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SEPTIC VARIANCE office use n s s s
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APPLICATION emit#: �,�,d �— �,��
Town of Qecens.ury 1F9e: OCT ,v cU1�Pe 102Qir742 Bay Road,Queensbury,NY 12804 QUENS y JP:518-761-8256 www.queensburv.net Inv ,#:' l.E fors 1-/'Y /'
Appro a
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Submittal: I (one)original &8 copies of the completed application package
Property Owner(s): 11.-1 L'„,,A , Owner's Agent:
Address: i.c ts," 4:to"4 Di? Address:
Phone#: 9— fac'7 — fY 7 i Phone#:
Site Address: 1 Z /iL4z L. lam! ✓i)tT Tax ID#: 2„SCC s !/ —/--I'7
Directions to Site:
Distance from well on property to septic system(if applicable) 1 3-7 feet
Is it possible to install a conforming septic system on this property? Yes 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? Yes y No If NO, please explain: L 11 4.4" ,--1 /5 a",•A
Si i 62.0o.-1 w -T ea i44u !-t)
Is the proposed system to be installed under a parking area? 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.):
— L-64c a S l>,—e--i l S g-7 ( 4 4,,jF1 e. L ftr?--b A- 8 l t_iZ to 1 i! o A-s )4.7-
/446L1— I'oC?ti 2% qi' i Fr.+''
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Septic Variance Applica 't4�r ,C� d February 2018
List the names, parcel addresses, and tax mapnumbers of all adjoining
� g property owners. You may obtain tax
map numbers from the Assessor's Office as well as the names and addresses:
North Name MAP I Linl A-2A K "f V 4774-9—r=
Address /42 /4/)..Le tz p IA i
Tax Map ID Z.9M ,
I .
South Name ' '/f (.4,?L r,isz--. 4LL'R2 i
Address zv #4ie._. / b x
Tax Map ID Z er
East Name Alt��;ira� - 1�1 7 C-At-A-7 /J-
Address 13t-,g,-r? t)
Tax Map ID , d L
West Name 14 f A
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:
I/We realize that putting the well,septic tank or leaching system less than the required lc:" feet from the §.1"6" K
may increase the risk of pollution.
Owner—Print Name: /4-1> Date: 91z�c/c}
- I /
Owner—Signature: Date: Tt z` t
NEIGHBOR OR TENANT RELEASE STATEMENT.(if applicable)
I/We do hereby relieve the Town of Queensbury from any liabilities on the plumbing and septic system located at:
lab E'tr
I/We realize that putting the septic tank or leaching system less than the required /cX feet from the woj
may increase the risk of pollution. n • Ryan Date: 10l71/9
Neighbor/Tenant-Signature: Date: f c) 7//`).
Septic Variance Application February 2018
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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:
Designates: as agent regarding the Septic Variance for
Tax Map#:
OWNER'S SIGNATURE: DATE:
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.
Official 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: ,fi,A,A4 L 3 1
OWNER—SIGNATURE: � DATE: ?Jz9/I9
AGENT—PRINT NAME:
AGENT—SIGNATURE: DATE:
Septic Variance Application February 2018