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2004-560 TOWN OF QUEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201 Community Development - Building & Codes (518) 761-8256 CERTIFICATE OF COMPLIANCE Permit Number: P20040560 Date Issued: Thursday, August 12, 2004 This is to certify that work requested to be done as shown by Permit Number P20040560 has been completed. Tax Map Number: 523400-295-014-0001-027-001-0000 Location: 11 ELDRIDGE Rd Owner: ROBERT & MILDRED GORDON Applicant: ROBERT & MILDRED GORDON This structure may be occupied as a: By Order of Town Board Septic Alteration Residential TOWN OF QUEENSBURY 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: . P20040560 Application Number: A20040560 Tax Map No: 523400-295-014-0001-027-001-0000 Permission is hereby granted to: RnR-FRT &1VM,DR-FD G0RD0N For property located at: 11 ELDRIDGE 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: ROBERT &MILDRED GORDON 12 LAFAYETTE St Septic Alteration Residential Total Value HUDSON FALLS, NY 12845-0000 Contractor or Builder's Name/Address Electrical Inspection Agency Plans&Specifications A2000-560 SEPTIC ALTERATION $25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Tuesday, July 19, 2005 (If a longer period is required,an application for an extension must be made to the code Enforcement Officer of the Town of Queensbury before the expiration date.) Dated at the T Que_ej ury•s / da July 19, 2004 SIGNED BY N for the Town of Queensbury. Director of Building&Code Enforcement Application for.hermit—Septic Disposal System 'fowl! of Queensbla y 742 Bay Road Queen.b w y, NY 12804 (518) 761-8256 1. OWNER INFORMATION: ........................................................................................................................... , �� �•Ti v rJ Location of installation: Office Use File Porwit No. Tax Map No. / / ���jV��1�Cj0- , Up j� j / l �J Fee raid Owner's Nam©: 1 o Q Address: /—c2 7 2, INSTALLER'S NAME r �� ( ` L PHONE NO.✓Z �l� l 3. RESIDENCE INFORMATION: (circle year of dwelling, indicate #be(hoom(v) and multiply (1 of bedrooms with applicable gallons per bedroom to equal total Bail},J1010 Year of House: No. of Bedrooms x Computation = Total Daily Flow 1980 or older_ x 150 gal/bdrm = �S a 1980— 1991 x 130 gal/bdrm = l _ =1991--present — — - — - - x 1 lU gal/bdrm =- - �E1VED Garbage Grinder Installed yes / no '3V 6 Z004 Spa or%ir$ool Installed yes / no T3 OF QUEENSSURY 4. PARCEL INFORMATION: (circle applicable information & indicate measurements) UILDING AND EY rollitt'gi �pl_l1v S urn_ CrQ�iiid Wgtor Bedrock or Impervious Material __I on _,__ _, atcr 5uhhly and al w laf/epllh a(what d'pfh uu�i�lpc�/ oant 'et eer Steep slope clay if well; water supply slope other from(Illy septic-system depth: absotplion is ft. other Percolation Test: (7 o be Completed by licensed projLssiorral engineer or architect) Rate: minute pet,inch 5, PROPOSED SYSTEM: For New Construelion: All individual sewage disposal systems must be designed by a licensed professional engineer or architect(unless installed in a Planning Doard approved subdivision). Add 250 gallons to the sire of the septic lank and leach field for cacti Garbage Grinder, Spa or Whirlpool'I'th Septic Tank: gallon (min. size 1,000gal.) Tile Field: each Trench ft. Total System Length: _f1. 1/4-, Seepage Pit(s): nuthber of size of each: fl. by f1. Size of Stone to be used: N _ / depdr or thickness fuel Bed System Size: x T` Alternative System: length andlor size 6. HOLDING TANK SYSTEM: (if required) Number of tanks: / Size of each: gallons /TOTAL Capacity: gallons Note: Alarm System and associated electrical work roust 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 perinit 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 road tlao regulations wit.l� respect.to this application and agree to aUido by lhesa and all requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance. 7//��o Signature of responsible person Date = - qV- ?oR R`� Septic Inspection Report }^ Office No. (518)761-8256 Date Inspection request received: Queensbury Building& Code Enforcement Arrive: ann/p �epart: am/pm ''r 742 Bay Rd., Queensbuly,NY 12804 Inspector's Initials:`-�� w NAME: PERMIT NO.: LOCATION: /R-r/d J SPECT ON: J 0 r RECHECK: ` Comments and/or diagram Soil T : San AM—/ ay T e of Naje. Municipa /Well Water Waterline sep ration di ance ft. Well separation't4stgnce ft. Other wells: ft. Absorption Field: Total length ft. Length of each trench ft. Depth of trenches ft. Size of Stone `� p Seepage Pits: Number Size: x Stone Size: Piping S iz Type Building to tank Tank to Distribution Box, 0 Distribution Box o Yield/Pit << Opening Sealed /N/Partial Location/Separations Foundation to tank ft. Foundation to absorption ft. Separation of Pits ft. Conforms as per Plot Plan Y N Location of System on Property: Front Rear Left Side CighteMiddle Front Middle Rea System Use Statu, . u,.. Approved Partial Approved and needs to be re-inspected,please call the Building&Codes Office Disapproved LASueHemingway\$uilding.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003 f N ---------- V "I have seen or erved, or believe-1.saw_evide'nce':of,_____�___ observed,—_ all objects such,as houses, wells, trees, ienc'es, etc. .shown-6rrthis-'docum�i t. I--'I n a so represent that I have onally- pasured-the-distances- -forth on-t ---diagr set am. J T ­ 22e e vi c d en etc.,c of at have th L�_'d n a 1,1 yZ-a 0 � �!d ia�ram."_ ,1� r i 4n su -i IGN IGNATURE_________ t DATE -- -- -•—i ----—----- —--r---;r) QU�Et4sBURY___J­ B UMIJ TOWN OF IJILOING AND CODE, ---------- r" J0 Ril -E3UILDING--&'-- EPT