BOTH-000326-2016 4
Town of Queensbury Building & Codes office use only
SEPTIC VARIANCE APPLICATION Receive
Tax ��1
Submittal: 1 original&8 copies of the completed application package
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Aprovals MAY 2 7
QUEENIRRI
CLERKS OFFICE
Owner Steven Hoag Owner's Agent Hutch SlEm i ee i
Address 124 Sunnyside Road East Address 169 Haviland oa
Queensbury,NY 12804 Queensbury,NY 12804
Phone Phone (518)745-0307
Directions to Site: 124 Sunnyside Road East
Distance from well on property to septic system (if applicable) 85 feet
Is it possible to install a conforming septic system on this property? Yes ✓ No
If YES, please explains and attach diagram:
Does proposed system meet setback requirements for distance from wells &septic systems on neighboring properties?
✓ Yes _No If NO,please explain:
Is proposed system to be installed over a parking area? Yes ✓ No
Section of the Sanitary Sewage Ordinance from which you are seeking the variance: (example: leaching system will be 89 ft.
from well in lieu of required 100 ft. separate distance):
Absorption bed will be 85 feet from existing well in lieu of required 100 feet well setback requirement
Absorption bed will be 5 feet from rear property line in lieu of required 10 feet property line setback requirement.
Town of Queensbury Building&Codes Septic Variance Application 548-761$256
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List the names, parcel addresses, and tax map numbers of all adjoining property owners. You may obtain tax map numbers
from the Assessor's Office as well as the names and addresses:
North Name Sunnyside Road East
Address
Tax Map ID
South Name: Lawrence,John
Address 1 Brookfield Run
Tax Map ID 290.4-76
East Name: Ennis,Robert
Address 130 Sunnyside Road East
Tax Map ID 290•-1-77
West Name: Millington,Corrina Beckwith
Address 118 Sunnyside Road East
Tax Map ID 290.4-79
OWNER STATEMENT
1,we do hereby relieve the Town of Queensbury from any liabilities on the plumbing and septic system located at:
124 Sunnyside Road East
1, we realize that putting the well,septic tank,or leaching system less than the required 100 feet from the
absorption area may increase risk of pollution.
Owner-Print Name: Steven Hoag
Owner-Signature: Date: 'Z
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:
1, we realize that putting the septic tank or leaching system less than the required feet from the
may increase risk of pollution.
Neighbor or Tenant-Print Name:
Neighbor or Tenant-Signature: Date:
Town of Queensbury Building&Codes Septic Variance Application 518-761-8256
617.20
Appendix B
Short Environmental Assessment Form
Instructions for Comi letin
Part 1 -Project information. The applicant or project sponsor is responsible for the completion of Part 1. Responses
become part of the application for approval or funding,are subject to public review,and may be subject to further verification.
Complete Part 1 based on information currently available. If additional research or investigation would be needed to fully
respond to any item,please answer as thoroughly as possible based on current information.
Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful
to the lead agency;attach additional pages as necessary to supplement any item.
Part I -Project and Sponsor Information
Hoag Wastewater System
Name of Action or Project:
Wastewater System
Project Location(describe,and attach a location map):
124 Sunnyside Road East
Brief Description of Proposed Action:
Install a 15'x30'absorption bed to replace failing septic system.
Name of Applicant or Sponsor: Telephone:
Steven Hoag E-Mail:
Address:
124 Sunnyside Road East
City/PO: State: Zip Code:
Queensbury NY 12804
1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES
administrative rule,or regulation?
If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that Fv/� r
may be affected in the municipality and proceed to Part 2. If no,continue to question 2.
2. Does the proposed action require a permit,approval or funding from any other governmental Agency? NO YES
If Yes,list agency(s)name and permit or approval: ❑
Town of Queensbury Buildings&Codes
3.a.Total acreage of the site of the proposed action? .72 acres
b.Total acreage to be physically disturbed? Less than 0.1 acres
c.Total acreage(project site and any contiguous properties)owned
or controlled by the applicant or project sponsor? .72 acres
4. Check all land uses that occur on,adjoining and near the proposed action.
❑Urban [:]Rural(non-agriculture) ❑Industrial [-]Commercial m Residential(suburban)
❑Forest OAgriculture ❑Aquatic []Other(specify):
❑Parkland
Pagel of 4
PLEASE ATTACH THE FOLLOWING TO YOUR APPLICATION:
1. Location map showing the site within the Town of Queensbury;
2. 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(streets,steep slopes, lakes,wetlands, etc.)
f) Location of all wells and septic systems on neighboring properties
g) Adjacent ownership
h) All properties within 500 feet.
A sample plot plan and location are shown below
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Sample Location Map
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Town of Queensbury Building&Codes Septic Variance Application 518-761-8256
5. Is the proposed action, NO YES N/A
a.A permitted use under the zoning regulations? F� a ❑
b.Consistent with the adopted comprehensive plan? El 0
6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES
landscape?
7. Is the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO YES
If Yes,identify: 17] ❑
8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES
❑✓ ❑
b.Are public transportation service(s)available at or near the site of the proposed action? a El
c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? 0
9.Does the proposed action meet or exceed the state energy code requirements? NO YES
If the proposed action will exceed requirements,describe design features and technologies: ❑ ❑
10. Will the proposed action connect to an existing public/private water supply? NO YES
If No,describe method for providing potable water: On-site Well 0 ❑
11.Will the proposed action connect to existing wastewater utilities? NO YES
If No,describe method for providing wastewater treatment: Q M
12. a. Does the site contain a structure that is listed on either the State or National Register of Historic NO YES
Places? a M
b.Is the proposed action located in an archeological sensitive area? ❑ ✓
13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES
wetlands or other waterbodies regulated by a federal,state or local agency? F71 ❑
b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? 0 ❑
If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres:
14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply:
❑Shoreline ❑Forest ❑Agricultural/grasslands ❑Early mid-successional
❑ Wetland ❑Urban ®Suburban
15.Does the site of the proposed action contain any species of animal,or associated habitats,listed NO YES
by the State or Federal government as threatened or endangered? F/_� ❑
16.Is the project site located in the 100 year flood plain? NO YES
17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES
If Yes, Q Q
a. Will storm water discharges flow to adjacent properties? ❑NO ❑YES
b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)?
If Yes,briefly describe: ❑NO [—]YES
Page 2 of 4
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18.Does the proposed action include construction or other activities that result in the impoundment of NO YES
water or other liquids(e.g. retention pond,waste lagoon,dam)?
If Yes,explain purpose and size: ❑ ❑
19.Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES
solid waste management facility?
If Yes,describe: FV] ❑
20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES
completed)for hazardous waste?
If Yes,describe: ❑
I AFFIRM THAT THE INFORMATION PROVIDED ABOVE 1S TRUE AND ACCURATE TO THE BEST OF MY
KNOWLEDGE
Applicant/sponsor name: Steven Hoag Date:
Signature:
Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the following
questions in Part 2 using the information contained in Part 1 and other materials submitted by the project sponsor or
otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my
responses been reasonable considering the scale and context of the proposed action?"
No,or Moderate
small to large
impact impact
may may
occur occur
1. Will the proposed action create a material conflict with an adopted land use plan or zoning El 1:1regulations?
2. Will the proposed action result in a change in the use or intensity of use of land? F1
3. Will the proposed action impair the character or quality of the existing community? F-1 ❑
4. Will the proposed action have an impact on the environmental characteristics that caused the El ❑
establishment of a Critical Environmental Area(CEA)?
'S. Will the proposed action result in an adverse change in the existing level of traffic or 1:1affect existing infrastructure for mass transit,biking or walkway?
EJ 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate ❑
reasonably available energy conservation or renewable energy opportunities?
7. Will the proposed action impact existing:
a.public/private water supplies?
F-1-
b.public/private wastewater treatment utilities? F] El
8. Will the proposed action impair the character or quality of important historic,archaeological, El El
or aesthetic resources?
9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, El Elwaterbodies,groundwater,air quality,Elora and fauna)?
Page 3 of 4
No,or Moderate
small to large
impact impact
may may
occur occur
10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage Q Q
problems?
11. Will the proposed action create a hazard to environmental resources or human health? ❑
Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every
question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular
element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3.
Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by
the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact
may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring,
duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-term,long-term and
cumulative impacts.
Check this box if you have determined,based on the information and analysis above,and any supporting documentation,
that the proposed action may result in one or more potentially large or significant adverse impacts and an
environmental impact statement is required.
Check this box if you have determined,based on the information and analysis above,and any supporting documentation,
that the proposed action will not result in any significant adverse environmental impacts.
Name of Lead Agency Date
Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer
Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer)
PRINT Page 4 of 4
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: Steven Hoag
Designates: Hutchins Engineering as agent regarding Septic Variance for
Tax Map ID: 290.-1-78
OWNER'S SIGNATURE: T� _� , '"� � ,- Date: i
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 application, and that 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 the checklist.
PRINT NAME OF OWNER: Steven Hoag
SIGNATURE OF OWNER:
DATE:
PRINT NAME OF AGENT: Huc ins Engineering
SIGNATURE OF AGENT:
DATE: 2_S
Town of Queensbury Building&Codes Septic variance Application 516-761-8256
RESOLUTION APPROVING STEVEN HOAG'S APPLICATION FOR
SANITARY SEWAGE DISPOSAL VARIANCES
RESOLUTION NO.: BOH 20,2016
INTRODUCED BY: Mr.Anthony Metivier
WHO MOVED ITS ADOPTION
SECONDED BY: Mr. Doug Irish
WHEREAS, Steven Hoag filed an application for variances from provisions of the Town of
Queensbury On-Site Sewage Disposal Ordinance, Chapter 136 to place an absorption bed, to
replace a failing septic system:
1. 85' from the existing well instead of the required 100' setback; and
2. 5' from the rear property line instead of the required 10' setback;
on property located at 124 Sunnyside East, 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 200',2016, 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
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 is 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 Steven
Hoag for variances from the Sewage Disposal Ordinance to place an absorption bed, to replace a
failing septic system:
1. 85' from the existing well instead of the required 100' setback;and
2. 5' from the rear property line instead of the required 10' setback;
on property located at 124 Sunnyside East,Queensbury and bearing Tax Map No.: 290.4-78.
Duly adopted this 20''day of June,2016,by the following vote:
AYES : Mr. Clements,Mr. Irish,Mr.VanNess,Mr. Strough,Mr.Metivier
NOES : None
ABSENT:None
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