2001-190 `' TOWN OF QUEENSBURY
i
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20010190 Date Issued: Wednesday, April 25, 2001
This is to certify that work requested to be done as shown by Permit Number P20010190
has been completed.
Tax Map Number: 523400-114-000-0002-021-000-0000
Location: 72 Dixon Rd.
Owner: LEE &DOREEN FOTHERGILL
.Applicant: LEE & DOREEN FOTHERGILL
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
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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: P20010190 Application Number: A20010190
Tax Map No: 523400-114-000-0002-021-000-0000
Permission is hereby granted to: LEE&DOREEN FOTHERGILL
For property located at: 72 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. Type of Construction Value
Owner Address: LEE& DOREEN FOTHERGILL Septic Alteration Residential
10 JEFFERSON St Total Value
GLENS FALLS,NY 12801
Contractor or Builder's Name/ Address Electrical Inspection Agency
SIGNORELLI & SON
589 WEST MOUNTAIN ROAD
OUEENSBURY,NY
Plans &Specifications
2001-190
SEPTIC ALTERATION AS PER PLOT PLAN SPECIIFICATIONS
$25.00 PERMIT FEE PAID - THIS PERMIT EXPIRES: Friday,April 25,2003
(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 To Quee ; d sday,April 25,2001
SIGNED BY for the Town of Queensbury.
Director of Building Code nforcement
' Application for Permit—Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
Location of installation: 12. Di xon Road 7 Q uzeosbo ry Office U File Permit N l/se—/90
Tax Map No. / / pw 5s dc,
!.
Owner's Name: t-it' `1 Mrs. Le z Fo,{iner`j.11( • Fee Paid
Address: 16 ie.cce-son S-1rc1- , C-1exis Fal15
2. INSTALLER'S NAME : 1 o al S,tenore,l 1; PHONE NO. 1Q 2 -l(0oo
3. RESIDENCE INFORMATION: (circle year 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 ? x 150 gal/bdrm = L S-6
1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm = APR 2 4 2001
Garbage Grinder Installed yes / no TOWN OF QUEENSBI.'
Spa or Whirlpool Installed yes / no BUILDING AND COD,-
4. PARCEL INFORMATION: (circle applicable information &indicate measurements)
aphv ,;..x ure Ground Water Bedrock or Impervious Material D ter Supply
Flat 4 sand at what depth at what depth municipal
Ro ling oam feet feet well
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 •-(6) ft. Total System Length: ft'
Seepage Pit(s): number of size of each: ft. by ft.
Size of Stone to be used: # / depth or thickness feet
Bed System Size: x
' Alternative System: :lit//6 1/o7- length and/or 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 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 of Queensbury Sanitary Sewage Disposal Ordinance.
S natufe of sponsible perso
n Date
TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804
C
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name ;—p l l-\CeG(c(--
Locati on 'fa- V 1`1/4,0 gb ,
Date 7,6 0 Permit # d - I9C>
SOIL TYPE: Sand- am- lay-
Results of Percola ion Te t-
(if applicable) Ra a-Minut /Inch
-TYPE OF SYSTEM: --7
ABSORPTION FIELD: T tal Le gtly r
Length of each trenc t(
Depth of trenches 2
Size of stone ti,210-0 D
SEEPAGE PITS: Number /
Size - ft. x / ft.
Stone size Ad
PIPING: '— Size Type
Bldg. to Tank
Tank to Dist. Box
Dist. Box to Field/Pi ' / ' 56
Openings Sealed? Y:s No Partial
LOCATION/SEPARATIONS:
Foundation to Tank feet
Foundation to Absorption feet
Separation of Pits feet
Conforms as per Plot P1 an . No
LOCATION OF SYSTEM-0 OPERT
(circle one) —1
Front - Rear Left Si - Right Side
Middle Front - ' die Rear
COMMENTS:
3 Lev-7-6,74G5 2_ SO
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/5 %v`A_L
SYSTEM USE APPROVED: YES NO
Arrived:
Departed: / v
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Building Inspector
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TOWN OR QUEE?JSBURY
BUILDING VCODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name AD) ro'
if(
Lo ati on �� ' �i�jp�� '—
e S Permit # 0� —/ /2
SOIL TYPE. San Loam-Clay-
Results of Percolat' .o Test-.
(if applicable) Ra e-M ute/Inch
TYPE OF SYSTEM: —
ABSORPTION FIELD: Total L-ngth, c)
Length of each tr-nch1 '
Depth of trenche , "Z
Size of stone A - — C
SEEPAGE PITS: N ber
Size - ft ft.
Stone size
PIPING: Sire Type
Bldg. to Tank �,
Tank to Dist. Box ," L
Dist. Box to Fi el ./' '
Openings Sealed? No Partial
LOCATION/SEPARATIO
Foundation to Tank J/ feet
Foundation to Absorption g-9 feet
Separation of Pits feet
_
--'Conforms as per Plot Plan No
LOCATION OF SYSTE ON PROPER
(circle one)
Front - Rear - Lef' Side - igtit Side
Middle Front - Middle Rear
COMMENTS: /4-/'T 4- -
623 /cj f. C
l,4,,,izz - ck' Ceni- 4
/q6•-&/1: , F,,,i /,-,f.tv L oe/i-T/o,)
SYSTEM USE APPROVED: YES NO
Arrived:
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