variance applicationSEPTIC VARIANCE|S822
Received:—tlejroroAPPLICATIONPermit#:SEP -0024-202.0
Town of Quvenstery P-o
742 Bay Road,Queensbury,NY 12804 Pormitree VOO°ry Road,Queensbury,DP:518-761-8256 www.queensbury.net Invoice DSSApprovals:
Submittal:|original &8 copies of the completed application package
Contact:Jane Barton
Property Owner(s):Jane Nolan Barton&5 Siblings Owner's Agent:Hutchins Engineering
Address:445 Ridge Road Address:169 Haviland Road
Queensbury,NY 12804 Queensbury,NY 12804
Phone #Phone #:518-745-0307
Site Address:52 Nolan Camp Road Tax ID#;289.15-1-42
Directions to Site:Tee Hill Road,to Hall Road,to Barber Road,to Nolan Camp Road--take Nolan Camp to end
(not open in winter)Distance from well on property to septic system (if applicable)_N/A feet
is property?Yes ¥No\s it possible to install a conforming septic system on tl
If YES,please explain and attach a diagram:
Does the proposed system meet setback requirements for distance from wells &septic systems on neighboring
properties?v¥Yes No INO,please explain:
Is the proposed system to be installed under a parking area?=-W__Yes No
Section of the Sanitary Sewage Ordinance from which you are seeking the variance (i.e.leaching system will be 89 ft
from well in lieu of required 100 ft.):
Absorp\Field separation to Glen Lake -100"required;70'provided
Absorption Field separation to house -20'required;11'provided
Septic Variance Application February 2018
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¢List the names,parcel addresses,and tax map numbers of all adjoining property owners.You may obtain tax
map numbers from the Assessor's Office as well as the names and addresses:
North Name Lance,Christa Barber,Daniel R &Barbara L
Incdress)47 BARBER RD HALLROAD
Tax Map ID _289.11-1-1 289.11-1-60
South Name Hogan,Robert G &Elizabeth L.
Address 105 FITZGERALD RD
Tax Map ID _289.14-1-27.2
East Name Surrey Field Homeowners Assoc
‘Address SURREY FIELDS DR
Tax Map ID _289.15-1-34.45
West Name N/A-Glen Lake
Address
Tax Map ID
OWNER STATEMENT
\We do hereby relieve the Town of Queensbury from any liabilities on the plumbing and septic system located at:
52 Nolan Camp Road
\/We realize that putting the well,septic tank or leaching system less than the required 100"feet from the Lake
may increase the risk of pollution.
owner—PrintName:__Jane Nolan Barton Date:_}|a|Jaose
Owner—Signature:Spas heloe Ve pate:|ar [aoao
NEIGHBOR OR TENANT RELEASE STATEMENT (if applicable)
\/We do hereby relieve the Town of Queensbury from any liabilities on the plumbing and septic system located at:
We realize that putting the septic tank or leaching system less than the required feet from the
may increase the risk of pollution.
Neighbor/Tenant—Print Name:Date:
Neighbor/Tenant-Signature:Date:
Septic Variance Application February 2018
AUTHORIZATION AND SIGNATURE PAGE
This page includes the Authorization to Act as Agent form,engineering fee disclosure,authorization for site
visits,other permit responsibilities and agreement to provide documentation required.
Complete the following if the OWNER is using an Agent:
Owner's Name:_Jane Nolan Barton and5Siblings
Designates:_Hutchins Engineering as agent regarding the Septic Variance for
Tax Map #;289.15-1-42
OWNER’S SIGNATURE:QeDelon!Ditins pare:{2.1 [ooxe
Engineering Fee Disclosure:Applications may be referred to the Town consulting engineer for review of septic
design,storm drainage,etc.as determined by the Town Board of Health.Fees for engineering review services
will be charged directly to the applicant.
Authorization for Site By signing this page and submitting the application materials attached herein,the
Owner,Applicant and his/her/their agent hereby authorize the Town Board of Health,building and code
Enforcement Officers and Town Engineer to enter the subject properties for the purpose of reviewing the
application submitted
Please Note:Other permits may be required for construction or alteration activity subsequent to approval bytheTownBoardofHealth.It is the applicant's responsibility to obtain any additional permits.
Officiatial Meeting Minutes Disclosure:It is the practice of the Town Board of Health to have a designated
stenographer tape record the proceedings of the meetings resulting from the application,and that the
minutes transcribed from those tapes constitute the official record of all proceedings.If there is a discrepancy
between such record and the handwritten minutes taken by the designated stenographer,the handwritten
minutes shall be deemed the official record.
|,the undersigned,have thoroughly read and understand the instructions for submission;agree to the
submission requirements and completed checklist:
OWNER—PRINT NAME:Tone tle fucien
OWNER—SIGNATURE:Quelew Buti pate:_[fa,jo?20
AGENT—PRINTNAME:yoo ns Wuregme SSO
AGENT—SIGNATURE:EX i,=|Ql).pate:[>[20
Septic Variance Application February 2018,