SEP-0067-2021 SEPTIC VARIANCE Office Use Only
Received:
APPLICATION Permit#: D o\g - 2.021
Permit Fee:
742 Bay Road,Queensbury,NY 12804 c,
P:518-761-8256 www.gueensbury.net Invoice#:
Approvals:
Submittal: I (one) original &8 copies of the completed application package
Property Owner(s): U 4 Riq 1�btk/17 5-HjPut LUwner's Agent: pp IEj? 13 (�'5 f�
Address. 5�1 M opts PI-0- CE Address: 15 l c- FU UTi�—
�1�97'1N",y A l t 7 / r69-1- l_OUPPP. Al�! ir�r�g
3 �~ r
Phone#: ��l� o� [ � � � Phone#: �/ �`� - 7�L.�r
Ll
Site Address:3( Tax ID#: /
Directions to Site: 1'77P 90 —ro R6 U f F qt_ re) R-15 5 1V,5z K PT I'M
Distance from well on property to septic system (if applicable) C 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 sy -ern meet setback requirements for distance from wells&septic systems on neighboring
properties? Yes No If NO, please explain:
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.):
Fore 6 z
FEB I . 2021
T01N BUILDING&CODES QUEENSBURY
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
Address ) R-65 R-1151- R
Tax Map ID �13
South Name �t1 q�'`� t L t� �5_,5 J / UJ
Address t 0 LO PS C=1161 K 1-`7_90Z,4KE
Tax Map ID
East Name ,
Address
Tax Map ID �✓��I l � .
?n�-rvel)q 0 ti'l—ek
West Name
Address
Tax Map IDS'-�
OWNER STATEMENT
I/We do hereby relieve the Town of Queensbury from any liabilities on the plumbing and septic system located at:
v �
I/We realize that putting the well,se tic tank or leaching system less than the required feet from the
may increase the risk of pollution. 1�� Lei ;gyinp11i-xrj
Owner—Print Name: � ��' ` , Date.
/a� �� �l
� ...� � t � �
Owner—Signature: ' J� � Date:
(W8 S76ENANT
�r�-[(_ - '
NEIGHBORRELEASE STA EMENT if a licabie
p )
I/We do hereby relieve the Town of Queensbury from ny ' biliti son the plumbing and septic system located at:
I/We realize that putting the septic tank or lea)ng Sys em I s tha 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:
Designates: PV 4—_9 13U S H E Y' as agent regarding the Septic Variance for
Tax Map#: l
OWNER'S SIGNATURE: ��°�''~'�'lf`t� ''`L�� .L� DATE: l ` 21
� s
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:
OWNER—SIGNATURE: DATE: �21
AGENT—PRINT NAME: e as IS �-5
AGENT—SIGNATURE: k3 DATE:
Septic Variance Application February 2018
P.O. Box 99 • 1133 NYS Route 86 • Ray Brook, NY 12977 • Tel: (518) 891-4050 • www.apa.ny.gov
March 15, 2021
Dave Hatin
Director, Building & Codes
Town of Queensbury
742 Bay Rd
Queensbury, NY 12804
Re: LV2021-0020
Variance Application: Shirvell
Town Resolution: BOH12,2021
Tax Map Number: 239.12-2-9
Dear Dave Hatin:
Adirondack Park Agency staff review of the above referenced variance determination
has been completed. The applicant proposes to install two holding tanks to service a
proposed single family dwelling. Relief is required from the Town for use of holding
tanks.
Based on the information presented in the record, no further Agency review is required
for this variance since the project does not involve provisions of the Adirondack Park
Agency Act.
Thank you for your referral of this variance determination.
Sincerely,
/s/Robyn Burgess
Robyn Burgess
Principal Adirondack Park
Local Planning Assistance Specialist
REB:KOK
cc: John Strough, Supervisor, Town of Queensbury
Craig Brown, Zoning Administrator, Town of Queensbury
Caroline Barber, Town Clerk, Town of Queensbury
/
O N E a Tlg fy 5, su n / P^oneNv Owncr: Raymond and Linda Shirvell icrz
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;s` a+,''o '""' / e f Project Address: 31 AssomblyPomt Road z 0Lake GeorgeO °)oTown ofQueensbury Q Von.Warren Countyz Z9; fill
..---.._.._---.•..••••••. .....---•-••---- tLtU�O< 0 FDy3ign Recommendation: 1-U W OWDue to site constraits,limited available pmpertA unobtainable separation distance F0 rW LU3008FIg51p,[aN� /°•'w ec ° t= :' restrictions and poor soil conditions,I have determined that a dual holding tank system with a M 5 Wj m^ '"iOe1 % high water alarm syst6ra is the best possible and onlyfeasble septic system solution for this , WN Q.\UIRtnNI A(:g s:1 ""-".+'.",: Q ..t site. b ZN yBased on the available property,a holding tank system is recommended as follows: WM RaJ2 30�IL9',D1l °,^"N ''+ '= -Two(2)new 1750 gallon holding tanks(concrete tank recommended)to be installed is series Wyp.F a0bfor3500gallonstoragecapacity. = OW=Ahighwateralarmsystemisto beset at the 280D gallon level(80%a capacity). ,�0 uWl<OThe tanks and all pipe connections are to be seated and watertight.No groundwater,surfacepF WWowater or any other non-septic flows are to enter the storage tanks. O O O W FA u f641h'.All r a o OFw a �Lu NGeneralNotes: pYY
a • 'w 1.If eny unusual or unexpected field conditions am encountered(groundwater,rock,utilities,etc,)the O 0>rlii Z_W p C
contractor shdll stop work and notify this engineer immediately. 2 C a W Z }..� .• ` nm ,w FFORTz 0 u 2a 0
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ANN 2.The Sketch Plan provided is for informational purposes only.The actual layout of the home and/or � it
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.iDP� fix .. p••a m,�eiow� �"C c°7wu' "iry101 theproposedsonitary system may very slightly from that shown.
ur•• °` ' I 3.Inspections ofthe proposed sanitary system are to be performed by the local codes efforcerricid ,
��/a r �s/ 9 m ,� �,f. •" officer and shall be-scheduled by the contractor or property owner.No parts ofthe system are to be
backdled without an inspection.If required,inspect:ons can be made by this engineer ifthe local
o•' I ` ,s+ e '1 of enforcement officer is unavailable. `
4.The propertylmcs on the Site Plan are shown in the approximate locations,Ifthe septic system is to
J.�� �)$ 1 � ) ..:• m , be placed in close proximity to a property line,the line should be properly located and marked by a
ciT'OiYYs fr !% °,... R �� NYSlicensed land surveyor.
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AFTER ALARM 76.64(_ Phone:315-822-5329
Fax.,315-266-1205
GAuorJs Email:ken.roberts.pe@gmail.com
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