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2000-918 r TOWN OF OUEENSBURY 742 Bay Road, Queensbury, NY 12804-5902 (518) 761-8241 Community Development - Building & Codes (518) 761=8256 CERTIFICATE OF COMPLIANCE Permit Number: P20000918 Date Issued: Tuesday, August 14, 2001 This is to certify that work requested to be done as shown by Permit Number P20000918 has been completed. Tax Map Number: 523400-302-009-0001-038-000-0000 Location: 301 DIXON Rd Owner: H. GERALD & LYNN WHITE Applicant: H. GERALD & LYNN WHITE This structure may be occupied as a: By Order of Town Board Septic Alteration Residential TOWN OF QUEENSBURY 4(7 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: P20000918 Application Number: A20000918 Tax Map No: 523400-096-000-000 1 -0 10-000-0000 Permission is hereby granted to: H. GERALD & LYNN 'WHITE lior property located at: 301 DIXON Rd in the Town of Quvensbury, 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: H. GERALD & LYNN WHITE Septic Alteration Residential 301 DIXON Rd Total Value QUEENSBURY, NY 12804 Contractor or Builder's Name / Address Electrical Inspection Agency CONDONS SEPTIC & DRAIN SERVICE Plans & Specifications BP 2000- SEPTIC SYSTEM FOR 2 BEDROOM HOUSE $25,00 PERMIT FEE PAID - THIS PERMIT EXPIRES: 'Wednesday, December 049, 2002 (ifa 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 Toym ueen ury d , December 04, 2000 ST(3NE A D BY for the Town of Queensbury. Director of Building 8c Code nforcement Applation for Permit — Septic 'll�sp al System -�--- Town of Queensbury 742 Buy Rood Queensbury. NY 12804 (518) 761-8256 1 . OWNER INFORMATION: ..................... .............................. © � � Office use Location of installation; Xov OR D � �j�,,,.� � �,, File Permit No. U��`►''�'' f f 'ax Map No. -�-��il� ! _,_�__ I � �,...%� �✓ Fee Pai Owner's Name: Address: t" D/7J ,Id DEC 01 2000 2. INSTALLER'S NAME /), L r ra C ,C�f � E NO 79 �-� 2~'" 3 . RESIDENCE INFORMATION: (circle year of dwelling, indicate d# bedroom(y) and multiply # of bedrooms with applicable gallons per bedroom to equal total daily flow) Ye r of House Na of Bedrooms x omputation Total Daily Flow 1980 or older '2-. x 150 gallbdrm — '�, 00 1980 — 1991 x 130 gaVbdrm 1991 — present x 110 gaVbdrm = Garbage Grinder Installed yes / no Spa or Whirlpool Installed yes .___ I no 4. PARCEL INFORMATION: (circle applicable information & indicate measurements) Topgaraphv Soil Nature GrQund Water Bedrock or Impervious Material DomQstic Water Supply Flat <ZED at what depth at what depth municipal Rolling loam feet J /1 - feet well Steep slope clay if well; water supply Yo slope other from any septic-system depth: absorption is 4�Wft- 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 dcsigned 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. �L ' Q Septic Tank: AZOO gallon (min. size 1, 000 gal.) f 1-7 4� Tile Field: each trench 570 ft. Total System Length: Seepage Pit(s): number of size of each: _ _ft. by Size of Stone to be used: # / depth or 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 I 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. AID Aw Signature of responsible person Date TOWN OF r EElrsewRx BUILDING S CODE ENFORCEMENT 742 Bay Road Queensbury NY 12804 (518) 761-8256 SEPTIC DISPOSAL SYSTEM INSPECTION Fame Location Date 'Permit SOIL TYP San, am- Clay- Results of 'Percolation Test- ( if applicable ) Rate- Minute/ Inch TYPE OF SYSTEM: ABSORPTION FIELD: Total Length •�. -,.-s' Length of each trench Depth of trenches Size of stone SEEPAGE PITS : Numb r- Size - ft . I ft . Stone size PIPING: - ize 7yFe - Bldg . to Tank rr Tank to Dist . Box jr Dist . Sox to Field/P - Openings Sealed ? No art a LOCATION/SEP Foundation to Tank i feet Foundation to Absorpt on 3 feet , Separation of Pits feet.-"" Conforms as per Plot P an �` e's. LOCATION OF ;SYSTEM ON ROPERTY : one ) Front Rear _ - Left Sid runt - Middle R a COMMENTS : % SYSTEM USE APPROVED • YES No Arriv �. Depa Wing Inspe t/ J �V /0 A Q) f `r` 7 3 ` e2 y `� 7 Cn o " r SCR :t �c r 14(16 t UJI q c O l V 9 N AY )k ( V k)41 d q� seen or observed, or believe ! saw evidence of, i !a{I objects such as houses, wells, trees, fences: etc., shown on this document I also represent that I have `personally measured the distances set forth on the diagram." Nt If jU SIGNATME TOWN OF QUEEN Y DATE BUILDING & REAMED BY � DATE 3e r Dt xolv AD -� 14#61 D HIIAR � S �