2004-538 TOWN OF QUEENSBURY
742 Bay Road;Queensbury,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20040538 Date Issued: Tuesday, July 13, 2004
This is to certify that work requested to be done as shown by Permit Number P20040538
has been completed.
Tax Map Number: 523400-301-013-0002-068-000-0000
Location: 22 ALGONQUIN Dr
Owner: RICHARD & JANET GRABOWSKI
Applicant: RICHARD & JANET GRABOWSKI
This structure may be occupied as a:
By Order.of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
Lj
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: P20040538 Application Number: A20040538
Tax Map No: 523400-301-013-0002-068-000-0000
Permission is hereby granted to: RTC'HARD &JANET C"TRABOWSKT
For property located at: 22 ALGONQUIN Dr
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: RICHARD & JANET GRABOWSKI Septic Alteration Residential
22 ALGONQUIN Dr Total Value
QUEENSBURY, NY 12804-0000
Contractor or Builder's Name /Address Electrical Inspection Agency
SANITARY SEWER
D AN DRELLO S
PO BOX 224'
GLENS FALLS NY
Plans&Specifications
2004-538
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday, July 13, 2005
(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 Tor7;:7
�; rruly 13, 2004
SIGNED BY v for the Town of Queensbury.
Director of Building&Code ffnforcement
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: f v d 4 ! U /:J Df'I v /IV _
3�>
File Permit No. 1
Tax Map No. i I
• �Owner's Name: (G -Fee Paid
iZA a�[ffGi ..........
..-.....................
................................................................................,................
Address: 12- AL!T a Af 4 2-1 d e-
r
2. INSTALLER S NAME �N �✓ PHONE NO.-7
3. RESIDENCE INFORMATION: (circle year of dwelling,indicate#bedroom(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
1980 or older x 150.gal/bdrm =
1980-1991 S" x 130 gal/bdrm = ��
1991-present x /110 gal/bdrm =
Garbage Grinder Installed yes_ / no t/ J U L 12 2004
Spa or Hot Tub Installed yes_./ no
TOWN OF QUEENSBURY
4: PARCEL INFORMATION: (circle applicable information&indicate:measur-
BUIWING AND CODE
Tg=gggphv Sail-Nature Ground Water Bedrock or Impervious Material Domestic Water Su 1
at what depth at what depth m
Rolling loam 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: y gallon(min.size 1,000 gal)
Tile Field: each trench .� 0 fl. Total System Length: 2
Seepage Pit(s): number of—WA-A- size of each: ft. by ft.
Size gf Stone to be used: ## I 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
Tequirern/eATF-of1he Town of QecAsbury Sanitary Sewage Disposal-Ordinance,
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7. SjrTN4TURE
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Septic Inspection Report
Office No. (518)761-8256 Date Inspection re st e eive
Queensbuly Building&Code Enforcement Arrive: mlp D part: an In
742 Bay Rd., Queensbuiy,.NY 12804 Inspector's Initi /
4_ 3 .
(
NAME: � � �� � P RMIT NO.:
LOCATION: SPECT ON:
RECHECK:
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: $,
Absorption Field: Total length ! ft.
Length of each trench _ i� ft.
Depth of trenches Z ft.
Size of Stone `C
-Seepage Pits: Number
Size: x
Stone Size:
-Flp-ing Size Type
Building to tank
Tank to Distribution Box t^ 11 7
Distribution Box t ie d/Pit
Opening Sealed Y/>0 Partial
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Location of System on Property:
Fr ea Left Side Right Side
Middle Fro iddle Rear .
System Use St us:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:'SueHemingway\Building.Codes.[nspection.FORMS\.Septic Inspection Report.doe January 28,2003
RECEIVE
C
JUL .7 2 2004
TOWN OF QUEENSB
BUILDING AND CO E
Y—L
O O
o
h
"I have seen or observed, or believe I saw evidence of,
.a3 ,�
°' all objects such as houses, wells, trees, fences, etc.,
"Gn F 0 °"g am''°=° i °' shown on this document. I also represent that I have
p ily measured the distan set forth on the diagram."
REVIF,W G
DATE
DATE