2005-179 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFI CATE OF COMPLIANCE
Permit Number: P20050179 Date Issued: Friday, April 08, 2005
This is to certify that work requested to be done as shown by Permit Number P20050179
has been completed.
Tax Map Number: 523400-301-019-0001-035-000-0000
Location: 46 HAMPTON Ct
Owner: THOMAS & PEGGY JABLONSKI
Applicant: THOMAS & PEGGY JABLONSKI
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: P20050179 Application Number: A20050179
Tax Map No: 523400-301-019-0001-035-000-0000
Permission is hereby granted to: T140MAS & PRCrCTY JAB1.0NSKI
For property located at: 46 HAMPTON Ct
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. Tyne of Construction Value
Owner Address: THOMAS & PEGGY JABLONSKI
46 HAMPTON Ct Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
MORNING STAR SEPTIC
Plans& Specifications
2005-179
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday, April 06, 2006
(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 Tgovia,01f Queens ury; Wednesday,April 06, 2005
SIGNED BY for the Town of Queensbury.
Director of Buddin Co Enforcement
Application for Permit=Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804;(S18) �61-8256
1. OWNER INFORMATION: ,.................... ..............................................................................................,.
.. ,
} Office Use
Location of installation: ..,, ,,,
Tax Ma No. / / T File Pet No.
P E
Fee Paid 1z, v0
Owner's Name:
,�
n ..........................................................................._.......................... ....................4
Address: �� � v ,•. A
2. INSTALLER'S NAME : - � ;Tu,�. 5�,.�.L. PH6NE No-W32'Zq
i
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate#bedroom(s) and multiply#of
bedrooms with applicable gallons per bedroom to equal total daily flow)
�i
Year of House: No.of Bedrooms x Computation = Total IDai1y Flow
1980 or older x 150 gandrm =
1980— 1991 x 130 g al/bdrm =
1991 —present 3 x 110 gal/bdrm = 3n E1 VE
Garbage Grinder Installed yes / no 4 PP n Z(20a j
Spa or Hot Tub Installed yes_ / no .�
I TOWN OF
BUILDING AND CODE
4. PARCEL INFORMATION: (circle applicable information&indicate mea m�nts)
ToT)oeraDhv Soil Nature Ground Water Bedrock or impervious Material . Domestic Water Sgpply
s at what depth at what depth munlci al
oiling 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 C� ft. Total System Length: 0 ft.
Seepage Pit(s): number of size of each: ft. by ft.
i
Size of Stone to be used: # A _ 1 depth or thickness et,
Bed System Size: x
Alternative System: length and/or size
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: J 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
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.
Signature of responsible person date
Town Of OuLwilabut-Y
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Septic Inspection Report
1 l
Office No.(518) 761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: a �pp��,Depart: am/pm
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials.m l K,
' ) /
NAME: _ � � PERMIT NO.: /
LOCATION: INSPECT ON: -
�4:
Comments and/or diagram
Soil Type: San o a
Type of Water:vunicipa ell Water
Waterline se aration istance ft.
Well separation distance
Other wells: ft.
Absorption Field: Total length ft.
Length of each trench ft.
_Depth of trenches ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank _
Tank to Distribution Box /
Distribution Box to Field/Pit_ �.
Opening Sealed: Y/N/Partial
End Caps
Location/Separations
Foundation to tank Xft.
Foundation to absorption
Separation of Pits ft.
Conforms as per Plot Plan Y
Engineer Report and As-Built Y VN
Location of S7Rear
n Property:
FrontLeft Side Right Side
Middle Front Middle Rear
fa.
System Use Status-
Approved
Partial Approved and needs to be re-inspected, please call the Building&Codes Office
Disapproved
Last revised 1/6/05
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection re uest received: /
Queensbury Building&Code Enforcement Arrive: Depart: am/pm
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initia a
NAME: PERMIT NO.: s
LOCATION: �1►�af' ' :: -- INSPECT ON:
RECHECK:
Comments and/or diagram
Soil Type: Sand/Loam/Clay
Type of Water: Municipal/Well Waterer--G( � .
Waterline separation distance ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenches ft.
Size of Stone
-Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
-Building to tank
Tank to Distribution Box � ���� p�
Distribution Box to Field/Pit
O enin Sealed: Y/N/Partial
O/V
Location/Separations
Foundation to tank
Foundation to absorption ft.
Separation of Pits ft.
Conforms as er Plot Plan Y N
Location of System on Property:
Front Rear Left Side Right Side
Middle Front Middle Rear
_System Use Statu .
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
U'SueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
L (00
04 PL
BUILDING A T.
REVIEWED Q
DATE
sef�n or m"iserved, or believe I saw -evidence of,
-1,3su as houses, v,,0s, trees, fenctes, etc.,
S I�OCL:MrMf, I aiso represent that I have
ances set forth on the diagran"
E DATI E