Variance submission I
SEPTIC VARIANCE Office Use-Only
Received:
APPLICATION Permit#: 0 2 ka• 2,02Z
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Permit Fee:
742 Bay Road,Queensbury,NY 12804
Invoice#: 2-tO 21
P:518-761-82S6 www.queensbury.net
Approvals:
Submittal: I original &8 copies of the completed application package
Property Owner(s): Robert Stutz owner's Agent: Hutchins Engineering PLLC
Address: 76 West Mountain Road Address: 169 Haviland Road
Queensbury,NY 12804. Queensbury,NY 12804
Phone#: (518) 727-7490 Phone#: 518-745-0307
Site Address: 16 Mayflower Lane Tax ID#:227.6-1-7
Directions to Site:
Distance from well on property to septic system(if applicable) 60 feet (60' existing failed, 135' proposed)
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 If NO,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 5'from building where 10'is required
Absorption field is 15'from building where 20'is required
Absorption.field is 95'from Lake George where 100'is required
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RECEIVE[ •
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QUEENSSUfiy
Septic Variance Application CLERK'S OFFICE :",j
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 Kevin Walsh
Address 100 Pennsylvania Ave Tuckahoe,NY 10707
Tax Map ID 227.6-1-8
South Name Kimberly Pfelffenberger
Address 106 20 West Drive Altamont,NY 12009
fax Map ID 227,6-1.6
East Name ThingvellrLLC
Address P.O.Box 157 Katskill Bay,NY 12844
Tax Map ID 227.6-1.5
West Name Lake George
Address
Tax Map ID
OWNER STATEMENT
I/We do hereby relieve the Town of Queensbury from any liabilities on the plumbing and septic system located at:
16 Mayflower Lane
I/We realize that putting the well,septic tank or leaching system less than the required 10' feet from the building
may increase the risk of polluti n.
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Owner—Print Name:
�CYDate:
Owner—Signature: / ; Date:
N R OR TENANT RELEASE STATEMENT(if applicable)
I/We do hereby relieve wn of Queensbury from any liabilities on the plumbin eptic system located at:
I/We realize that putting the septic tank or leaching s ss than the required feet from the
may increase the risk of pollution.
Neighbor/Tenant—Print N Date:
Neighbor nt-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: Robert Stutz
Designates: Hutchins Engineering PLLC as agent regarding the Septic Variance for
Tax Map#:227.6-1-7 ,
OWNER'S SIGNATURE: / r �/ / DATE: id/6/2-6
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.
I, the undersigned, have thoroughly read and understand the instructions for submission;agree to the
• submission requirements and completed checklist:
OWNER—PRINT NAME: i/O e e� , liv"
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OWNER—SIGNATURE: WI)/ / '� DATE: 6 //j' ZO
AGENT—PRINT NAME: kl-k0 I
AGENT—SIGNATURE: DATE:4/94/—?—
Septic Variance Application February 2018