SEP-0812-2021 _,.., SEPTIC DISPOSAL PERMIT Office Use only
APPLICATION Permit#!: W- 0a\2- ?A?i1
Town VrQ¢atab"U' 9)
Permit Fee:$
Invoice M 'OT(a
742 Bay Read,Queensbury,NY 12804
P:518-761-8256 www,pueensbury.net Septic Variance? N ej`cA-t'NJ:�,y-'ejj'
Flood zone? Y No
Wetlands? Y Reviewed By: �
Project Location: 161 Cleverdale Road
Tax Map #: 226.12-1-53
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per total daily flow
per day bedroom Garbage Grinder Yes No
1980 or older 150 Installed? (choose one) ❑ Q
1981-1991 130 Spa or Hot Tub Yes No
1992-Present 110 s 110 550 Installed? (choose one) ❑ [�
PARCEL INFORMATION:
Topography ❑ Flat Rolling ❑ Steep Slope 10 % Slope
Soil Nature =_=— ❑ Sand ❑ Loam ❑ Clay- - -0 Other, explain: - _
Groundwater At what depth? >s,
Bedrock/Impervious material At what depth? >5'
Domestic Water Supply ❑ Municipal ❑ Well []Lake
(if well or lake, water supply from any septic system absorption is
>100' ft.)
Percolation Test Rate: 1-5 per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size 1.500 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: Pressurized HUENGSP Distribution bed 21 Modules Total
Holding Tank System Total required capacity? ; tank size ;
# of tanks
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL.-
Applicant:
Name(s): chrisMattson
Mailing Address, C/S/Z: 1044 Sylvan Road,LaucasterPA 17601
Cell Phone: Land Line:
Email:
• Primary Owner(s):
Name(s):
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): 01- -s ' '' AY
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
"Workers' Comp documentation must be submitted with this application"
• Enigineer(s)_;
Name(s): Environmental Design Partnership LLP
Mailing Address, C/S/Z: 900 Route 146 Clifton Park NY 12065
Cell Phone: 518-371-7621 Land Line:
Email: dmaeelroy@edpilp.eo n cdemyer@edpllp.eom
Contact Person for Compliance in regards to this project:
Cell Phone: Land Line:
Email:
NOTES: 1. Alarm system and associated electrical work must be inspected by a Town approved electrical
inspection agency; 2. VUe 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: &A14) ,cD( ,,A4 -
SIGNATURE: ~ DATE: 2 Z Z
r
TOWN OF QUEENSBURY
742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
Plan)to scale
i�Received Deep hole perc test results from engineer/Architect if applicable(Town Approved Engineers and
Architects;June 30 to April 15 Town Engineer for unapproved Engineers and Architects)
NSAII wells on property and adjacent properties shown
_!v FF�
Water line shown Municipal or well 10'separation to any part of system 'Cf
Setback to property lines show 10' or more for any part of system"Z-j6/G
Septic 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
AD.Leech Field 20' from foundation 100'from any well 10'from water line
Seepage pit 150'from well 50'from septic tank
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 mottlirlg� 36"within 1000' of Lake George
Leech field 100'from watercourse or wetland
PI
M lkToe 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
ilkoepartment of Health Approval for all mobile home park new systems Flood Plain requirements
l�2' above established flood elevation to bottom of system
All tanks anchored or 2' above flood elevation
uP.ViCP.d 4/1 5/7.n71
ENVIRONMENTAL DESIGN
PARTNERSHIP, LLP 900 Route 146 Clifton Park,NY 12065
Si-ranin, the ph sir_ai en';.^nr!ent (P)518.371.7621 (F)518.371.9540 edplip.com
November 8, 2021
Town of Queensbury Board of Health
742 Bay Road
Queensbury, NY 12804
Attn: John Strough,Supervisor
Re: Mattson—383 Cleverdale Road
Seguljic—26 Forest Road
BOH Variance Request
Dear John:
Submitted for your distribution and review are nine sets each of two(2) Board of Health wastewater
system variance applications. Each property is a single family residence located in the Lake George
waterfront zoning district(WR). The following summarizes each of the properties and associated
variance requests.
Mattson—363 Cleverdale Road
This property consists of a main house along with a separate guest house. The Owner is proposing
a new replacement system which will accommodate the five total bedrooms. The system will
consist of a 1500 gallon septic tank, a 1000 gallon pump tank with a duplex pump assembly and time
dose controls and an Eljen GSF trench absorption field. There are no wells (this lot or neighboring
lots)within 100' of the proposed absorption field. Two (2)setback variances for the absorption field
to the main house foundation and to the southern property line will be required for this proposed
wastewater system.
Seguljic—26 Forest Road
This Owner of this property is anticipating a renovation of the existing residence and thus proposes
an upgrade of the absorption field. As the property is served by the `seasonal'Shore Colony Water
District the Owner is planning on having a drilled well constructed onsite. Due to the size of the
property and other neighboring wells a new onsite well cannot meet the required 100'setback to a
proposed absorption field area. A variance is therefore requested for relief from the 100'setback
from the new replacement absorption field to the residence's proposed onsite well.
I am available to meet with you and/or other Board members to further discuss these proposals prior
to the public hearing. Thank you for your consideration of these requests.
Sincerely,
Dennis MacElroy
Dennis MacElroy, PE
Environmental Design Partnership
SEPTIC VARIANCE Office Use Only
Permit ObN2 ?02-I
APPLICATION Permit Fee:$
To;,a of Quccnsburr
Invoice
742 Bay Road,Queensbury,NY 12804 '—
P:518-761-8256 www.gueensbury.net Approvals:
Submittal: 1 (one) original &8 copies of the completed application package
Contact Information: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
Property Owner(s):C' %n� ,A"�"'C'c�� Owner's Agent* 1 9a9.4't-0 �• x-cv'r
Address: ip444 L-�/,41� � Address: R o.O `+}C"
BA i 7e-01 CA., =row . , Ky jz,.ac�
Phone#: -717 1 -- -7 SZ I Phone#: c5i La "77d-- -1i g':�P
Email:_e-%-%, nV-jr -c;-vYL Email: xy-A-Mc P ri' yo iL p. czarA
Site Information:
Site Address:_=.--s j - Tax ID#: -ZZ6;;-. lZ— --'>3
Directions to Site: �R i; 9 L Ta iz
Distance from well on property to septic system (if applicable) 1.A feet
Is it possible to install a conforming septic system on this property? ❑Yes � LP
If YES, please explain and attach a diagram:
V�-Iln
!LDl e "vociuRy
Does the proposed system meet setback requirements for distance from wells&septic systems on nelgRl3-d In
properties? 19Yes ❑ No If NO, please explain:
Is the proposed system to be installed under a parking area? ❑Yes KNo
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.):
°�1— � 1-4 obi�i�A.L���'1P�4�•�fi�`L r� au���.e'T'iat•k �o
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�d'Vzt23 r ti E>� ' tom u�� �l'3. 1 Gvi.g'Q E�
Septic Variance Application Revised September 2021
List the names, parcel addresses, and tax map numbers of all adjoining property owners. You may obtain this
f
information from the Town of Queensbury's Assessor's Office:
North Name _ I5A 177A
Address -5(ca5 Gy
Tax Map ID ��
South Name
Address (2A_Z: )�AOL_Z7
Tax Map ID e,g>. 12 — ze> oL
East Name LL b_ �-'�t-%-A
Address
Tax Map ID l Z
West Name
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:
Wa* 4R. ��We realize that putting the well,septic tank or leaching systemless than the required ZA feet
from the 4ou0k≫*i&-•n may increase the risk of pollution.
Owner—Print Name: +_ I-n �6
i Owner—Signature: U,jo
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:
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:
Neighbor/Tenant-Signature: Date:
Septic Variance Application Revised 5epternber 2021
AV
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: q
Designates. �f�i-rLlnnWGGs—" t regarding the Septic Variance for �'f3A<=.4 .�
Site Address: ?�65
Tax Map#: M-.i2p, 1 Z
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 toth-e
submission requirements and completed checklist:
OWNER—PRINT NAME:
OWNER—SIGNATURE: DATE: 2A
AGENT—PRINT NAMAE: 1 C,
AGENT—SIGNATURE t4 t 27 DATE:
Septic Variance Application Revised September 2021
NEWYORK Adirondack
STATE OF
OPPORTUNITY_ Park Agency
KATHY HOCHUL TERRY MARTINO
Governor Executive Director
December 13, 2021
Dave Hatin
Director, Building & Codes
Town of Queensbury
742 Bay Rd ITOWN
C u vQueensbury, NY 12804Re: LV2021-0126 MAR 0 12.022
Variance Application: Mattson Ot=QUEENSBURYTown Resolution: BOH79,2021 LDING&' CODES
Tax Map Number: 226.12-1-53
Dear Dave Hatin:
Adirondack Park Agency staff review of the above referenced variance determination
has been completed. The applicant proposes to install a replacement Eljen septic
system. Relief is required from the Town for the proposed absorption field to be:
1. 10 feet from the foundation instead of the 20-foot required setback; and
2. 4 feet from the property line instead of the 10-foot required setback;
Based on the information presented in the record, no further Agency review is required
for this variance since the project does not involve provisions of the Adirondack Park
Agency Act.
Thank you for your referral of this variance determination.
Sincerely,
Robyn Burgess
Principal Adirondack Park
Local Planning Assistance Specialist
REB:KOK
cc: John Strough, Supervisor, Town of Queensbury.
Craig Brown, Zoning Administrator, Town of Queensbury
Caroline Barber, Town Clerk, Town of Queensbury
P.O. Box 99•1133 NYS Route 86•Ray Brook, NY 12977•Tel:(518)891-4050•www.apa.ny.gov
RESOLUTION APPROVING MARY AND CHRIS MATTSON'S
APPLICATION FOR SANITARY SEWAGE DISPOSAL VARIANCE
RESOLUTION NO.: BOH 79,2021
INTRODUCED BY: Mr.Anthony Metivier
WHO MOVED ITS ADOPTION
SECONDED BY: Mr.Harrison Freer
WHEREAS, Mary and Chris Mattson (Applicants) filed an application for variances from
provisions of the Town of Queensbury On-Site Sewage Disposal Ordinance Chapter 136 to replace
their existing wastewater system with its absorption field to be located:
1. 10' from the foundation instead of the 20' required setback; and
2. 4' from the property line instead of the 10' required setback;
on property located at 363 Cleverdale Road 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 duly conducted a public hearing concerning the
variance request on Monday,December 60', 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 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 are the minimum variances which would alleviate the
specific unnecessary hardship found by the Local Board of Health to affect the
Applicants; and
BE IT FURTHER,
RESOLVED, that the Local Board of Health hereby approves the application of Mary and
Chris Mattson for variances from the Sewage Disposal Ordinance to replace their existing
wastewater system with its absorption field to be located:
1. 10' from the foundation instead of the 20' required setback; and
2. 4' from the property line instead of the 10' required setback;
on property located at 361-363 Cleverdale Road in the Town of Queensbury and bearing Tax Map
No: 226.12-1-53, 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 60'day of December,2021,by the following vote:
AYES Mr.Freer,Mr. Ferone,Mr. McNulty,Mr. Strough,Mr. Metivier
NOES : None
ABSENT:None