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2002-007 TOWN OF OUEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201 Community Development-Building&Codes (518) 76178256 C ERLT VAIF %U11j. Ir "rE OF COMPLIANCE Permit Number: P200200.07 Date Issued: Tuesday,January 08,2002 This is to certify that work requested to be done as shown by Permit Number P20020007 has been completed. Tax Map Number: 523400-301-017.0002-045-000-0000 Location: 869 SHERMAN Ave Owner: LATHY JORDON Applicant: CATHY JORDON 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: P20020007 Application Number: A20020007 Tax Map No: 523400-301-017-0002-045'000-0000 Permission is hereby granted to: CATHY JORDON For property located at: 869 SHERMAN Ave 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: CATHY JORDON Septic Alteration Residential 869 SHERMAN Ave Total Value QUEENSBURY,NY 12804 Contractor or Builder's Name/ Address Electrical Inspection Agency CONDONS SEPTIC&DRAIN SERVICE Plans &Specifications 2002-007 SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS $25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday,January 03,2003 (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 Tow f Queen ury; Th rsday,January 03,2002 SIGNED BY - for the Town of Queensbury. Director of Building Cod nforcement Application for Permit—Septic-Disposal System . Town of Queensbury 742 Bay Road Oueensburg NY 12804 (518) 761-8256 1. OWNER INFORMATION: ....................................................................... ..........._............ ..........................._....., Office Use Location of installation:J LS? O� File Permit NoC90� Tax Map No. / / C)6 Fee Paid D,5 ' Owner's Name: ................................. ......................................._... Address: G u 2. INSTALLER'S NAME : () 1/��ni S � ©4,t CAC,,,J F,A,- PHONE NO. 3. RESIDENCE INFORMATION: (circle year of dwelling, indicate 4 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 9I980- 1991 980 or�old x 150 gaUbdrm = �-�S x 130 gallbdrm = 1991 -present x 110 gal/bdrm = Garbage Grinder Installed yes` / no `X Spa or Whirlpool Installed yes_ I no _ 4. PARCEL INFORMATION: (circle applicable information&indicate-measurements) T o ra h Soil Nature Ground Water Bedrock or Lmpervious Material Domestic Water Supply. let sand at-,;lot depth at what depth municipal Rolling loam feet 'feet well Steep slope clay ifwell; water supply, `io slope other from any septic-system depth: absorption is ft. other Percolation Test: _(To be con pleted 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: /00 G gallon (min. size 1,000 gal.) r C� t. - Total System Length: �e����� Tile Field: each trench f y Seepage Pit(s): number of size of'each: ft. by fl- Size of Stone to be used: =_ / depth or thickness feet Bed System Size: :x 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 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 ofthe 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 ofthe Town of Queensbury Sanitary Sewage Disposal Ordinance: Signature of.responsible person Date 0 Q1 1 4J 000 or. o 4- 4- � v I � 0 W 4 C 0 h C �+ V? U. b � � r Iw ro t� 01 01 � r. a"' N z z C� (q U ro I Q � �U W W CC I 0 I r >- ► In N N W � �► OJ ;� IZ th a � r•' '. �� N � , or- OU C Cr©� ' 00 0 ro ro r► ( 2 E „ °0 ,*1 o ,� r- CY S. Ul n.r I� In C. W C . .0 in I o � o z ai r�� � ro A 't- � C C .1 � or-Zf U rr .C c ' 0 W .0 U +ll. 0 � 4 0 I ! Q p �W ►� roi N f 0H ro ,U)j4' vW v►W ro " M 0 °" QLJM H 0 4-W ;n ►► -P 0 CO G) Dp 'P � 41 I V) b� W W C 01L01 � � M.YPC CC04• - Cti ►� � 0 E U � cn4� 1V? CA. NWN4L� '0CIn (D 00acu 'll- 010K Ll (a 0 fo 0 4) or- �vm 0 0 or"W or- 4.1Hr- Mor- ao 0 0 y 00 u 'L -r0 )m �, � 06& t9�' " �Yl `(aU)'' C � uoj2�S � lC /�`�C��1/UC.1 W (ykMmo P�-,M, fTY� �Owvsgw L()-ko gAgufali k o-w �o 3is T(y rl DD f 10 RECEIVED l have seen or observed,or believe I saw evidenc . all objects such as houses,wells,trees,fences,etc., JOIN 0 3 200, shown on this document I also represent that �� p I have ` `` R � Tows OF a1�►EINs personally mea ured the distances set forth on the di gran' BUILDING Ai�p BURY � cooE SIGNAIURE � ����Y BUILDING& EPT S � REVIEWED BY DATE Pawl A q 9116A ���r