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septic variance application
Office Use OnlySEPTICVARIANCE rocowved APPLICATION Permit #:»O194-2020Dee: g Pomit Fee:10”742 Bay Road,Queensbury,NY 2004 S ZS 2A:518-761-8256 yww.queensburystet Ay _imeiApprovals: Submittal:|original &8 copies of the completed application package Property Owner(s):JAMES &PATRICIA ROUND Owner's Agent:Hutchins Engineering ‘Address:34 PERSHING ROAD Address:169 Haviland Road Queensbury,NY 12804 Queensbury,NY 12804 Phone #:518 -636-9566 Phone #;518-745-0307 Site Address:_34 PERSHING ROAD Tax Di;30214-1-74 Directions to Site:SOUTH SIDE OF PERSHING ROAD BETWEEN HUGHS COURT AND QUEENSBURY PLACE Distance from well on property to septic system (if applicable)_/A feet \s it possible to install a conforming septic system on this property?Yes x No. IF YES,please explain and attach a diagram: Does the proposed system meet setback requirements for distance from wells &septic systems on neighboringproperties?Yes No If NO,please explain: Is the proposed system to be installed under a parking area?Yes X__No 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.}: +Absorption field will be 2'from northern property line in lieu of required 10° +Absorption field will be 2'from eastern property line in lieu of required 10° -Absorption field will be 18°from structure in lieu of required 20° Septic Variance Application February 2018 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 NICHOLAS PASCO /JAMES GERRAND ‘Address 35 PERSHING ROAD /33 PERSHING ROAD Tax Map ID _302.14-1-8 /_302.14-1-9 South Name SCOTT STIASSNEY /KURT CONDUZIO Address 9 BENTLEY PLACE /_8 BENTLEY PLACE Tax Map ID 302.14-1-76 f 302.14-1-77 East Name DAVID WILES Address 32 PERSHING ROAD Tax Map ID _302.44-1-73 West Name EDWARD PETRUSH ‘Address 36 PERSHING ROAD Tax Map ID _302.14-1-75 OWNER STATEMENT \WWe do hereby relieve the Town of Queensbury from any liabilities on the plumbing and septic system located at: 34 PERSHING ROAD \/We realize that putting the well,septic tank or leaching system less than the required 20__feet from the HOUSE may increase the risk of pollution. owner—Print Name:_SeeMES 11s ound vate:S/y [Lote ‘Owner—Signature:_X?-Aw Q——pate:_2/i/rew NEIGHBOR OR TENANT RELEASE STATEMENT (if applicable) \/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 the risk of pollution. Neighbor/Tenant—Print Name:Date: Neighbor/Tenant-Signature:_‘Date: Sentic variance Application February 2018 PLEASE ATTACH THE FOLLOWING TO YOUR APPLICATIO! 1.Alocation map showing the site within the Town of Queensbury 2.Aplot plan showing existing and proposed features of the property,including: a.Lot dimensions b.North arrow and scale:1 inch=40 feet Location &dimensions of existing and proposed buildings,showing setback distances and uses Parking layout to scale (if applicable) Physical features (street,steep slopes,lakes,wetlands,etc.) Location of all wells and septic systems on neighboring properties ‘Adjacent ownerships All properties within 500 feet Fee oe A sample plot plan and location are shown below: Septic Variance Appliation February 2018 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:JAMES ROUND Designates:Hutchins Engineering as agent regarding the Septic Variance for Tax Map #:302.14-1-74 OWNER’S SIGNATURE:x Seen Be g pate:5/7/2020 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. Officiatial 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. |,the undersigned,have thoroughly read and understand the instructions for submission;agree to the submission requirements and completed checklist: OWNER—PRINT NAME:es oun OWNER—SIGNATURE:pate:St fee AGENT—PRINT NAME: AGENT—SIGNATURI DATE:Ww Septic Variance Application February 2018, Short Environmental Assessment Form Part I -Project Information Instructions for Completing 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 |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 1 -Project and Sponsor Information |JAMES &PATRICIA ROUND ‘Name of Action or Project: ‘34 PERSHING ROAD SEPTIC SYSTEM VARIANCE Project Location (describe,and attach a location map) {34 PERSHING ROAD Brief Description of Proposed Action’ ICONTSRUCT A REPLACE ABSORPTION SYSTEM. ‘Name of Applicant or Sponsor:Telephone:516-6369566 JAMES ROUND E-Mail ‘Address: [34 PERSHING ROAD City/PO:State:Zip Code: [QUEENSBURY INy 112804 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance,NO|YESadministrativerule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that 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 finding from any other government Agency? If Yes,list agency(s)name and permit or approval:TOWN OF QUEENSBURY BOARD OF HEALTH. 3.a Total acreage of the site of the proposed action?OSacres ’,Total acreage to be physically disturbed?OA acres ©.Total acreage (project site and any contiguous properties)owned or controlled by the applicant or project sponsor?bse acres 4,Check all land uses that occur on,are adjoining or near the proposed action: 5.[Urban (7)Rural (non-agriculturey)(2)industrial [I]Commercial Residential (suburban) CForest (1 Agriculture (Aquatic ~[[)Other(Specify): Cparkiand Page 1 of 3 Ts the proposed action, a.A permitted use under the zoning regulations? b.Consistent with the adopted comprehensive plan? 6.Is the proposed action consistent with the predominant character of the existing built or natural landscape? 7,Ts the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? If Yes,identity:_ 8.a.Will the proposed action result in a substantial increase in traffic above present levels? b.Are public transportation services available at or near the site of the proposed action? .Are any pedestrian accommodations or bicycle routes available on or near the site of the proposed action? 9.Does the proposed action meet or exceed the state energy code requirements? 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? IfNo,describe method for providing potable water: TI.Will the proposed action connect to existing wastewater utilities? IENo,describe method for providing wastewater treatment: |ONSITE ABSORPTION SYSTEM NO YES T2.a.Does the project site contain,or is it substantially contiguous to,a building,archaeological site,or district which is listed on the National or State Register of Historic Places,or that has been determined by the ‘Commissioner of the NYS Office of Parks,Recreation and Historic Preservation to be eligible for listing on the State Register of Historic Places? b.Is theproject site,or any portion of it,located in or adjacentto an area designated as sensitive for archaeological sites on the NY State Historic Preservation Office (SHPO)archaeological site inventory? NO 13,a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain wetlands or other waterbodies regulated by a federal,state or local agency? .Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres:_ Page 2 of 3 14,Identify the typical habitat types that occur on,or are likely to be found on the project site.Check all that apply: CShoretine [[]Forest [7]Agricultural/grasslands (]Early mid-successional CWetland 2)urban ‘Suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats,listed by the State orFederalgovernmentasthreatenedorendangered? Kamer Blue,Frosted Eifin 16.Is the project site Tocated in the 100-year flood plan? 17.Will the proposed action create storm water discharge,either from point or non-point sources? If Yes, a.Will storm water discharges flow to adjacent properties? 'b.Will storm water discharges be directed to established conveyance systems (runoff and storm drains)?If Yes,briefly describe: 18.Does the proposed action include construction or other activities that would result in the impoundment of water|NO|YES or other liquids (e.g.,retention pond,waste lagoon,dam)? If Yes,explain the purpose and size of the impoundment: [ONSITE ABSORPTION SYSTEM 19.“Has the site of the proposed action or an adjoining property been the location of an active or closed solid waste|NO|YES ‘management facility? If Yes,describe: 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:v CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE ‘Applicant/sponsor/name:THOMAS CENTER JR,HUTCHINS ENGINEERING Date:05/11/2020 Signature:C,/Title:PROJECT ENGINEER PRINT FORM Page 3 of 3 EAF Mapper Summary Report Monday,May 11,2020 2:39 PM Disclaimer:The EAF Mappers 8 screening too intended to assist project sponsors and reviewing agencies in preparing an environmental fSssessmert form (EAF)Nota questions asked inthe EAF are ‘answered by the EAF Mapper.Alona information on ary EAF {Question can be obtained by consulting the EAF Workbooks.Although the EAF Mopper provides the most up-to-date digital data avatabe 0 DEC.you may aleo need to contact local or athe datasources in order to obian data not provided by tne Mapper.Digital data isnot a ‘subatiute for agency determinations. Pershing Ra 302.14-1-73 Toroate.\free|‘, \ |sowens hea Gorm,dager 7 Gievaind -“dota 202.14-1-76 (feria TROREMENT®NRCBo,Esti 3 AP oe open MET.Esha (rong oes —on sr Widens Bt Whe,Gam. |Keres.Esti Thaler),NGCE,fe)fg Columbus PPUMEMEE"USCinterne.INCREMENT nicthie GEE!72 8 B.NRCen.Esri Japan,METI.7 yabskigitine Hore Keneh Eri Part 1 /Question 7 [Critical Environmental No Areal Part 1 /Question 12a [National or State No Register of Historic Places or State Eligible Sites] Part 1/Question 12b [Archeological Sites]No Part 1 /Question 13a [Wetlands or Other No Regulated Waterbodies] Part 1 /Question 15 [Threatened or ‘Yes Endangered Animal] Part 1 /Question 15 [Threatened or Karner Blue,Frosted Elfin Endangered Animal -Name] Part 1/Question 16 [100 Year Flood Plain}Digital mapping data are not available or are incomplete.Refer to EAF ‘Workbook. Part 1/Question 20 [Remediation Site]No Short Environmental Assessment Form -EAF Mapper Summary Report