2005-676 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20050676 Application Number: A20050676
Tax Map No: 523400-297-017-0001-062-000-0000
Permission is hereby granted to: ROBERT BLANCHARD
For property located at: 56 MEADOW VIEW 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: ROBERT BLANCHARD
Septic Alteration Residential
LEE ANN POULIOT
56 MEADOWVIEW Rd Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
QUEENSBURY SEWER
JAY SWEET
Plans&Specifications
2005-676
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday,August 24, 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 T n of Zt e esday, August 24, 2005
SIGNED BY a for the Town of Queensbury.
Director of Building&Code Enforcement
Application for Permit— Septic Disposal System
Town of Queensbury 742 Bay Road Queensbun;, NY 12804 (518) 761-8256
1. OWNER INFORMATION: .................................
/ Office Use
Location of installation: e* /
f
File Permit No. o
Tax Map No.
Fee Paid
1tX P1 C L
19- r44
Owner's Name:�a r t
................ .......... ...............................
Address:
2. INSTALLER'S NAME PHONE NOI 7 )Yp y
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate#bedroonz(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
�oro x 150 gal/bdrm =
1980- 1991 x 130 gal/bdrm =
1991 -present x 110 gal/bdrm =
Garbage Grinder Installed yes_ / no
Spa or Hot Tub Installed yes! ! no
4. PARCEL INFORMATION: (circle applicable information& indicate measurements)
T-QDographv Soil Nature Ground Water Bedrock or Impervious Material Domestic Water Su lv
CFlatD sand at what depth at what depth muniCapa
fling oam feet feet well
Steep slope clay if well; water supply
,%slope other from any septic-system
depth: absorption is f t.
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�h field for each Garbage Grinder. Spa or Whirlpool Tub. l
SepticTank: p 0 0 gallon (min. size 1,000gal.) Ce {� `J�/+� �� 6,-) /-ew-r -
Tile Field: each trench ft. Total System Length: ft see �
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: 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 Sanita Sewage Disposal Ordinance.
Si a r of responsible person Date
1
I
Town of Queensbury
Sewers and Sewage Disposal Chapter
Appendix C
ABSORPTION FIELD
SEPARATION REQUIREMENTS
N _ .r
Appendix C
ABSORPTION FIELD
SEPARATION REQUIREMENTS
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Septic Inspection Report ,
Office No. (518)761-8256 Date Inspection requ rec ive '
Queensbury Building&Code Enforcement Arrive: pm D art: �a p in ---'`�
742 Bay Rd.,Queensbury,NY 12804 Inspect is Initia
NAME: P IT NO.:
LOCATION: SPECT ON: '
RECHECK:
u
Comments and/or diagram
Soil Type: Sand/Loam/Clay
Type of Water: Municipal/Well Water
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 C -qds
Building to tank ri11
Tank to Dis ion Box
Distribution Box to_F4eld/ it
Opening Seale • artial
End Caps
Location/Separations
Foundation to tank
Foundation to absorption ft.
Separation of Pits ft. "'>C) b 1 t U- ? i 2 0)
Conforms as per Plot Plan Y N Y
Engineer Report and As-Built Y N
Location of System on Property:
Front Rear Left Side Right Side
Middle Fro ' iddle Rear
S stem Use Sta s•
Approved
Partial Approved and needs to be re-inspected, please call the Building&Codes Office
Disapproved
Last revised 1/6/05
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