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SEPTIC VARIANCE|ooo Sin,2 dose
APPLICATION porns:FEP-002%-AvroccanpedPermitFee:%/50.00
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net invoice #:_LF 34
Approvals:
Submittal:|ori inal &8 copies of the completed application package
Property Owner(s):John and Tammy Aust Owner's Agent:Hutchins Engineering
‘Address:2440 Ridge Road ‘Address:169 Haviland Road
Queensbury,NY 12804 Queensbury,NY 12804
Phone #:(518)744-1963 Phone #;518-745-0307
Site Address;2440 Ridge Road Tax ID#:240.6-1-37
Directions to site:4-4 miles North of NYS Route 149 on east side of Ridge Rd (91.)
Distance from well on property to septic system (if applicable)_>120 feet
Is it possible to install a conforming septic system on this property?Yes x No
If YES,please explain and attach a diagram:
Does the proposed system meet setback requirements for distance from wells &septic systems on neighboring
properties?X_Yes No INO,please explain:
Is the proposed system to be installed under a parking area?Yes X___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.):
Septic tank/pump station setback to house:"proposed instead of the 10'required
Septic Variance Application February 2018
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)Peter &Cheryl Fraser
eee 2444 Ridge Road Queensbury,NY 12804
Tax Map 1D
South Name Harry N.&RobertScott Haigh /John &Tammy Aust.
‘Address _2436Ridge Road Queensbury,NY /_Ridge Road Queensbury,NY (vacant)
Tax Map 1D _240.6-1-38 (Warren Co.)/240.6-1-39 (Warren Co.)
East Name Peter &Cheryl Fraser
Address Ridge Rd,Fast Fort Ann,NY (vacant)
Tax Map ID _94-1-22.1 (Washington Co.)
West Name Margaret W.Bolen
‘Address 2445 Ridge Road Queensbury,NY 12804 (across Ridge Road)
Tax Map ID _240.6-1-2 (Warren Co.)
OWNER STATEMENT.
We do hereby relieve the Town of Queensbury from any liabilities on the plumbing and septic system located at:
2440 Ridge Road
\/We realize that putting the well,septic tank or leaching system less than the required 10 feet from the house
may increase the risk of pollution.L '
owner—Print Name:“LM mrny |AVS
1 Date:LA20a=ate:_/~2/~20Owner—Signature:LO
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
PLEASE ATTACH THE FOLLOWING TO YOUR APPLICATION:
1.Alocation map showing the site within the Town of Queensbury
2.Aplot plan showing existing and proposed features of the property,including:
a.Lot dimensions
b.North arrow and scale:1 inch=40 feet
Location &dimensions of existing and proposed buildings,showing setback distances and
uses
Parking layout to scale (if applicable)
Physical features (street,steep slopes,lakes,wetlands,etc.)
Location of all wells and septic systems on neighboring properties
Adjacent ownerships
All properties within 500 feet
FRomee
A sample plot plan and location are shown below:
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:John or Tammy Aust
Designates:
HutchinsEngineering
===as agent regarding the Septic Variance for
Tax Map #:240.6-1.37 =ns
OWNER’S sour (Abrrrmg2(aK i DATE:L=2-20
T
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 Visits: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 by
the Town Board of Health.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 checks
OWNER—PRINT NAME:(AnonyL:flsh
OWNER—SIGNATURE Cony Mex :
DATE:[-2/-2==AGENT—PRINT NAMES Lach g PE
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Septic Variance Application February 2018