SEP-0621-2022 SEPTIC DISPOSAL PERMIT Office Use Only
? APPLICATION Permit mac-2- -2022
Town of Quemsbury
Permit Fee:$
Invoice#: �� \
742 Bay Road,Queensbury,NY 12804 CY
P:518-761-8256 www.gueensbury.net Septic Variance? ) N fbO tk V8 2-C�2-2—
Flood Zone? Y
Wetlands? Y N eviewed By:
Project Location: r
Tax Map #:
RESIDENCE-INFORMATION: NOV �� 2022 6
P
Year Built Gallons #of bedrooms: X gallons per =total daily IowTO
per day bedroom �f LO' bage�G► s�Y Yes No
1980 or older 150 f InstaIle'd?--(choose-Q e) ❑
1981-1991 130 Spa or Hot Tub Yes No
1992-Present 110 Installed? (choose one) ❑
PARCEL INFORMATION:
Topography Flat Rolling ❑ Steep Slope % Slope
Soil Nature ❑ Sand 'Loam ❑ Clay El Other, explain:
Groundwater At what depth?
Bedrock/Impervious material At what depth? &ox-L
Domestic Water Supply ® Municipal ✓ Well ❑Lake
(if well or lake, water supply from any septic system absorption is
ft.)
Percolation Test Rate: 1.Al7 er minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size i 6bO 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 $'� ft.
Seepage Pit w/#3 stone How many: ; Size:
Alternative System Bed or other type:
Holding Tank System Total required capacity? ; tank size ;
# of tanks
Septic Application Revised April 2021
j CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): . j J
Mailing Addr s, C/S/Z:
Cell Phone:i > 365-76/ Land Line:
Email: A L UD Cr,S X z
• Primary Owner(s):
Name(s): J/;nnn_a��
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
❑ Check-If all-work-Will-be performed by property owner only
• Contractor:
Contact Name(s): �
Contractor Trade: /A a/��__,n�
Mailing Address, C/S/Z:
Cell Phone: , /�lb�f_'�) �j Land Line:
Email:
"Workers' Comp documentatio must be submitted with this application"
• Engineer(s):
Name(s):
Mailing A dr ss, C/S/Z:
Cell Phone:,$'&-7 16Y,4 Land Line:
Email:a7� "� �'La.{-� , r • co�.�
Contact Person for Compliance in regards to this project:
Cell Phone:l`-? 69 t - ril Land Line:
Email:
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: 0=q� L�J CLLC4VuV
SIGNATURE: DATE:
Septic Application Revised April 2021
TOWN OF QUEENSBURY
742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
q-KLPlan to scale
(Received Deep hole perc test results from engineer/Architect if applicable(Town Approved Engineers and
rchitects;June 30 to April 15 Town Engineer for unapproved Engineers and Architects)
'SAII wells on property and adjacent properties shown
�``ll water line shown Municipal or well 10'separation to any part of system
f
tJ Setback to property lines show 10'or more for any part of system UG-�Gw&I - p
t� Septic tank and pump stations 10'from foundation 50'from any well/lake/wetland 10'from any waterline
N 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)
,J!� 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
AL
Seepage Pits 3-times diameter apart A-
Septic tank and pump stations over 30 gallons 50'from watercourse or wetland
distance from bottom of trench or system 24"to bedrock or mottling.3�6�"within 1000'of Lake George
Leech field 100'from watercourse or wetland
n/*Toe of mound or bottom of retaining wall 10'from property line 100'from well 20'from
Foundation
lf!��Provide Engineer/Architect stamp for bed or design systems
pj a Department of Health Approval for all mobile home park new systems Flood Plain requirements
IN/0 2'above established flood elevation to bottom of system
N10 All tanks anchored or 2'above flood elevation
SEPTIC VARIANCE office use only
` - Permit#:sP - O z 1 - 2-0 7-
APPLICATION Pem,it Fee:$ 5"
Town ofLhrrcns urp
Invoice
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.ciueensbury.net Approvals:
Submittal: 1 (one) original &8 copies of the completed application package
PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
Section 1•
Contact Information:
PropertyOwner(s): Al Williams Owner's Agent: Wales Engineering
Address: 7 Thourobred Way Address: 68 Waterview Drive
CliftonPark, NY 12065 Saratoga Springs, NY 12866
Phone#: 518.365.7015 Phone#: 518.703.2480
Email: slwgsxr13@gmail.com Email: waleseng@nycap.rr.com
Section 2•
Site Information:
Site Address: 23 Sunset Lane Tax ID#: 226.19-2-8
Directions to Site: Assembly Point
Section 3•
z
. 65' to existing �� � �
Distance from well on property to septic system(if applicable) g feet 'p O ® �
Section 4: G) t
Is it possible to install a conforming septic system on this property? ❑Yes Q NoCn
p
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? QYes ❑� No If NO,please explain: small lots,septic separation of 100'cannot be acheived
Section 6•
Is the proposed system to be installed under a parking area? ❑Yes Q No
Section 7:
Section of the Sanitary Sewage Ordinance from which you are seeking the variance f i.e.leachin system will be 89 ft.
from well in lieu of required 100 ft.):rear setback from 10'to 3', well to new each fielc�approx 77'
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 Mathew Neuber
Address 24 Sunset Lane
Tax Map ID 226.19-1-7
South Name Scott Dubin
Address Sunset Lane - Off
Tax Map ID 226.19-2-12
East Name Scott Hunt
Address 15 Sunset Lane
Tax Map ID 226.19-2-6
West Name William S. Levett
Address 27 Sunset Lane
Tax Map ID 226.19-2-9
Section 9•
OWNER STATEMENT
I/We do hereby relieve the Town of Queensbury from any liabilities on the plumbing and septic system located at:
23 Sunset Land . I/We realize that putting the well,septic tank or leaching system less than the required 100 feet
from the new leach field may increase the risk of pollution.
Owner—Print Name: Al Williams
owner—signature:.Arz&&��C Date: 9.16.22
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:
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.
Neighbor/Tenant—Print Name:
Neigh bor/Tenant-Signature: Date:
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: AI Williams
Designates: Wales Engineering as agent regarding the Septic Variance for Williams Res
Site Address: 23 Sunset Lane
Tax Map#: 226.19`2`8
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. AI Williams
OWNER--SIGNATURE: Ad A DATE: 9•1 6.22
AGENT—PRINT NAME: Timothy W. Wales P.E.
AGENT—SIGNATURE: DATE: 9•16.22
Septic Variance Application Revised December 2021
Office Use Only
AMk SEPTIC VARIANCE
Permit
APPLICATION Permit Fee:$ 1
Timm of C?ivccnsbur}
Invoice#: t)f��fl Z
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Approvals:
Submittal: ) (one) original &8 copies of the completed application package
PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
Section 1:
Contact Information:
PropertyOwner(s): Al Williams Owner's Agent: Wales Engineering
Address: 7 Thourobred Way Address: 68 Waterview Drive
Clifton Park, NY 12065 Saratoga Springs, NY 12866
Phone#: 518.365.7015 Phone#: 518.703.2480
Email: slwgsxr13@gmaii.com Email: waleseng@nycap.rr.com
'Section 2•
Site Information:
Site Address: 23 Sunset Lane Tax ID#: 226.19-2-8
Directions to Site: Assembly Point _
r
Section 3: c o
5
65' to existing �
Distance from well on property to septic system (if applicable) g feet O ( ;:
Section 4' p 'c
Is it possible to install a conforming septic system on this property? ❑Yes No 0
I n�
If YES,please explain and attach a diagram: i _
Section S:
Does the proposed system meet setback requirements for distance from wells&septic systems on neighboring
properties? ❑Yes' 0 No If NO,please explain: small lot,septic separation of 100'cannot be acheived.
Section 6'
Is the proposed system to be installed under a parking area? ❑Yes n 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.):rear setback 1 O'to 3', site well to septic 77', neighbor well to 80'
Septic Variance Application Revised December 2021
Section$•
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 Mathew Nueber
Address 24 Sunset Lane
Tax Map ID 226.19-1-7
South Name Scott Dubin
Address Sunset Lane-off
Tax Map ID 226.19-2-12
East Name Scott Hunt
Address 15 Sunset Lane
Tax Map ID 226.19-2-6
West Name William S. Levett
Address 27 Sunset Lane
Tax Map ID 226.16-2-9
Section 9•
OWNER STATEMENT
I/We do hereby relieve the Town of Queensbury from any liabilities on the plumbing and septic system located at:
23 sunset Lane . I/We realize that putting the well,septic tank or leaching system less than the required 100 feet
from the new leach field may increase the risk of pollution.
Owner—Print Name: Al Williams
Owner—Signature: 11 / A . J/Ri/1/t i1 Date: 11.16.22
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:
. I/We realize that putting the well,septic tank or leaching system less than the required JOQfeet
from the may increase the risk of pollution.
Neighbor/Tenant—Print Name: _I( fro
Neighbor/Tenant-Signature: Date:
Septic Variance Application Revised December 2021
s
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: Al Williams
Designates: Wales Engineering as agent regarding the Septic Variance for Williams Residence
Site Address: 23 Sunset Lane
Tax Map#: 226.19-2-8
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: Al illiam
OWNER—SIGNATURE: �i ' �� �GG� DATE:
11.16.22
AGENT—PRINT NAME: Timothy W. Wales P.E.
AGENT—SIGNATURE: DATE: 11 .16.22
Septic Variance Application Revised December 2021
RESOLUTION APPROVING AL WILLIAMS' APPLICATION FOR
SANITARY SEWAGE DISPOSAL VARIANCE
RESOLUTION NO.: BOH 88,2022
INTRODUCED BY: Mr.Anthony Metivier
WHO MOVED ITS ADOPTION
SECONDED BY: Mr.Harrison Freer
WHEREAS, Al Williams (Applicant) filed an application for variances from provisions of
the Town of Queensbury On-Site Sewage Disposal Ordinance Chapter 136 to install a new leach
field on property located at 23 Sunset Lane in the Town of Queensbury with such leach field to be
located::
1. 3' from the side yard property line instead of the required 10' setback; and
2. 77' from the well instead of the required 100' setback;
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 request on Monday,November 7 h,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
RESOLVED,that
1. due to the nature of the variances, the Local Board of Health determines that the
1
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 Al
Williams for variances from the Sewage Disposal Ordinance to install a new leach field on property
located at 23 Sunset Lane in the Town of Queensbury with such leach field to be located::
1. 3' from the side yard property line instead of the required 10' setback; and
2. 77' from the well instead of the required 100' setback;
on property located at 23 Sunset Lane in the Town of Queensbury and bearing Tax Map No:
226.19-2-8, 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 any lawful action by the Adirondack
Park Agency during such period.
Duly adopted this 7t'day of November,2022,by the following vote:
AYES Mr. Freer,Mr. Ferone,Mr. McNulty,Mr. Strough,Mr. Metivier
NOES None
ABSENT: None