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2002-691 t` TOWN OF QUEENSBURY 742 Bay Road,Queensbury,NY 12845902 (518)761-8201 Community Development-Building&Codes (518)761.8256 CERTIFICATE OF COMPLIANCE Permit Number: P2.0020691 Date Issued: Tuesday,.August 20,2002 This is to certify that work requested to be done as-shown by Permit Number - P20020691 - } has been completed. Tax Map Number: 523400-308-006-0001-010-000-0000 Location: 65 BURCH Rd Owner: ROSEMARY POTTER Applicant: ROSEMARY POTTER This structure may be occupied as a: By Order of Town Board Septic Alteration.Residential TOWN of QUEENSBURY �a 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: P20020691 Application Number: A20020691 Tax Map No: 523400-308-006-0001-010-000-0000 Permission is hereby granted to: ROSEMARY POTTER For property located at 65 BURCH 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: ROSEMARY POTTER 65 BURCH Rd Septic Alteration Residential QUEENSBURY,NY 12804 Total Value �7, 1! Contractor or Builder's Name Address Electrical Inspection Agency Plans&Specifications 2002-691 Replacement of residential septic system $25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday,August 14,2003 (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 n Wofens August 14,2002 SIGNED BY for the Town of Queensbury. Director of Building&Code Enforcement Application for Permit—Septic Disposal System_ Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761=8256 1. OWNER INFORMATION: Office use Location of installation: Tax Map No. __ d1 i /�-J 1 p D f File Permit No..?1�0Z_P Cp f Fee Paid { Owner's Name: j-" n .co- t o f- _ Address '2. INSTALLER!SNAME bill 1-kl c../ i--rcl PHONENO. 3. RESIDENCE INFORMATION: (circle year of.dwelling;-indicate#bedroom(s)and multiply#of bedrooms with applicable gallons per bedroom to equal total datly flow) Year of House: No of Bedr6oxns x Computation = Total Daily Flow 1980 of older - x 150 gaUbdri n 1980—1991 x 130 gailbdrm = " 1991—present x 110 gaUbdrnn = Garbage Grinder Installed yes u / no_X Spa or Whirlpool Installed. yes_ / no AUG 1 3- 2002 4. PARCEL INFORMATION: (circle applicable information&indicate measurement;RWN OF QUEENa 6Uf3g1 BUILDING AW)wort Tgpo&Kaph Soil Nature Ground Water Bedrock or a •ous Material Dom Water Su 1 at what depth' at what depth tnpaolltnfeet feeteep slope clay l;water supply Yoslope_ other any septicsystem depth;.. orption is . 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 mast be desiguedby 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: t:04o'.0 gallon (min.size 1,000 gal.) Tile Field: each trench b ft Total System.Length: Za b ft Seepage Pit(s): number of size of each: f+i by�fl Size of Stone to be used: # Z. / depth or thickness feet Bed System Size: x Alternative System- length andlor size 6. HOLDING TANK SYSTEM:: (if required) Number oftanks: / 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 ofthe 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 factor, circumstance Imown by or on behalf of all applicant; shall be void. I have read theregulations 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 a VA i �j n '' /�1�/o�vy�-n -pryaa -�c bcncnyurv/r� N Aa1 r hz� V (D 0 © 0 1�J '"1« a `r) � C+ -J,�.1«(D yid W 4-i« � � W 0 !++ 4 V„.IJ 0 'n�,o c C �(D rn q. " Q N �'M 1. N 'a`h V) M r} 6 > `$21 :3 - :« (`f' '�W M� (D V 0 i'i'�k o M C M C} � �� I Grip �� ID � � fD ,� fh `� Itl W 0 Q .is -' 0 1-4 -j M M ON Ow F. (A u(IT04, 0 m (D "e oil 0 ( 'U A rim 7 0 Q � 0 � O , a (D Ii0 o V .� WC p (DM it 11 � -I a � � +"►4 Q W N I co x a rD ONO C �« ID M (D ' Z{A (D rD -l« . (D ,�J (D C} tt C+ tt a r 4 i :Z Z • 0UJ v o1 0 a m� -a CO)UL"10 m < C G� . . �' tr .. v�44aG g Z f•, � 0 LX aN aCO "I have seen or observed,or believe I saw evidence of, all obiects such as houses,wells,gees,fences,etc., ��rn V� shown on this document, I also represent that I have personally measured the distances set forth on the diagram." SIGNATURE BATE