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SEP-0408-2021 SEPTIC DISPOSAL PERMIT office use only _ APPLICATION Permit#: -G—P-- a sot) - Z0-21 'town of Qucensbuzy Permit Fee:$ Invoice#: O� 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.aueensbury.net Septic Variance? U N Flood Zone? Y N Wetlands? Y -I!� wed Project Location: 2n!Bn 3; �'.9 L. LTOVVN Tax Map #: 2?R_ %� 2 5 ` �1 %UEENSBURY RESIDENCE INFORMATION: G&COMES Year Built Gallons #of bedrooms: X gallons per =total daily flow per day bedroom Garbage,Grinder Yes No 1980 or older 150 Installed? (choose one) ❑ 1981-1991 130 2- 3 ��lo� Spa or Hot Tub Yes No 1992-Present 110 Installed? (choose one) ❑ PARCEL INFORMATION: Topography Flat Rolling ❑ Steep Slope % Slope Soil Nature ❑ Sand i7,4 Loam [],Clay ❑ Other, explain: Groundwater At what depth? -T;Ep C—,P -54.! Bedrock/Impervious material At what depth?--:;!5�` Domestic Water Supply ❑ Municipal X Well ❑Lake (if well or lake, water supply from any septic system absorption is ft.) C��z>r�.i-a i-E CA4 Percolation Test Rate: -7 per minute per inch (test to be completed by a licensed-engineer/architect) PROPOSED SYSTEM INFORMATION: Tank size in= gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub System Absorption field w/#2 stone Total length ft.; Each Trench ft. Seepage Pit w/#3 stone How many: ; Size: Alternative System Bed or other type: G a — Z -zBUF—Ti Holding Tank System Total required capacity? _ tank size ; # of tanks Revised Anril 2021 .� CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL Applicant: Name(s): Jc> -&lzff>Cy� G' �1 teDeK Mailing Address, C/S/Z: coo lH= Cell Phone:91-7 8H(,,o-o3�9 Land Line: 1.-06kK.a Email: �{hct�in�_ e1•jc�ctr9r�c e�.Gym �Cll'�'.-5q Ie��m�t1.c, • Primary Owner(s): l� Name(s): -6A0A_ Mailing Address, C/S/Z: Cell Phone: Land Line: Email: ❑ Check if all work will be performed by property owner only • Contractor: Contact Name(s): Contractor Trade: Mailing Address, C/S/Z: \A,42�1C= Cell Phone: j71 S 3Col -Ze- 4a6 Land Line: Email: c_teyall [_ %bi590:f-wtiG• cCs+M "Workers' Comp documentation must be submitted with this application • Eneineer(s): Name(s): E>r tv t<F.+e�'h1�� Mailing Address, C/S/Z:"R•9©O r-. 1,044a, Cell Phone: 151B MC Land Line: Email: Contact Person for Compliance in regards to this project. Cell Phone: t'2 tie W42-.t}�$5and Line: 9 Email: cmeh.-�lr'�-,.�_c�_Q �L�.G�Y1r1 NOTES: 1. Alarm system and associated electrical work must be inspected by a Town approved electrical inspection agency; 2. We will no longer allow systems to be covered until such time as an as-built plan is received and approved.The installed system must match the septic layout on file-no exceptions. 3. As- built drawings must be submitted prior to the inspection, if there has been a change to the submitted plans. 4. If, for any reason, the building permit application is withdrawn, 30% of the fee is retained by the Town of Queensbury. After 1 year from the initial application date, 100%of the fee is retained. Declaration: Any permit or approval granted which is based upon or is granted in reliance upon any material representation or failure to make a material fact or circumstance knowrfb-y--or on-behalf of an applicant,shall be void. I have read the regulations and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance. PRINT NAME: SIGNATURE: �" " G. DATE: TOTAW OF QUEEiTSBURY 742 Bay Road, Queensbury, NY. 12804-5902 Septic System Checklist *lan to scale *Received Deep hole perc test results from engineer/Architect if applicable(Town Approved Engineers and Architects;June 30 to April 15 Town Engineer for unapproved Engineers and Architects) qa Lq_All wells on property and adjacent properties shown Water line shown Municipal or well 10'separation to any part of system Y41setback to property lines show 10' or more for any part of system AIV64- 14- Septic tank and pump stations 10'from foundation 50'from any well/lake/wetland 10'from any waterline /v ) Septic tank to foundation crawl space/slab on grade,grade in crawl space must be above top of septic tank for 0',Separation required (field verification required) y / { ` Septic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each Leech Field 20'from foundation 100'from any well 10'from water line Seepage pit 150'from well 50'from septic tank I"l►k Seepage Pits 3-times diameter apart XSeptic tank and pump stations over 30 gallons 50'from watercourse or wetland Xclistance from bottom of trench or system 24"to bedrock or mottling 36"within 1000'of Lake George XLeech field 100'from watercourse or wetland Toe of mound or bottom of retaining wall 10'from property line 100'from well 20'from Foundation rovide Engineer/Architect stamp for bed or design systems Department of Health Approval for all mobile home park new systems Flood Plain requirements 2' above established flood elevation to bottom of system n All tanks anchored or 2'above flood elevation ENVIRONMENTAL DESIGN CEO PARTNERSHIP, LLP. 900 Route 146 Clifton Park,NY 12065 (P)518.371.7621 (F)518.371.9540 edpllp.com Shaping the physical environment September 20,2021 Town of Queensbury Building&Codes 742 Bay Road Queensbury, NY 12804 AS BUILT Attn: Dave Hatin, Mark Smith Re: Joshua's Rock Corporation Caretaker's Residence Wastewater—3089 Rt.9L Dear Dave: In compliance with application approvals granted by the Town of Queensbury 1 offer the following regarding the referenced project. The design plans, prepared by this office and reviewed and approved by the Town as associated with the wastewater system application,are as follows: Proposed Wastewater Improvements For Joshua's Rock Corp. • Sheet S-1 Cover Sheet Sheet S-2 Existing Conditions Sheet S-3 WW Plan • Sheet S-4 Wastewater Details Dated: May 27,2021 During the course of construction I was on the job site to observe key components of the system installation culminating with the backfilling of the field area on August 5, 2021. The field location of the septic tank and the wastewater absorption system and D-Box have been installed as per the approved design plan.An As-built' plan is provided which provides dimensions to the buried D-box location. The septic tank has an access cover at grade. Based on my inspection of the system start-up it is my opinion that the wastewater system is in compliance with the intent of the approved design plan and is ready for operation. Sincerely, D Dennis MacElroy, PE cc: Kit Seelye t - - - Office Use Onlv SEPTIC VARIANCE Permit#: Zile? . 0408-.2zzl - APPLICATION Permit Fee: Fnt m of Qirecnsbuly Invoice 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www. ueensbu .ne D v O `=° Approvals: JUN 0 1 2021 Submittal: 1 (one) or I &:8 copies of the 1pleted application package TOWN OF QUEENSBURY BUILDING&GOD.::S Contact Information: PLEASE-PRINT LEGIBLY OR TYPE; PLEASE'INCLUDE AN, EMAIL , Property Owner(s): J o5 N v►A -* Rc=CA<, Owner's Agent: G r_?ces o>rd " Address: Goo Lo► �ouse Address: . IIZ _7e+ TOO" .3o t}ir-L-EsA D�►VE � �"����L 1�1�' " l Z.�b� , Phone#: . 9.17 ?9 Phone#: Email: Email: a w,��1�� � a 1� ,cr�vY / � � ,r,•ffitiwr<.¢.3. cam Site Information: Site Address: Tax ID#: " 2.39A — Z Directions to Site: _f Distance from well on property to septic system (if applicable) feet Is it possible to install a conforming septic system on this property? ❑Yes KNo If.YES,please explain and attach a diagram: Does the.proposed system meet setback requirements for distance from wells&septic systems on neighboring properties? Dyes ❑ No If NO, please.explain: Is the proposed system to be installed under a parking area? ❑Yes JNo 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.): �J cur Septic Variance Application Revised January 2621 LISL lrIe IIdIIICJ, PcIIU11 duuICJJC�,-dtlu ICIA IIICI.1 II.urlluCi.J UI tlII c1ujuIIIII1r"IJt.UPt=I LY.uwt.iCiJY;.rVu:IIjCIY'.u.u.LC1JI V information from the Town'of Queensbury's Assessor's Office: North Name.. � E3Cs+ ®� � +T cam' . ..� .. Address;:- , -50�.VACA V CIC) .' 7 Tax Map ID 9 e 19 South Name Address gg Tax Map ID East Name �� .�� Ems ` . Address A+ lA�:> a a �4 Tax Map ID �`�-� `�e���9 C.,A `� West Name Address Tax Map ID bWNER 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 U. from the may increase the risk of pollution. e �� 4"K coy*' Owner—Print Name:K Owner--Signature: Date: _iQ �.. ,�-. 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 well,septic tank or leaching system less than the required feet from the may increase the risk of pollution. S ... Neighbor/Tenant—Print Name: Neighbor/Tenant-Signature; AADate: . i 5eptic variance Application Revised Jawary.2021 n ION AND SIGNATUkt:PAGE: :AUTHORIZAT. This page includesthe Authorization to Act as:Agent,form; engineering.fee;disclosure, authorization fors e visits;•other,p.ermit responsibilities and agreement to provide documentation-required: Compiete the following if the:OWNER:is using an Agenti Owner s,Name: •o��r. J Cwl � 1 . Designates: as agent regarding.the Septic.Variance for « L Site Addressu . 3 L TaxMap Engineering Fee Disclosure:Applications maybe.referred to the.Town consulting engineerfor 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 ubmitting 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`peoperties 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 l own Board of Health. It is the applicanfs;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 of the in 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,.th&h,andvi►ritten. 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: A .®S ?t�& OWNER "P. NAME: OI�� 'Qlt'�.�' � 1 i •�' 06 >. OWNER" SIGNATURE: : _DATE;`" a: I`. AGENT=PRINT..NAME: 1►4► ( , AGENT. SIGNATURE. 1.• - - - - - - - - - - Septic Variance A ppication l .'Re3ised'Jan-_ry, v. P . t RESOLUTION APPROVING JOSHUA'S ROCK CORPORATION'S APPLICATION FOR SANITARY SEWAGE DISPOSAL VARIANCES RESOLUTION NO.: BOH 31,2021 D E C tr INTRODUCED BY: Mr.Anthony Metivier J U N 2 5 2021 WHO MOVED ITS ADOPTION TOWN OF QUEENSBURY SECONDED BY: Mr.Harrison Freer BUILDING &CODES WHEREAS, Joshua's Rock Corporation(Applicant) filed an application for variances from provisions of the Town of Queensbury On-Site Sewage Disposal Ordinance, Chapter,136 to install a replacement wastewater treatment system with its components to be located as follows: 1. Absorption bed to be 75' from the well instead of the required 100' setback; and 2. Septic tank to be 45' from the well instead of the required 50' setback; on property located at 3089 State Route 9L in the Town of Queensbury, and WHEREAS,the Town Clerk's Office published the Notice of Public Hearing in the Town's official newspaper and the Local Board of Health duly conducted a public hearing concerning the variance requests on June 21St,2021,and WHEREAS, the Town Clerk's Office has advised that it duly notified all property owners within 500 feet of the subject property, NOW,THEREFORE,BE IT RESOLVED,that 1. due to the nature of the variances, the Local Board of Health determines that the variances would not be materially detrimental to the purposes and objectives of this If Ordinance or other adjoining properties nor otherwise conflict with the purpose and objectives of any Town plan or policy; and 2. the Local Board of Health finds that the granting of the variances is necessary for the reasonable use of the land and are the minimum variances which would alleviate the specific unnecessary hardship found by the Local Board of Health to affect the Applicant; and BE IT FURTHER, RESOLVED, that the Local Board of Health hereby approves the application of Joshua's Rock Corporation for variances from the Sewage Disposal Ordinance to install a replacement wastewater treatment system with its components to be located as follows: 1. Absorption bed to be 75' from the well instead of the required 100' setback; and 2. Septic tank to be 45' from the well instead of the required 50' setback; on property located at 3089 State Route 9L in the Town of Queensbury and bearing Tax Map No: 239.19-1-12, and BE IT FURTHER, RESOLVED, that the Town Board authorizes and directs the Town Clerk to forward by certified mall a certified copy of this Resolution to the Adirondack Park Agency for its review, and BE IT FURTHER, RESOLVED, that this approval Resolution shall not be effective until 30 days after such notice to the Adirondack Park Agency and shall be subject to review by the Adirondack Park Agency during such period. Duly adopted this 21"day of June,2021,by the following vote: AYES Mr. Metivier,Mr. Freer,Mr. Ferone,Mr. McNulty,Mr. Strough NOES None e ABSENT: None