SEP-0704-2020 M
E A 169 Haviland Road
Queensbury, NY 12804
Hutchins Engineering PLLC Phone: (518)745-0307
Fax: (518)745-0308
November 10, 2020
Town of Queensbury Town Board
Board of Health
742 Bay Road -- --- ---
Queensbury NY 12804 C IE 0
Re: Dave Barlow NOV 1 202�
18 Ward Lane
Tax Map ID: 240.6-1-7
TOWN OF OUEEKISBURY
BUILDING&CODES
Dear Supervisor Strough & Town Board Councilmen:
This office represents the Mr. Dave Barlow with respect to the pursuit of wastewater variances
for a holding tank system installation at his property located at 18 Ward Lane. Presently the
home is served by a unknown sized seepage pit which is far from adequate and they desire to
bring the parcel up to the town's current on-site wastewater system standards. Given the terrain
and site constraints, it is not feasible to install an absorption field system, therefore we are
pursuing the holding tank system. A change of Deed for the property occurred on June 17,
2020. The required septic inspection found the existing wastewater system to be deficient.
Presently the house is served by a seepage pit, which is far from adequate and the applicants
desire to install (2) 1500-gallon tanks to support the existing 1-bedroom cottage.
Relief is requested for the installation of the holding tank system itself and setback relief is
requested from the applicant's home; these requests are detailed in the application.
We are also requesting a 6 month extension from the property transfer law requirements for the
installation of the holding tank system.
Enclosed please find ten submission packages for this project. We respectfully request, if
possible, that this item be placed upon the agenda of the next town board meeting. Please
contact me if you have any questions or if you require additional information.
Best Regards,
1;i�
Thomas R. Center Jr., P.E.
Associate - Design Engineer
Cc: Dave Barlow
Town of Queensbury Building & Codes Office Use Only
SEPTIC VARIANCE APPLICATION Received:
Tax Map ID:
Submittal: 1 original&8 copies of the completed application package Permit No.:
Permit Fee: $ cF.�
ovals:
Owner DAVE BARLOW Owners Agent HUTCHINS ENGINEERING
Address 162 HUDSON POINT Address 169 HAVILAND ROAD
QUEENBSURY NY 12804 QUEENSBURY,NY
Phone 518-955-1180 Phone 518-796-2515
Directions to Site: RIDGE ROAD TO WARD LANE TO 18 WARD LANE ON WEST SIDE OF ROAD
Distance from well on property to septic system(if applicable) NA feet
Is it possible to install a conforming septic system on this property? Yes ✓ No
If YES, please explain 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):
136-11A REQUEST TO INSTALL 2-1500 GALLON HOLDING TANKS
136-91)REQUEST TO INSTALL HOLDING TANKS 4 FT FROM THE STRUCTURE WHERE 10 FT OF SEPARATION IS
REQUIRED REQUESTED RELIEF IS 6 FT
CHAPTER 137-REQUEST A 6 MONTH EXTENSION TO INSTALL THE NEW HOLDING TANK SYSTEM TO MEET THE
TOWN PROPERTY TRANSFER REQUIREMENTS.
Town of Queensbury Building&Codes Septic variance Application 518-761-8256
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 ERIK ROSS
Address 12 LOCOST LANE,CLIFTON PARK NY 12065
Tax Map ID 240.6-1-8
South Name: ROBERT LAYOY
Address 7108 CHANDLER ROAD,ALTAMONT,NY 12009
Tax Map ID 240.6-1-6
East Name: ROBERT C KENDALL
Address 2469 RIDGE ROAD,QUEENSBURY,NY
Tax Map ID 240.6-1-5
West Name: NA
Address
Tax Map ID
OWNER STATEMENT
I,we do hereby relieve the Town of Queensbury from any liabilities on the plumbing and septic system located at:
18 WARD LANE
I, we realize that putting the well, septic tank,or leaching system less than the required NA feet from the
NA may increase risk of pollution.
Owner-Print Name: DAVE BARLOW ��
Owner-Signature: aA w"`" 3 Date: 11/9/20
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:
NA
I,we realize that putting the septic tank or leaching system less than the required feet from the
NA may increase risk of pollution.
Neighbor or Tenant-Print Name: NA
Neighbor or Tenant-Signature: Date:
Town of Queensbury Building&Codes Septic Variance Application 518-761-8256
f Signature Page
This page includes the Authorization to Act as Ardent 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: DAVE BARLOW
Designates: HUCTCHINS ENGINEERING as agent regarding Septic Variance for
Tax Map ID: 240.6-1-7 r
OWNER'S SIGNATURE: -�u%"� Date: 11/9/2020 _
Enctineering 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 hislherltheir 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: DAVE BARLOyW,
SIGNATURE OF OWNER: � t
DATE: 11/9/20z0
PRINT NAME OF AGENT: HUTCHINS ENGINEERING-THOMAS CENTER
SIGNATURE OF AGENT: l
DATE: 1119/2020
Town of Queensbury Building&Codes Septic Variance Application 518-761-8256
r
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 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 1—Project and Sponsor Information
DAVE BARLOW
Name of Action or Project:
18 WARD LANE-HOLDING TANK SYSTEM
Project Location(describe,and attach a location map):
18 WARD LANE, QUEENBSURY
Brief Description of Proposed Action:
INSTALL NEW HOLDING TANK SYSTEM
Name of Applicant or Sponsor:
Telephone: 518-955-1180
DAVE BARLOW
E-Mail:
Address:
162 HUDSON POINT
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 ❑
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 government Agency? NO YES
If Yes,list agency(s)name and permit or approval:TOWN OF QUEENSBURY BOARD OF HEALTH SEPTIC VARIANCE ❑
3. a.Total acreage of the site of the proposed action? 0.4 acres
b.Total acreage to be physically disturbed? 0.1 acres
c.Total acreage(project site and any contiguous properties)owned
or controlled by the applicant or project sponsor? 0.74 acres
4. Check all land uses that occur on,are adjoining or near the proposed action:
5. ❑Urban ❑ Rural(non-agriculture) ❑ Industrial ❑ Commercial m Residential(suburban)
❑Forest ❑ Agriculture ❑ Aquatic ❑ Other(Specify):
❑Parkland
Page 1 of 3
5. Is the proposed action, NO YES N/A
a. A permitted use under the zoning regulations? ❑ ❑✓ ❑
b. Consistent with the adopted comprehensive plan? ❑ ❑✓ ❑
NO YES
6. Is the proposed action consistent with the predominant character of the existing built or natural landscape?
❑ ❑
7. Is the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO YES
Name:Lake George,Reason:Protect the resources of the park,Agency:Lake George Park Commission,Date:11-
If Yes,identify: 16-88 ❑ ❑
NO YES
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? ❑✓ ❑
c. 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? 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:
EXISTING LAKE WATER SUPPLY FV71 ❑
11. Will the proposed action connect to existing wastewater utilities? NO YES
If No,describe method for providing wastewater treatment:
PROPOSED NEW HOLDING TANK SYSTEM r7l ❑
12. a.Does the project site contain,or is it substantially contiguous to,a building,archaeological site,or district NO YES
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 the project site,or any portion of it,located in or adjacent to an area designated as sensitive for El ❑
archaeological sites on the NY State Historic Preservation Office(SHPO)archaeological site inventory?
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? ❑ ❑✓
b.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:
®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 by the State or NO YES
Federal government as threatened or endangered? ❑ ❑
Northern Long-eared Bat
16. Is the project site located in the 100-year flood plan? NO YES
21 ❑
17. Will the proposed action create storm water discharge,either from point or non-point sources? NO YES
If Yes, Fv� ❑
a. Will storm water discharges flow to adjacent properties? Fv] ❑
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: ❑ ❑
SEPTIC AND PUMP STATION
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: ❑ ❑
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF
MY KNOWLEDGE
Applieant/spons /name: HUTCHINS ENGINEERING-THOMAS CENTER PE Date:11/10/2020
Signature: Title:PROJECT ENGINEER
PRINT FORM Page 3 of 3
EAF Mapper Summary Report Monday, November 9,2020 8:25 PM
Disclaimer: The EAF Mapper is a screening tool intended to assist
•, } - .. , , project sponsors and reviewing agencies in preparing an environme
ntal
240. -1'2 r 1 assessment form(EAF).Not all questions asked in the EAF are
? 0°fi-1 2 7 answered by the EAF Mapper.Additional information on any EAF
question can be obtained by consulting the EAF Workbooks. Although
the EAF Mapper provides the most up-to-date digital data available to
DEC,you may also need to contact local or other data sources in order
y ; r
24 0.6-1 5 7 :t to obtain data not provided by the Mapper.Digital data is not a
1 ; f substitute for agency determinations.
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Sao A 6
Part 1 /Question 7 [Critical Environmental Yes
Area]
Part 1 /Question 7 [Critical Environmental Name:Lake George, Reason:Protect the resources of the park, Agency:Lake
Area- Identify] (George Park Commission, Date:11-16-88
Part 1 /Question 12a [National or State 'No
Register of Historic Places or State Eligible
Sites]
Part 1 /Question 12b [Archeological Sites] :Yes
Part 1 /Question 13a[Wetlands or Other ;Yes- Digital mapping information on local and federal wetlands and
Regulated Waterbodies] _ waterbodies is known to be incomplete. Refer to EAF Workbook`
Part 1 /Question 15 [Threatened or Yes
Endangered Animal]
Part 1 /Question 15 [Threatened or Northern Long-eared Bat
Part 1 /Question 16 [100 Year Flood Plain] -�____._.__
Endangered Animal - Name] _
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 1
FILE COPY
RESOLUTION APPROVING SANITARY SEWAGE DISPOSAL
VARIANCES FOR DAVE BARL QW-p
RESOLUTION NO.: BOH 58,2020
INTRODUCED BY: Mr.Anthony Metivier
WHO MOVED ITS ADOPTION
SECONDED BY: Mr.Harrison Freer
WHEREAS, Dave Barlow (Applicant) applied to the Local Board of Health for a variance
from Chapter 136, §13 6-11 which requires applicants to obtain a variance for holding tanks, as the
Applicant wishes to install two (2) 1500 gallon capacity holding tanks, thus meeting the required
total capacity of 3,000 gallons, with the holding tanks to be located 4' from the structure in lieu of
the required 10' setback on property located at 18 Ward Lane 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 conducted a public hearing concerning the
variance requests on Monday,December 7h,2020, and
WHEREAS, the Town Clerk's Office advised that it duly notified all property owners
within 500 feet of the subject property, and
WHEREAS, Town Code Chapter 137 Article I "Septic Inspection Upon Property
Transfer" requires inspection of Onsite Wastewater Treatment Systems (OWTS) prior to the sale
of certain real property, and
WHEREAS, a change of deed for the Applicant's property occurred on June-17, 2020 and
when the required property transfer septic inspection took place, it was found that the existing
wastewater system was deficient but the proposed holding tank wastewater system was not able
to be completed within the required six (6)month time period, and
v
WHEREAS, the Applicant accordingly applied for a timeline extension or until June 8,
2021 to install the holding tank system and the Director of Building and Codes Enforcement
recommends that the Town Board grant such extension,
NOW,THEREFORE,BE IT
RESOLVED,that:
1. due to the nature of the variances,-it is felt 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 Dave
Barlow (Applicant) for variances from the Sewage Disposal Ordinance to allow installation of two
(2) 1500 gallon capacity holding tanks, thus meeting the required total capacity of 3,000 gallons,
with the holding tanks to be located 4' from the structure in lieu of the required 10' setback, on-
property located at 18 Ward Lane in the Town of Queensbury and bearing Tax Map No.: 240.6-1-7,
and
BE IT FURTHER,
RESOLVED, that the Local Board of Health hereby authorizes and grants the Applicant
additional time or until June 8th, 2021 to obtain a certificate of compliance from the Town's
Building and Codes Enforcement Office as set forth in Chapter 137 for installation of the holding
i
tanks and authorizes and directs the Director of Building and Codes Enforcement to take any and
all action necessary to effectuate the terms of this Resolution, 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 7th day of December, 2020,by-the following vote:
AYES Mr. Freer,Mr. Ferone,Mrs. Magee, Mr. Strough,Mr. Metivier
NOES : None
ABSENT: None
FILE COPY
RESOLUTION APPROVING I SANITARY SEWAGE DISPOSAL
F---- -
VARIANCES FOR DAVE BARL 0 W:6= P �Iwr _�rl
-1,
RESOLUTION NO.:.BOH 58,2020 DEC 10 2020
INTRODUCED BY: Mr.Anthony Metivier
To.
WHO MOVED-ITS ADOPTION
SECONDED BY: Mr.Harrison Freer
WHEREAS, Dave Barlow (Applicant) applied to the Local Board of Health for a variance
from Chapter 136, §136-11 which requires applicants to obtain a variance for holding tanks, as the
Applicant wishes to install two (2) 1500 gallon capacity holding tanks, thus meeting the required
total capacity of 3,000 gallons, with the holding tanks to be located 4' from the structure in lieu of
the required 10' setback on property located at 18 Ward Lane 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 conducted a public hearing concerning the
variance requests on Monday,December 7h, 2020, and
WHEREAS, the Town Clerk's Office advised that it duly notified all property owners
within 500 feet of the subject property, and
WHEREAS, Town Code Chapter 137 Article I "Septic Inspection Upon Property
Transfer" requires inspection of Onsite Wastewater Treatment Systems (OWTS)prior to the sale
of certain real property, and
WHEREAS, a change of deed for the Applicant's property occurred on June-17, 2020 and
when the required property transfer septic inspection took place, it was found that the existing
wastewater system was deficient but the proposed holding tank wastewater system was not able
to be completed within the required six (6) month time period, and
v i f
i
WHEREAS, the Applicant accordingly applied for a timeline extension or until June 8,
2021 to install the holding tank system and the Director of Building and Codes Enforcement
recommends that the Town Board grant such extension,
NOW, THEREFORE,BE IT
RESOLVED,that:
1. due to the nature of the variances,"it is felt 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 Dave
Barlow(Applicant) for variances from the Sewage Disposal Ordinance to allow installation of two
(2) 1500 gallon capacity holding tanks, thus meeting the required total capacity of 3,000 gallons,
with the holding tanks to be located 4' from the structure in lieu of the required 10' setback, on-
property located at 18 Ward Lane in the Town of Queensbury and bearing Tax Map No.: 240.6-1-7,
and
BE IT FURTHER,
RESOLVED, that the Local Board of Health hereby authorizes and grants the Applicant
additional time or until June 8th, 2021 to obtain a certificate of compliance from the Town's
Building and Codes Enforcement Office as set forth in Chapter 137 for installation of the holding
tanks and authorizes and directs the Director of Building and Codes Enforcement to take any and
all action necessary to effectuate the terms of this Resolution, 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 71h day of December,2020,by-the following vote:
AYES Mr. Freer, Mr. Ferone,Mrs. Magee, Mr. Strough,Mr. Metivier _
NOES : None
ABSENT: None
Office Use Only
SEPTIC DISPOSAL PERMIT APPLICATION Permit#: I - Q4-20f210
Permit Fee: $ ' ; Invoice#: 322a,
Torvn ofQucens6un Septic Variance? V Yes No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net
Tax Map ID#: 240.6-1-7
Project Location: 18 WARD LANE
• Applicant:
Name(s): DAVE BARLOW
Mailing Address, C/S/Z: 162 HUDSON POINT, QUEENSBURY,NY
Cell Phone: _( 518 ) 955-1180 Land Line:
Email: ( 4R17 FW E
IU]
.; L i
• Primary Owner(s): DEC 0 2020 � i
Name(s): same as applicant !
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line:
Email:
V Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
• Engineer(s):
Name(s): HUTCHINS ENGINEERING PLLC , TOM CENTER
Mailing Address, C/S/Z: 169 HAVILAND RD, QUEENSBURY,NY
Cell Phone: _( ) Land Line: _(518 ) 745-0307
Email: tcenter36@yahoo.com
Contact Person for Building & Code Compliance: Dave Barlow
Cell Phone: ( 518 ) 955-1180 Land Line: ( )
Email:
Septic Application Revised February 2019
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No
1980 or older 150 1 150 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 110
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope 5-10 /Slope
Soil Nature _Sand ✓ Loam _Clay Other(explain: )
Groundwater At what depth? N/A
Bedrock/Impervious material At what depth? 36"
Domestic Water Supply Lake Water Municipal _Well (if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: N/A per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 2 1,500 gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone Total length ft.; Each Trench ft.
Seepage Pit with#3 stone How many: ;Size:
Alternative System Bed or other type:
Holding Tank System Total required capacity? 3,000 ;tank size 1,500 ;#of tanks 2
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.
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: Dave Barlow DATE: 12/8/20
SIGNATURE: r � "` "j DATE: 12/8/20
Septic Application Revised February 2019