SEP-0030-2021 SEPTIC VAFJANCE Office Use Only
Permit#:-zp? -OD'a>0 — Zp2\
APPLICATION Permit Fee:-$
Tome of QtwensEury
Invoice* "C`✓ �`�
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www. ueensbury.net Approvals:
a
Submittal: I (one) original & 8 copies of the completed application package
PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
Section 1•
Contact In or-matiori:
Property Owner(s): _Phillip Mitchell_ Owner's Agent:.-None-
Address: 2960 NY-9L Address: RBUtLDING
"��
Lake George NY 12845
Phone#: (518) 656-3657 or(518)812-6615 Phone#: 7 ZOZ2Email: lauraphillmitchell@gmail.com Email:
Section 2: &GOl7CcS
Site Information:
Site Address: 2960 NY 9L Tax ID#: 239.20-1-10
Directions to Site: North on Bay Rd.to end, Right on 9L, 0.2mile on left
Section 3:
Distance from well on property to septic system(if applicable) -NA- feet
Section 4•
Is it possible to install a conforming septic system on this property? ❑Yes ® No
If YES,please explain and attach a diagram: Possible with Blasting 8ft from home (not Practical)
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 ® 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.): 1)Pump Basin will be 2 ft from South property line in lieu of 10 ft and
2)Pump Basin will be 45 ft.from Lake George in Lieu of 50 ft._
Septic variance Application Revised December 2021
Section 8•
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 Camp Bayview LLC
Address 2958 NY-91L
Tax Map ID 239.20-1-11
South Name Richard Cadena and Lisa Cadena Pole
Address 2962 NY-91L- ow4e'r>
Tax Map ID 239-20-1-9
East Name Mountainside Grange LLC
Address 2957 NY-91L
Tax Map ID 239.20-1-20
West Name Gary Banta
Address 2969 NY-91L
Tax Map ID 239.20-1-21
Section 9:
OWNER STATEMENT
I/We do hereby relieve the Town of Queensbury from any liabilities on the plumbing and septic system located at:
2960 NY-91L . I/We realize that putting the well, septic tank or leaching system less than the required Pump 10@90 50ft
from the Lake George may increase the risk of pollution.
Owner—Print Name: Phillip Mitchell
Owner—Signature: dA& Date: Feb.7th,2022
Section 10:
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:
G`710 NY= `JL I/We realize that putting the well,septic tank or eaching system less than the required 10 feet
from the nf A Pkol)er_�' ay increase the risk of pollution.
Neighbors—Print Name: R i C �/ C�
Neigh bor rare Si nature: Il ' � Y a I/A hJ� G+�/(9CJ( Date: ' f J2-022—
Septic Variance Application Revised December 2021
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 December 2021
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:
Owner's Name:
Designates: as agent regarding the Septic Variance for
Site Address:
Tax Map#:
Engineering Fee Disclosure:Applications maybe 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:
AGENT—PRINT NAME:
AGENT—SIG NATO RE; DATE
Septic Variance Application Revised December 2021
SEPTIC VALIANCE Office
Use On
Pemlit ig: - SC—P—o �o •?�
APPLICATION Permit Fee:$ 1 ��
Town of(_1t ensbun,
Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Approvals:
aQ�c -Gj�icS G u 2 L, i jricicu GPjJlJiaciiviI Na--nasc
PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
Section 1•
..__�_1,_t___I_L, _ REVISED
k..uriLa iruurr-- - -
Property Owner(s): Phillip Mitchell Owner's Agent: -None-
Address: 2960 NY-91- Address:
Lake George NY 12845 [E
Phone#: (518)656-3657 or(518) 812-6615 LW
Phone#:
Email: lauraphillmitchell@gmail.com Email: njy2O22 *Section 2: LTOWN OF QUEBUILDIF G&
Site'lnformation:
Site Address: 2960 NY-91- Tax ID#: 239.20-1-10
Directions to Site: North on Bay Rd. to end, Right on 9L, 0.2mile on left
Section 3-
Distance from well on property to septic system(if applicable) -NA- feet
Section 4•
Is it possible to install a conforming septic system on this property? ❑Yes ®No
If YES, please explain and attach a diagram: Possible with Blasting 8ft from home (not Practical)
Section 5•
Dees 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 ®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.): 1)Pump Basin will be 2 ft from South property line in lieu of 10 ft
2)Pump Basin will be 45 ft.from Lake George in lieu of 50 ft.and
Septic Variance Application 3)Pump Basin will be 3 ft from the Cabin in lieu of 10 ft. Revised December 2021
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:., Onsite Equipment, Inc.
_ P.O. Box 6265
Syracuse, NY 13217
315-254-6891
MAINTENANCE/SERVICE AGREEMENT
FOR CLARUS FUSION
Project Number: 120721
Owners Name: Phill and Laura Mitchell
Property Location: 2960 NYS Route 9L, Lake George, NY 12845
Owners Mailing Address: 2960 NYS Route 9L, Lake George, NY 12845
Email: lauraphillmitchell@gmail.com
Phone Number: 518-812-6615
Term: 4 Years
Start Date: December 7, 2021
This Agreement will serve as acknowledgement that Onsite Equipment, Inc. (Onsite) will
.provide service on the Glarus Environmental, Inc.. (Clarus) Fusion enhanced treatment
unit at the above referenced property. Onsite will perform annual scheduled service
checks of the Fusion for four years or until the first pump out is required. After this term,
the owner must subscribe to the inspection and maintenance program. Applicable
regulatory entity may be notified if the agreement is terminated at any time, regardless of
the reason.
Onsite will check the Fusion for proper operation and notify the owner of any deficiencies
that need to be addressed. The cost associated with additional items including
replacement of parts, pumping out accumulated foam/sludge or site grading is not
included in this agreement. Property owner agrees to operate the unit in accordance with
the manufactures recommendations as presented in the Fusion Owner's Manual. Owner
may transfer the benefits of this Agreement to any purchaser or other person who
acquires the property where the fusion is located.
Onsite is not responsible to redo any service checks delayed or prevented as a result of
limited access to the site, no electricity at the Fusion panel, or as a result of an Act of
God.
Property owner agrees to operate the unit in accordance with the manufactures
recommendations as presented in the Fusion Owner's Manual.
i • •,
ENGINEERING , PLLC
November 16, 2022
Town of Queensbury
Attn: Mr. John O'Brien
742 Bay Road
Queensbury,New York 12804
RE: Onsite Wastewater Treatment System Installation Certification
Mitchell Residence
2960 NYS Route 9L
Queensbury,New York
Dear Mr. O'Brien:
The undersigned completed final observation and startup of the above-referenced onsite wastewater
treatment system on December 7,2021. Construction observation was completed during the construction
phase. The installation was completed in substantial conformance with the intent of the design drawings.
Do not hesitate to contact me at (315) 254-6891 if you have any questions.
Sincerely;
Eric E. Murdock, P.E.
cc: Mr. Phil Mitchell, Owner
UtvSITE ENGINEERING R { fdG PO BOX 6265, SYRACUSE , R1 Elh' YURK i 32 } 7 TEL 31 5 . 254 . 6891
PRo `rECTING 0UP LAKES AND RIVERS I