2001-296 gat TOWN OF QUEENSBURY
Foiro 742 Bay Road, Queensbury,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20010296 Date Issued: Friday, May 18, 2001
This is to certify that work requested to be done as shown by Permit Number P20010296
has been completed.
Tax Map Number: 523400-090-000-0004-003-000-0000
Location: 458 DIXON Rd
Owner: MICHAEL & CHRISTINE TEAL
Applicant: MICHAEL & CHRISTINE TEAL
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
(--- aiv7P 4 -
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: P20010296 Application Number: A20010296
Tax Map No: 523400-090-000-0004-003-000-0000
Permission is hereby granted to: MICHAEL & CHRISTINE TEAL
For property located at: 458 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: MICHAEL & CHRISTINE TEAL Septic Alteration Residential
458 DIXON Rd Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name/ Address Electrical Inspection Agency
I.B.S. SEPTIC
2 LOWER WARREN STREET
OUEENSBURY.NY
Plans &Specifications
2001-296
SEPTIC ALTERATION AS PER APPLICATION
$25.00 PERMIT FEE PAID - THIS PERMIT EXPIRES: Sunday,May 18,2003
(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 wn Que sb y; ' y May 18,2001
SIGNED BY ��I( for the Town of Queensbury.
Director of Building&Code Enforcement
Application for Permit—Septic Disposal System .
Town of Queensbury 742 pay Road Queensbury, NY 12804 (518) 761-8256
1. OWNER INFORMATION: . . • .
- Location of installation: - . b ,' D A,/ � - Office Use (� •
Tax Map No. / /� File Permit No �`��( co
Owner's Name: kie,____Li72- Fee Paid as ."'•
•
'Address: / `9 to' .4
/ .
•2. • INSTALLER'S NAME :. PHONE NO.
•
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate #bedroom(s)andmultiply N 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 ga1/bdrnr IsO
. 1980- 1991 . - x 130 ga1/bdrm = �.
1991 —.present x 110 gal/bdrm - .
Garbage Grinder Installed: yes / no .'
Spa or Whirlpool Installed yes_ / no
• .
•
4. PARCEL INFORMATION: (circle applicable'information &indicate measurements).
•P9. t' . _ ■►A .19 Q.1:Quncl Wittor___.._BQS1.rock9r ltnpe yjcAll_ _trtcr_i.111 _Do • •. tcr_Supply
. ,1'Ha . , .van( at wh 1. lull at w ra ee h 4 m►�nlutpal .
Oiling oam ' eet ��" " "feel
Sleep slope clay if well; water supply
• _-_%slope . other from any septic-system
depth: absorption is fl.
•
s • other
i;
Percolation Test: o be completed by licensed professional.engineer-or architect)
Rate: .� ,minute per inch ..
5. PROPOSED SYSTEM: For New Construction: All individual sewagc.disposal systems must be designed by a licensed
professional engineer or architect(unless installed in a Planning Hoard approved sidxlivision). Add 240 gallons Io the sire
of the septic tank and leach field four each Garbage Grinder, Spa or Whirlpool Tub.
. F3E r
Septic Tank: f C' S gallon (min. size 1,0 110 gal.)
NAY I 4.Z001
Tile Field: each trench I'd ,Jl, Total System LengtlC3‘90 ,JT. 7-0111✓N OF QL
E
Seepage Pits :. number ofB�iL0j�0-.it.Q O� '
{ ( ) size of each: ,/1. by fit, ®�
' Size of Stone to be used: ll, ON; . •.. / depth ur thickness.___/___-_feet
Bed System Size: x
•
• • Alternative System: _ 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 workmust 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 Quoensbury, any'permit or approval granted which is based u• pon 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 v Ld.
. o
I have road the regulations with respect to this application and agree to•abide by those and all
• requirements of the Town a ueensbury Sanita Sewage Disposal Ordinance. •
V • /7:....ed,do
f
nature of responsil a person -• Date- :
.
TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name \,11�
Location ysb 0)X
Date Iu lPermit # () il-c)-C7'
SOIL TY4 .. -Clay-
Results of Percolation Test-
(if applicable) Rate-Minute/Inch
TYPE OF SYSTEM:
ABSORPTION FIELD: To al 'ength 200
Length of each trenc h -Y
Depth of trenches l 7-'-3
Size of stone • Z
SEEPAGE PITS: Numbe -
Size - ft. x ft.
Stone size
PIPING: ' Size Type.
Bldg. to Tank '�- �_
Tank to-Dist.--Box ----- -Q - — - -
Di st. Box to Field/Pi ' Li\N C-- VFW--
Openings Sealed? Y: s No Partial
LOCATION/SEPARATIONS:
Foundation to Tank G)1.1lh-1-.feet
Foundation to Absorpti n . -�v .feet . .
Separation of Pits feet
Conforms as per Plot P an �_1Ce�No
LOCATION OF SYSTEM ON 'OPERTY:
(circle one)
Front - Rear - Left i-de ' 'ght Side
Middle Front - iddle Rear
COMMENTS:
•
SYSTEM USE APPROVED: YE NO
Arrived: -Z
Depar .
`B ding Inspe o
i]
( "I 'have seen or observed,or believe I saw w evidence of,
alll objects;such esthouses,1 wells,t lees,'fences,;etc!,
—— shownf on this document.talso represent that I have-
- pe1rsonall ' - -.sured-the-d' ncesjset forth-on the-diagram."
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01 SIGNATURE— 1 1 1 DATE`
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1 —1 - I --- RECEIVED
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