Variance Application C r SEPTIC VARIANCE Office Use Only
Received:
APPLICATION Permit#:c�C — V il: ZD 40
TO%M of Cjircen-bury �n
Permit Fee:
742 Bay Road,Queensbury, NY 12804 q
P:518-761-8256 www.gueensbury.net Invoice#: I�
Approvals:
Submittal: I original &8 copies of the completed application package
Property Owner(s): Keith&Sarah Barton Owner's Agent: Hutchins Engineering PLLC
Address: 118 Sunnyside North Address: 169 Haviland Road
Queensbury,NY 12804 Queensbury,NY 12804
Phone#: 518-744-0824 Phone#: 518-745-0307
Site Address: 120 Sunnyside North Tax ID#: 279.17-2-11
Directions to Site: travel North on Bay Rd,turn right on Sunnyside North,parcel on right in 0.5 miles
Distance from well on property to septic system (if applicable) NSA 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 If NO, please explain:
Is the proposed system to be installed under a parking area? X 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.):
Install Infiltrator H-20 chamber absorption system beneath driveway.
Absorption field 1.5'from property line instead of required 10'.
Septic tank 3.5'from property line instead of required 10'
Distribution box 1.5'from property line instead of required 10'
-c_, r
s 1
Septic Variance Application February 2018
List the names, parcel addresses, and tax map numbers of all adjoining property owners. You may obtain tax-4
map numbers from the Assessor's Office as well as the names and addresses:
North Name Malcolm&Karen Nichols
Address 121 Sunnyside North Queensbury,NY 12804
Tax Map ID 279.17-1-33
South Name Lake Sunnyside
Address
Tax Map ID
East Name Malcolm&Karen Nichols
Address 121 Sunnyside North Queensbury,NY 12804
Tax Map ID 279.17-2-10
West Name Keith&Sarah Barton
Address 118 Sunnyside North Queensbury,NY 12804
Tax Map ID 279.17-2-12
OWNER STATEMENT
I/We do hereby relieve the Town of Queensbury from any liabilities on the plumbing and septic system located at:
120 Sunnyside North
I/We realize that putting the well, septic tank or leaching system less than the required feet from the
may increase the risk of pollutio
Owner—Print Name: Date:
Owner—Signature: Date:
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
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: Keith or Sarah Barton
Designates: Hutchins Engineering PLLC as agent regarding the Septic Variance for
Tax Map#: 279.17-2-11
f OWNER'S SIGNATURE: DATE: ,0
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:
j
OWNER—PRINT NAME:
OWNER—SIGNATURE: DATE.
AGENT—PRINT NAME: . Thomas Hutchins, P.E.
AGENT—SIGNATURE: Jll DATE: cJ
Septic Variance Application February 2018