SEP-0252-2022 > SEPTIC DISPOSAL PERMIT office Use only
APPLICATION Perm iit#: $EP- 02t>2- 2022. 5'
Town of Queensbury
Permit,Fee:$ .. . . CEIVE
Invoice#: 3 " ,� l.,!,, . �j z2 :.
742 Bay Road,Queensbu y. ,NY 12804
P:518-761-8256 .www.aueensburv.net. . SepticVariance? N <- CLERK'S,o-FICE
Flood Zone?. y
Wetlands? - Y- Reviewed,.By: �
Project Location::54 Russell Harris Road. . .
Tax Map #: 240.5=1-8._,. -
RESIDENCE INFORMATION:
Year-Built Gallons #of bedroorris: X gallons per. =.total daily flow
er day bedroom Garba a Grinder Yes No-
.per y g
1980 or older 150 Installed?- (choose one) : -❑ ❑X
1981-1991 130 Spa.or Hot Tub .Yes No
Installed? (choose one) ❑ Q
1992-Present 110 3 110 330
PARCEL INFORMATION:
Topography-• NIA Flat Rollin Stee -'Slo e, %.Slo e
:: : . - . ❑. . . g. . ❑ p , p p
Soil Nature N/A - ❑.Sand ❑ Loam ;❑ Clay ❑ Other.; explain:
Groundwater At wh at.dopth? .`NSA
Bed rock/Impervi.ous material - At"what depth?:• N/A`
Domestic'Water Supply ❑ Municipal ❑ 1Nell ❑Lake.
(if.well:or lake, water supply from:any.septic system absorption is
Percolation Test' Rate:: 'N/A per minute per inch (test;to be completed'by'a
licensed engineer/architect).
PROPOSED SYSTEM INFORMATION:
Tank size gallons:(min.size 1,000 gallons'; add 250:galloris for each-garbage cylinder or.:
spa/hot tub
' System . Abs lrpti.on.field-w/#2 stone. :Total.le.ngth. ft.; Each..Trench. ft.....
Seepage Pit W�1#3 stone How•rriany: ; Size:
Alternative System Bed brother type:
X, 'Holding Tank System Total required capacity-? 2500 tank size _,
-
# of tanks . 2
Septic Application Revised April2021,
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
�• P
• A►6'Picant.
Name(s): Gary Sampson
Mailing Address, C/S/Z: 30 CQWtty,-Club Rd., Queensbury, NY 12804
Cell Phone: .:- ' Land Line:_51-9 #yo-3153
Email: gary.w.sampson@gmail.com
• Primary Owner(s):
Name(s):
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): TBD
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
"Workers' Comp documentation must be submitted with this application"
• Engineer(s)•
Name(s): JARRETT Engineers. PLLC .
Mailing Address, C/S/Z: 12 E. Washington St., Glens Falls, NY 12801
Cell Phone: 518-769-0455 Land Line: 518-792-2907
Email: bholmesla-iarrettengineers.com
Contact Person for Compliance in regards to this project:_Robert Q. Holmes II, P.E.
Cell Phone: 518-769-0455 Land Line: 518-792-2907
Email: hhn_ImPsa.'srrPttPnainPPrs.com
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 known by 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: DATE: �ZS Af12- 7-v;2--L_
Septic Application Revised April 2021
4aTOWN OF QUEENSBURY
742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
q'�C7—��Plan to scale
4AReceived Deep hole pert test results from engineer/Architect if applicable(Town Approved Engineers and
Architects;June 30 to April 15 Town Engineer for unapproved Engineers and Architects)
II wells on property and adjacent properties shown
ycs Water line shown Municipal or well 10'separation to any part of system
1-Jb Setback to property lines show 10'or more for any part of system �`e ��et P t^ �/ 1 �--
VI
eptic tank and pump stations 10'from foundation 50'from any well/lake/wetland 10' from any waterline
'v J�Septic tank to foundation crawl space/slab on grade,grade in crawl space must be above top of septic tank
for0',Separation required (field verification required)
Septic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each ��"a 11n tom' RJ
�.J 4�eech Field 20'from foundation 100'from any well 10'from water line
40�- eepagee pit 150'from well 50'from septic tank
NANSeepage Pits 3-times diameter apart
eptic tank and pump stations over 30 gallons 50'from watercourse or wetland
distance from bottom of trench or system 24"to bedrock or mottling 36"within 1000' of Lake George
eech field 100'from watercourse or wetland
tToe of mound or bottom of retaining wall 10' from property line 100'from well 20' from
Foundation
(t4s
Provide Engineer/Architects e n systems
►V " Department of Health Approval for all mobile home park new systems Flood Plain requirements
't 2' above established flood elevation to bottom of system
rJ y All tanks anchored or 2' above flood elevation
V-;.PA All<mm1
JARRETT Engineers, PLLC Civil & Environmental Engineering
12 East Washington Street 518 792-2907
Glens Falls, NY 12801
Transmitted via Email
September 23, 2022
John O’Brien
Town of Queensbury
Building & Codes
742 Bay Road
Queensbury, NY 12804
johno@queensbury.net
Re: Sampson Residence
54 Russell Harris Road
Queensbury Permit #SEP-0252-2022
Wastewater Disposal System
JE# 21-051
Dear John:
This letter is to certify that representatives from this office visited the Sampson residence
during construction to observe the installation of the Wastewater Holding Tanks. Based
on our field observations, it is our belief that the system has been constructed
substantially in conformance with the ‘Issued for Construction’ design plans entitled,
“Replacement On-Site Wastewater System Petronelle & Gary Sampson Residence”
revision 2 dated 07/12/2022.
If you have any questions, please do not hesitate to contact us at (518)792-2907 or
bholmes@jarrettengineers.com.
Sincerely,
JARRETT Engineers, PLLC
Robert U. Holmes II, P.E.
Project Manager
Enc:
Cc: (ecopies) Petronelle & Gary Sampson
F:\DataFile\2021 Proj\Resid\21-051 Sampson WW - Qby\Work Docs\21051 220921 Sampson WW Cert\Srce Files\21051 220923
WW Cert Ltr.doc
s i .
40. �,
SEPTICVARIANCE once use oniv
Permit#:APPLICATION PermitFee:$ .
Invoice#:_�?J
742 Bay Road,Queensbury,NY 12804 .
P:518=761-8256 www.gueensbury.net Approvals:
Submittal: 1 (one)original &8 copies of the completed application package
PLEASE PRI T LEGI�L R TYPE '">=ASE INCLUDE AN EMAIL
�, 4
Section 1• .
�'IAY 0 M?
Contact Information:
Property Owners : Gary Sampson Pit t OF � Jft`t0 er's Agent: JARRETT Engineers, PLLC
Address: 30 Country Club RoadLA'd ress: 12.E. Washington St.
Queensbury, NY 12804 Glens Falls, NY 12801
Phone#: 518-480-3153 Phone#: 518-792-2907
Email:. gary.w.sampsonla'�,gmail.com . Email: bholmes aQarrettengineers.com
Section 2:
Site Information:
Site Address: 54 Russell Harris Road Tax ID#: 240.5-1-8
Directions to Site:
Section 3:
Distance from well on property to septic system (if applicable) N/A feet
.Section 4:.
Is it possible to install a conforming septic system on this property? ❑Yes X❑ No
If YES, please explain and attach a diagram:
Section 5:
Does the proposed:system meet setback requirements for distance from wells.&septic systems on neighboring
properties? ®Yes ❑ No' If,NO, please explain:
Section 6:
Is the.proposed system to be installed under a parking area? ❑Yes X❑ No
Section 7:
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.):_136-11.A Holding tank size and tank to property line setback
Septic Variance Application Revised December 2021.
Section S:
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 Gleasman. Michael F
Address 52 112.Russell Hams Road
Tax Map ID 240.5-1-7 .
South Name Spath,Andrew
Address 56 Russell Harris Road
Tax Map ID 240.54-9
East Name Bette Qualified Per Trust#1. Lisa K.
Address 34 Boathouse Road
Tax Map ID 240.5-1-2.1
West Name Lake Georae
Address
Tax Map ID
Section 9•
OWNER STATEMENT
I/We do hereby relieve the Town of Queensbury from any liabilities on the plumbing and septic system located at:
54.Russell Harris.Rd.I/We realize-that putting the.well,septic tank or leaching system less than the required<10 . feet
from the property line may increase the risk of pollution.
Owner—Print Name: jelA R "en)
Ouvner—Signature: Date: Z� ARVL 2.6 z 2
Section 10:
NEIGHBOR OR TENANT RELEASE STATEMENT(if opplicable)
I/We do hereby relieve.the Town of Queensbury from any liabilities on the plumbing and septic system located:at
.I/VVe realize that putting the well,septic tank or leaching system less than the required feet
from the may increase the risk of pollution.
Neighbor/Tenant—Print Name:
Neighbor/Tenant-Signature: Date:
septic Variance Application Revised December 2021
v\
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:
Fsamp�ltea;ni6lup n � .
i , N
L rM
R ac:
r` _J
- s{
- �:'•fkfls Lap; �,� .
Septic Variance Application Revised December 2021
C
Section 11:
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:
.Owners Name: Gary Sarnuson .
Designates: .IARRErr Engineers, al LC as agent regarding the Septic Variance for
.Site Address::'54 Russell Harris Road-
Tax Map#: 240.5-1-8.
Eneineerine 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.heteby authorize the Town Board:of Health,building and code;
Enforcement Officers and Town.Engineer to enter the subject propertiesfor 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 ariy:additional permits.
Official Meeting Minutes Disclosure: It is the practice of'theTown Board of Health:to have a designated
stenographer tape record the proceedings of the meetings resultirig.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 recotd'and.the handwritten minutes taken by.the des ignated,stenographer,the handwritten
minutes shall be deemed the official record.
I;the undersigned;have thoroughly read and understand the'instructior'is for submission;agree to the
submission requirements and completed checklist:
OWNER—PRINT NAME: A e,—i1
OVI/NER-SIGNATURE: DATE:
IZI
AGENT—PRINT NAME: Robert U. Holmes Il;.P.E.
by T SIGNATURE•. p �'
-AGEN
— DATE: . 4/28/22
-Se uc VaNante Appllcatlon Revised Dedum r 2021
227.14-1-1 227.14-1-2 227.14-1-3
Ayers,James B Dewey,Julia Dewey Irrevocable Trust,Julia L
413 Lincoln Dr 12 Lancestire Dr 12 Lancestire Dr
Guilderland,NY 12084 Queensbury,NY 12804 Queensbury,NY 12804
227.14-1-4 227.14-1-5 227.14-1-6
Ayers,James B Ayers,James B Ball,Donald&Marilyn
413 Lincoln Dr 413 Lincoln Dr 18 Woodside Ave
Guilderland,NY 12084 Guilderland,NY 12084 Oneonta,NY 13820
227.14-1-7 227.14-1-8 227.14-1-9
Ball,Donald&Marilyn Ball,Donald&Marilyn Freyer,Christian
18 Woodside Ave 18 Woodside Ave 51 Lenox Ave
Oneonta,NY 13820 Oneonta,NY 12820 Albany,NY 12203
227.14-1-10 227.14-1-11 227.14-1-12
Amann,James A DeMaranville Trust,Christine Bruce,Charles
46 Edsall Ave 2 Tailfeather Ct 32 Pulver Rd
Nanuet,NY 10954 Wartervliet,NY 12189 Kattskill Bay,NY 12844
227.14-1-13 227.14-1-15 227.18-1-21
Alonge,Gaetano Andretta,Vincent J Goodman,Craig L
9 Eliot Dr PO Box 1999 95 Pilot Knob Rd
Slingerlands,NY 12159 Kingston,NY 12402 Kattskill Bay,NY 12844
227.18-1-22 227.18-1-23 227.18-1-24
McClellan Fmly Irr Inc Only Tr McClellan,Bruce D Lakewood Homeowners Assoc.Inc
5 Lakewood Dr 5 Lakewood Dr 379 Quaker Rd
Kattskill Bay,NY 12844 Kattskill Bay,NY 12844 Johnsonville,NY 12094
227.14-1-16 227.14-1-17 227.14-1-18
Andretta,Vincent Freyer,Christian LaForte,Mary
PO Box 1999 51 Lenox Ave PO Box 60557
Kingston,NY 12402 Albany,NY 12203 Staten Island,NY 10306
227.14-1-19 227.14-1-20 227.14-1-21.1
Serbalik Family LP Phillips,Donna E.D. Cholakis Trust,George T
PO Box 270 PO Box 3368 6 Birch Ln
Mechanicville,NY 12118 Saratoga Springs,NY 12866 New Paltz,NY 12561
227.14-1-21.2 227.14-1-28 227.14-1-29
Filler,Martin Lamitie,Sarah Ball,Donald H
1157 Pilot Knob Rd 16 Summit Ave 18 Woodside Ave
Kattskill Bay,NY 12844 Latham,NY 12110 Oneonta,NY 13820
227.14-1-30 227.14-1-31
Seguljic,Thomas Sloan,Stephen
31 Lakewood Dr 35 Thomas Grove
Kattskill Bay,NY 12844 Pittsford,NY 14534
r
1.4
WASTEWATER-SEWER\Set PH\Sampson—Holding Tank&Property Line Setbacks-5-16-2022
RESOLUTION SETTING PUBLIC HEARING ON SEWAGE DISPOSAL
VARIANCE APPLICATION OF GARY SAMPSON
RESOLUTION NO.: ,2021
INTRODUCED BY:
WHO MOVED ITS ADOPTION
SECONDED BY:
WHEREAS, the Queensbury Town Board serves as the Town's Local Board of Health and
is authorized by Town Code Chapter 136 to issue variances from the Town's On-Site Sewage
Disposal Ordinance, and
WHEREAS, Gary Sampson (Applicant) has applied to the Local Board of Health for
variances from Chapter 136, §136-11 which requires applicants to obtain a variance for a holding
tank system, as the Applicant wishes to install a holding tank system consisting of two (2) 1,250
gallon capacity precast concrete holding tanks for a total capacity of 2,500 gallons in lieu of the
required total capacity of 3,500 gallons, and
WHEREAS, the Applicant has also applied for additional variances from Chapter 136 to
allow placement of the holding tank system:
1. 6'6"from the property line instead of the required 10' setback; and
2. 6'6"from the property line instead of the required 10' setback;
on property located at 54 Russell Harris Road in the Town of Queensbury,
NOW, THEREFORE,BE IT
RESOLVED, that the Town of Queensbury Local Board of Health will hold a public
hearing on Monday, June 131h, 2022 at 7:00 p.m. at the Queensbury Activities Center, 742 Bay
Road, Queensbury, to consider Gary Sampson's sewage disposal variance application concerning
property located at 54 Russell Harris Road in the Town of Queensbury and bearing Tax Map No.:
240.5-1-8 and at that time all interested persons will be heard, and
BE IT FURTHER,
RESOLVED, that the Local Board of Health authorizes and directs the Queensbury Town
Clerk to publish the Notice of Public Hearing presented at this meeting and send a copy of the
Notice to neighbors located within 500 feet of the property as required by law.
Duly adopted this 161h day of May, 2022, by the following vote:
AYES
NOES
ABSENT:
RESOLUTION APPROVING GARY SAMPSON'S APPLICATION FOR
SANITARY SEWAGE DISPOSAL VARIANCES
RESOLUTION NO.: BOH 50,2022
INTRODUCED BY: Mr.Anthony Metivier
WHO MOVED ITS ADOPTION
SECONDED BY: Mr.Harrison Freer
WHEREAS, Gary Sampson (Applicant) filed an application for variances from provisions
of the Town of Queensbury On-Site Sewage Disposal Ordinance, Chapter 136, §136-11 which
requires applicants to obtain a variance for a holding tank system as the Applicant wishes to install
a holding tank system consisting of two (2) 1,250 gallon capacity precast concrete holding tanks for
a total capacity of 2,500 gallons in lieu of the required total capacity of 3,500 gallons, and
WHEREAS, the Applicant has also applied for additional variances from Chapter 136 to
allow placement of the holding tank system:
1. 6'6"from the property line instead of the required 10' setback; and
2. 6'6"from the property line instead of the required 10' setback;
on property located at 54 Russell Harris Road 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 Monday,June 13t', 2022, 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
P
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
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 Gary
Sampson for variances from the Sewage Disposal Ordinance to allow installation of a holding tank
system consisting of two (2) 1,250 gallon capacity precast concrete holding tanks for a total
capacity of 2,500 gallons in lieu of the required total capacity of 3,500 gallons and allow placement
of the holding tank system:
1. 6'6"from the property line instead of the required 10' setback; and
2. 6'6"from the property line instead of the required 10' setback;
on property located at 54 Russell Harris Road in the Town of Queensbury and bearing Tax Map
No: 240.5-1-8, and
BE IT FURTHER,
RESOLVED, that the Town Board authorizes and directs the Town Clerk to forward by
certified mail 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 13th day of June,2022,by the following vote:
AYES Mr. Freer,Mr. Ferone,Mr. Strough, Mr. Metivier
NOES None
ABSENT: Mr. McNulty