SEP-0510-2021 SEPTIC VARIANCE Office Use Only `
Permit#: 3-Q— 9St O — ZOZI
- _ APPLICATION Permit Fee:$ l�5
Twim of CZrccn.sbun
Invoice#:
742 Bay Road ��JS
,Queensbury,NY 12804 �1 ,
P:518-761-8256 www.gueensbury.net Approvals: eOA `56,202-(
Submittal: 1 (one) original &8 copies of the completed application package
Contact Information: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
Property Owner(s): Harley & Tia Griffiths Owner's Agent: SRA Engineers
Address: 298 Cleverdale Road Address: 453 Dixion Rd., Suite 7, Bldg. 3
Queensbury, NY 12804 Queensbury, NY 12804
Phone#:(917) 826-4424 Phone#: (518) 761-0417
Email: harley@4as.org Email: info@sraengineers.com
Site Information:
Site Address: 298 Cleverdale Road Tax ID#: 226.12-1-86
Directions to site: The address is on the right, approximately 1.35 miles down Cleverdale Road from 9L
Distance from well on property to septic system (if applicable)100+feet From Lake
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? ❑Yes ❑ No If NO, please explain: Unknown
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.): Section 136-11 Holding Tanks.
Holding tank capacity will be 4,000 gallons in lieu of required 5,000 gallons for a 6 bedroom
residence.
D � C �
JUL 07 2021
TOWN OF QUEENSBURY
BUILDING&CODES
Septic Variance Application Revised January 2021
List the names, parcel addresses, and tax map numbers of all adjoining property owners. You may obtain this
information from the Town of Queensbury's Assessor's Office:
North Name Albert F. Freihofer
Address 300 Cleverdale Road
Queensbury, NY 12804
Tax Map ID 226.12-1-85
South Name Sandy Bay Onaway LLC
Address 296 Cleverdale Road
Queensbury, NY 12804
Tax Map ID 226.12-1-87
East Name Lake George
Address N/A
Tax Map ID N/A
West Name Cleverdale Road West Name John A Brock
Address N/A Address 297 Cleverdale Road
Queensbury, NY 12804
Tax Map ID N/A Tax Map ID 226.12-1-2
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 eaching system less than the required feet
from the may increase the risk of p ution.
Owner—Print Name: Harley Griffiths
Owner—Signature: Date: 7/6/21
NEIGHBOR OR TENANT RELEASE STATEMENT(if pplicable)
I/We do hereby relieve the Town of Queensbury from any liabilities on the pl mbin nd septic system located at:
I/We realize that putting the well,septic tank or leaching system less tha a required feet
from the may increase the risk of pollution.
Neighbor/Tenant—Print Name:
Neighbor/Tenant-Signature: Date:
Septic Variance Application Revised January 2021
1 ,
PLEASE ATTACH THE FOLLOWING TO YOUR APPLICATION:
1. A location map showing the site within the Town of Queensbury
2. A plot plan showing existing and proposed features of the property, including:
a. Lot dimensions
b. North arrow and scale: 1 inch=40 feet
c. Location &dimensions of existing and proposed buildings, showing setback distances and
uses
d. Parking layout to scale (if applicable)
e. Physical features (street, steep slopes, lakes,wetlands, etc.)
f. Location of all wells and septic systems on neighboring properties
g. Adjacent ownerships
h. All properties within 500 feet
A sample plot plan and location are shown below:
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Septic Variance Application Revised January 2021
'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 ifahe OWNER is using an Agent:'
Owner's Name: Harley and Tia Griffiths
Designates: SRA Engineers (Erik:Sandblom; P.E:) .as agent regarding the Septic Variance for--
Site Address:-298 Cleverdale.Road
Tax Map-#:..226.12-1-86=
Enigineerine'Fee.Disclosure: Applications may be referred to the
:Town.consulting engineer for review:of septic.
design, storm drainage;etc:as determined by the:Town.Bbard of Health. Fees for engineering:review services
-will be charged directl.y.to the applicant..
Authoriiation.for Site Visits: By signirig:this page-arid submitting the application materials attached herein;the .
Owner;Applicantand his/her/their agent:hereb_y: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 resultingfrom:the application; an_d that the
minutes transcribed from those tapes constitute.the' officialrecord.of all.'proceed.ings..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 arid understand the instructions for submission; agree to the
submission,requirements and corripleted.chec ist:.
.OWNER.-PRINT NAME: Harley Griffiths
OWNER—SIGNATURE: - DATE: 7/6/2'1
AGENT—PRINT NAME: �.
AGENT-SIGNATURE.,. DATE: . 7 ZG��
Septic Variance Application Revised-January 2021