednesday, August 24, 2005
This is to certify that work requested to be done as shown by Permit Number P20050675
has been completed.
Tax Map Number: 523400-302-014-0002-081-000-0000
Location: 91 DIXON Rd
Owner: IRENE M ZABRISKIE
Applicant: IRENE M ZABRISKIE
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 r
P
property owner of the responsibility for compliance with Site Plan,
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.
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20050675 Application Number: A20050675
Tax Map No: 523400-302-014-0002-081-000-0000
Permission is hereby granted to: IRENF,M ZABRISKIE
For property located at: 91 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. Tyne of Construction Value
Owner Address: IRENE M ZABRISKIE
91 DIXON Rd Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
SANITARY SEWER
DAN DRELLOS
PO BOX 224
GLENS FALLS NY
Plans&Specifications
2005-675
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday, August 23, 2006
(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 To of Quee bu T sday, August 23, 2005
SIGNED BY for the Town of Queensbury.
I Director of Buildin &Co Enforcement
Application for Permit— Septic Disposal S stem
Town of Queensbury 742 Bay Road Queensbury, NY 12804 (518) 761-8256
1. OWNER INFORMATION:
Office Use
Location of installation:
File Permit No. �15
Tax Map No.
Fee Paid
Owner's Name: e1ye. re, ~
Address: 77) ,a
2. INSTALLER'S NAME PHONE NO. 79 7.0S-2
3. RESIDENCE INFORMATION: (circle ye 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
1980 or older 2 x 150 gal/bdrm = l�J
1980- 1991 x 130 gal/bdrm =
1991 -present x 110 gal/bdrm =
Garbage Grinder Installed yes— / no
Spa or Hot Tub Installed yes_ / no ✓-
AU(C (I( r
4. PARCEL INFORMATION: (circle applicable information& indicate measurements)
Tovoarai)hv Soil Nature Ground Water Bedrock or Impervious Material Domestic Water Su i
a and at what depth at what depth munici a
rolling feet feet we
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 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 to the size
of the septic tank and leach field for each Garbage Grinder, Spa or Whirlpool Tub.
Septic Tank:' gallon (min, size 1,000 gal.)
Tile Field: each trench aJ " ft. Total System Length: ft.
Seepage Pit(s): number of A size of each: ft. by ft.
Size of Stone to be used: # / depth or thickness feet
Bed System Size: 1° x
Alternative System: length and/or size
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: / Size of each: gallons /TOTAL Capacity: gallons
t
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 o nsbury Sanitary Sewage Disposal Ordinance.
Ph,6_t 4kA�_
i nature of_re poKible person Date
Town of Queensbury
Sewers and Sewage Disposal Chapter
Appendix C
ABSORPTION FIELD
SEPARATION REQUIREMENTS
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Appendix C
ABSORPTION FIELD
SEPARATION REQUIREMENTS
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Septic Inspection Report
Office No.(518) 761-8256 Date Inspection r quest ec ve
Queensbury Building&Code Enforcement Arrive: es
epart: ,\ -�am/pm
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initi
NAME: _ 7 `, i P IT NO.:
LOCATION: SPECT ON: -
RECHECK:
Comments and/or diagram
Soil T Sand oam/Clay
Type of Water: nicipal Well Water
Waterline se aration istance ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length
Length of each trench ft.
Depth of trenches ft.
Size of Stone L ij
Se age Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank ' 1�12 ,J)C_), "Az� U
Tank to Distribution Box
Distribution Box field/Pit
Opening Seale Y/ Partial
End Caps
Location/Separations
Foundation to tank
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Engineer Report and As-Built Y N
Location of System on Property:
Front Rear Left Side Right Side
VSt
Middle Rear
System pproved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
Last revised 1/6/05
5
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