SEP-0785-2020 Office Use Only
SEPTIC DISPOSAL PERMIT APPLICATION Permit#: SCE'' O ftf> 24ZM
Permit Fee: Invoice#: 3808
WafoQueens Septic Variance? ✓ Yes No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.aueensbury.net
Tax Map ID#: 279.17-1-10 E C E
Project Location: 62 Dream Lake Road JUN 0 2 2021
TOWN OF QUEENSBURY
• Applicant: BUILDING&CODES
Name(s): John Hampshire
Mailing Address, C/S/Z: 637 4th Street,Troy, NY 12180
Cell Phone:_( 518 ) 763-2964 Land Line: _( )
Email: hampsj@yahoo.com
• Primary Owner.(sh
Name(s): Same as Applicant
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
❑ Check if all work will be performed by homeowner only.
•.. Contractor: Workers' Comp documentation must be submitted with this.application
Contact Name(s): Arnica Septic Design & Installation
Contractor Trade: General Contractor
Mailing Address, C/S/Z: . 6049 Fish House Road, Galway NY 12074
Cell Phone:_( 518 ) 882754445. Land Line: _( )
Email:
• Engineer(s)•
Name(s): Dominick Arico
Mailing Address, C/S/Z: '6049 Fish House Road
Cell Phone:_( 518 ) 573-6989 Land Line: _( )
Email: aricoassociates@email.com
Contact Person for Building & Code Compliance: Veronica Zenz
Cell Phone: —( 518 ) 882-5445 Land Line: _( )
Email: veronica@galwayco-op.com
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) x
1981-1991 130 Spa or Hot Tub Yes No
1992-Present 110
Installed? (circle:one) x
PARCEL INFORMATION:
Topography x Flat Rolling ___L,.Steep Slope 3-10%Slope
Soil Nature _Sand, x Loam _Clay . _Other(explain: )
Groundwater At what depth? +10,
Bedrock/Impervious material At what depth? +10'
Domestic Water Supply _Municipal. x Well(if well,water supply from any septic system absorption is 71 ft.)
Percolation Test Rate: per minute per inch (test to-be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 2000 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? 2000 -tank size 2000 ;#of tanks 1
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: John Hampshire DATE: 11/16/2020
SIGNATURE: DATE: 1111619090
Septic Application Revised February 2019
TO-KW.OF,'-OUEENSBURY.
742 Bay Road, Queerisbury,,WY. 12804-5962
Septic System Checklist
Plan to scale
Received Deep hole perc test results from engineer/Architect if applicable(Town Approved Engineers and
Architects;June 30 to April IS.Town Engineer for unapproved Engineers and Architects)
All wells on property and-adjacent pr erties shown
Water line shown Municipal r well 's ation to any part of system
Setback to property lines show 10'or more,for any part of system
YSeptic tank and pump stations 10'from'foundation 50'from any well/lake/wetland 10'from any waterline
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)
`�- 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
01
Seepage Pits 3-times-diameter apart.
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 36"within 1000'of Lake George
" Leech field 100'from watercourse or wetland
kc Toe of mound or bottom of'retaining wall 10'from property line 100'from well 20'from
Foundation
Provide Engineer/Architect stamp for bed or design systems
N Department.of Health Approval for all-mobile home park new systems Flood Plain requirements
Y2'above established flood elevation to bottom of systemi
JAII tanks anchored or 2' above flood elevations
rr
RX Date/Time 0612112021 08:26 15162731202 P.003
Jun, 21. 2021 8:03A MDIA No, 6980 P, 3
MIDDLE DEPARTM 4NT INSPECTION AGENCY, INC.
Vo4&that the electrical wiring to the ectrical equipment listed below has been examined and is approved as
being in accord with the National Electrical Cod applicable governmental, utility and Agency rules in effect on the date
noted below and is issued subject to the followin conditions.
Owner: Date:
Slopey 06/10/2021
Occupant: Location:
Septic Pump 62 Dream Lake Road South
Occupancy: Queensbury,Warren Co. NY
,Single Family Dwg_
Applicant:Il
Galway Co-Op I I ... .. . . .. .. C� ' 8rA-%5—?A?,O
Michael Cassadei
PO Box 299
LSchenectady, NY 12301
No. Joseph A.Holmes
_145704152547EL
Equipment:
1 -Septic Pump&Control
I
Tnis certificate applies to the electrical wiring to the electrical eq i ant listed Immediately null and void. This certificate applies only to me use,occupancy and
above and the Installation inspected as of the above noted date bas d on a visual ownership as indicated herein, Upon a change in the use,occupancy or ownership
inspection, No warranty is expressed or implied as to the machani I safety.efrr of the property indicated above,this certificate shall be Immediately null and void.
ciency or fitness of the equipment for any particular purpose. This c ificate shall In the event that this certificate becomes invalid based upon the above conditions,
be valid for a period of one year from the above noted data. Should a electrical thls certificate may be revalidated upon relnspection by Middle Department
system to which this certificate applies be altered in any way,includin ut not limit inspection Agency,Inc, An application for inspection must be submitted to Middle
ad to,the introduction of additional electrical equipment and/or the r p acement of Department Inspection Agency, Inc,to initiate the inspection and revalidation
any of the components installed as of the above noted date,this certificate shall be process. A fee will be charged for this service.
,f
{% :Offi'ce Use�Only
SEPTIC VARIANCE
Received:.
APPLICATION Permit#:5C.r- 01-85- 202-0
P'ermit.Fee:
742 Bay Road,Queensbury,NY 12804
Invoice#: _T
P:.518-.761-8256 �nr�ww.aueensbur'v.net-. - -
Approvals:
Submittal: I (one) original &8 copies of the completed application package .
Property Owner(s): John-Hampshire - Owner's Ageff', Amica Septic Design & Installation
Address: -6374th'Street Address:' S 6049 Fish House Road
Troy, NY 12180 Galway, NY 1207
Phone#: 51&.763-2964-"
Phone##: "518-882-54.45.
.;. - V... .
Site Address:'_ 62 Dream Lake-Road, Queerisb-ury-- Tax ID#: 279.174-10
Directions to Site: Bay Rd to Sunnyside Rd North, left onto Dream Lake Rd south
,Distance from well•on-property to septic system (if applicable) 7P-+/- feet
Is 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 w,elis &.septic:Systems.on i eigliboring
properties? X Yes, , No If NO, please explain:
i. 77 "OV j I .
1 ,
Is the proposed system to be installed under a parking a"_r'ea?•- Yes. X-_ .N'o•'`!
Section of the''Sanitary'Sewage.Ordina_nce from_which you ore_seeking_thewariance.(i.e..leaching system'will;be 89"ft.
from well in lieu of required 100 ft.):-
Previously approved variance placed-the'-tank at 50•.0'+j1_ •-Dur'ing'installation''ofthe 2000'gallo'n '=-''
r}"holding.tank holding tank-.the.location ofahe.tank was measured,at.3:1.-1',+/-.in;lieu;of,required ,
r0 'o rt- t'6 p p y" maxlmiie tHe'set "ack from adjacent properties, wells and shorelin...e. "
i
\, 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: `:R J
North Name `', Barton
Address''," ..60 Dream Lake Road
Tax Map ID 179.17-1-11
South Name Rivette
Address 64 Dream Lake Road
Tax Map ID 279.17-1-9
East Name N/A
y
Address
Tax Map ID
West Name N%A
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:
,62:.D.r:eam Lake.-Road..
I/We realize-that putting the well,septic tank or leaching'system less than the required 100feet•from the well
may:increase the risk-of pollution.
Owner—Print Name:, John Hampshire. Date: 08/09/21 .
Owner_Signature::. .[. Date: 08/09/21 '._
NEIGHBOR AR TENANT.RELEASE STATEMENT (if..,applicable)
I/We do-hereby relieve the Town''of Queehsbtary from any'liabilities on theplu'rribing and septic'system located at:
N/A
I/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: NSA Date:
Neighbor/Tenant-Signature: NSA Date:
Septic Variance Application February 2019'
I
PLEASE ATTACH-THE FOLLOWING TO YOUR APPLICATION:
1. A location map showing,t,he site;withinahe:Town:of',Queensbu,ry.: ''
,wi
2. A plot plan showing existing and proposed features of the pro,perty,:incl,uding:`
a. Lot dimensions
b. North arrow and scale: 1 inch=40 feet - `'
c. Location & dimensions of existing and proposed buildings; sh6wing.5etback distances and,
uses
d:_ -Farking Payout to'scal'e (if ap.plicabie). t`
e. Physical features (street, steep slopes, lakes, wetlands, etc:)' -
f. Location of all wells and septic systems on neighboring prop erties
g.a 'Adjacent,ownerships,
h. All properties within 500'feet
A sample plot plan and+location ar'e shown`belowc
Ao
- 'i. 'i 'is f�.L' r`i:'{ �.Fj;S.autY:�.;• Ca2iit;FW+.
' -_): ..: ... .+}^•..' .. 5 ' .::s�4 - ... t -fir ,tiyf , � -
. • :�a.l ;'. � a'. .a*tra;�o ..� " takneit�de
Septic Variance Applicati ri February•2018 •;.
AUTHORIZATION"AND SIGNATURE'PAdE!• ''
This page includes the.Autho'rization to Act-as'Agent form,`engiheering 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: - John, Hampshire
Designates: Dominick Arico c/o Arnica Septic Design as.,,a.gpnt regardingthe:Septic Variance for
Tax Map#: 179.17-1-10
08/09/21
OWNER'S SIGNATURE: ;'DATE:
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 fromthe 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 1ristructions,for submission; agree to the
submission requirements and,completed checklist:
OWNER—PRINT NAME: John Hampshire
OWNER—SIGNATURE: DATE: 08/09/21
AGENT—PRINT NAME: Dominick Arico
``—AGENT—SIGNATURE: DATE: 08/09/21
Septic Variance Application February'2018
RESOLUTION APPROVING JOHN HAMPSHIRE'S APPLICATION FOR
SANITARY SEWAGE DISPOSAL VARIANCE
RESOLUTION NO.: BOH 57,2021
INTRODUCED BY: Mr.Timothy McNulty
WHO MOVED ITS ADOPTION
SECONDED BY: Mr. George Ferone
WHEREAS, John Hampshire (Applicant) previously filed an application for a variance
from provisions of the Town of Queensbury On-Site Sewage Disposal Ordinance Chapter 136,
§136-11,which requires applicants to obtain a variance for holding tanks as the Applicant wished to
install a new 2,000 gallon septic holding tank in lieu of a sewage disposal system on property
situated at 62 Dream Lake Road in the Town of Queensbury, and
WHEREAS, by Resolution No.: BOH 003.2021, the Local Board of Health approved the
Applicant's variance to install the new 2,000 gallon septic holding tank in lieu of a sewage disposal
system on the property located at 62 Dream Lake Road in the Town of Queensbury, and
WHEREAS, the Applicant has applied to the Local Board of Health for an additional
variance from Chapter .136, §136-11 to approve the already installed 2,000 gallon septic holding
tank 31.lf' from the Dream Lake shoreline in lieu of the required 50' 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, September 27f,2021, 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 variance, the Local Board of Health determines that the
variance 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 variance is necessary for the
reasonable use of the land and is the minimum variance 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 John
Hampshire for a variance from the Sewage Disposal Ordinance to place the already installed 2,000
gallon septic holding tank 31.1±' from the Dream Lake shoreline in lieu of the required 50' setback
on property located at 62 Dream Lake Road in the Town of Queensbury and bearing Tax Map No:
279.17-1-10.
Duly adopted this 27 h day of September,2021,by the following vote:
AYES Mr. McNulty,Mr.Metivier,Mr. Freer,Mr. Ferone
NOES : None
ABSENT: Mr. Strough
SEPTIC-VARIANCE Office Use Only
—Received:
APPLICA�T�ION � Permit#: -0' 5- 29�
! PTOW791 Cad TV
ermit Fee:
742 Bay Road,Queensbury,NY 12804 ����� f
-224
P:518-761-8256 www.aueensbury.net DEC 1 w 4- Ir oice#: �2
Approvals:
Submittal: I (one) original &8 copies of the completed application package
Property Owner's): John Hampshire Owner's Agent: Arnica Septic Design & Installation
Address: 637 4th Street Address: 6049 Fish House Road
Troy, NY 12180 Galway, NY 1207
Phone#: 518-761-2964 Phone#: 518-882-5445
Site Address: 62 Dream Lake Road, Queensbury Tax ID#: 279.17-1-10
Directions to Site: Bay Rd to Sunnyside Rd North, left onto Dream Lake Rd south
Distance from well on property to septic system (if applicable) 71'+/- feet
Is 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 neighboring
properties?- X 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.):
Installation will be for a 2000 gallon holding tank with high water-alarm sensor for pumping.
"
�14
oF�P d
Septic Variance Application ( February 2018
List the names, parcel addresses, and tax map numbers of all adjoiriirig property owners. You may obtain tax
map numbers from the Assessor's Office as well as the names and addresses:
North Name Barton
Address 60 Dream Lake Road
Tax Map ID 179.17-1-11
South Name Rivette
Address 64 Dream Lake Road
Tax Map ID 279.174-9
East Name N/A
Address
Tax Map ID
West Name N/A
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:
62 Dream Lake Road
/We realize that putting the well,septic tank or leaching systemless than the required 100feet from the well
may increase the risk of pollution.
Owner—Print Name: John Hampshire. Date: 11/19/20
Owner—Signature: Date: 11/19/20
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:
N/A
I/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: N/A Date:
Neighbor/Tenant-Signature: N/A Date:
Septic Variance Application February 2018
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.)
J. Location of all wells and septic"systerns on neighboring properties
g. Adjacent ownerships
h. All properties within 500 feet
A sample plot plan and location are shown below:
�.�r r..ICi1(.1.•6 �, .� ry ��
IINI
cc
_ w
i y j
i I/ V � persanlra' � .. .... ' '�• iO+n Cflkm
I, ° I a rnol.ur In
-'A
��-r-•--� "� �.is 1
.Fi _
Septic Variance Application 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 usingan Agent:
Owner's Name: John Hampshire.
Designates: Dominick Arico c/o Arnica Septic Design as agent regarding the Septic Variance for
Tax Map#: 179.17-1-10
OWNER'S.SIGNATURE: _ DATE: 11/19/20
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 Meetine 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 checklist:
OWNER—PRINT NAME: John Hampshire
OWNER—SIGNATURE: DATE: 11/19/2020
AGENT-PRINT NAME: Dominick-Arico
AGENT—SIGNATURE: / DATE: 11/8/2020
i
Septic Variance Application February 2018