Septic variance ~
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Office Use Only
SEPTIC
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APPLICATION
74%Bay Road,{lueensbun6NY 12804 en e-L
P:51O'761'82S6
Submittal: | ( ) original & 8 copies ofthe completed application package
Property Owner(s)-.ShUM [Atas6ls Agent:
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of. Cry
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Phone#
Site Address: Tax I D#:
Distance from well on property to septic system (if applicable) NS IA feet
Is it possible to install a conforming septic system on this property? Yes No
If YES, please explain and attach a diagram: nn iE n
Does the proposed system meet setback requirements for distance from wells&septic ;ysIls-on;ne�ighboring
properties? �!!N Yes No If NO, please explain: T WN OF QUEENS-121 IRv
BUILDING X, CODES
|s the proposed system tobe 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 10Oft]:
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Septic voname Application roumaryzo18
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 Au W,eaca�j._A
Address
Tax Map ID co "
South Name An �� H6w hcm�
Address
Tax Map ID � iLp
East Name
Address
Tax Map ID
West Names\
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 feet from the
may increase the risk of pollution. ,+ 7
Owner—Print Name: e Date: R � 21v -Z®20
Owner—Signature: Date: �? , ZLo-ZbZV
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:
I/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
BASIS 01
i 24't FROM THIS PLAN IN(
PROPERTY LINE AN EXISTING I
PROJECT FUSION ZF450 ETU TREATMENT U
NORTH SEE SPECS & DETAILS THIS SYSTEM
GENERATED A
ARE BEING PF
00
THIS DESIGN `
UV LIGHT FUSION .ZF45C
DISINFECTION 'UNIT 3 BEDROOM ZF 450 IS AN
SEE SPECS & DETAILS RESIDENCE SYSTEM WITH
(NO BASEMENT) FLOW THROUG
EXISTING ULTRA VIOLET
DRY WELL
ABANDON IN PLACE DESIGN FLOW
EXISTING SEPTIC TANKL
330 GALLO
Lo
ADDITIONAL B
DRINKING WA1
+I GEORGE. NO
t KNOWN TO BE
SEPTIC SYSTE
CONSTRUCTIOP
PROFESSIONAL
WAS INSTALLE
LAKE GEORGE APPROVED DC
PREPARED FO
OWNER. UNA
THESE PLANS
EDUCATION L/
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