SEP-0067-2020 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.: OD V'-- •2b2:0
Permit Fee:
Approvals:
Owner BRIAN HAYWARD Owners Agent HUTCHINS ENGINEERING,PLLC
Address 21 STODDARD ST Address 169 HAVILAND ROAD
GLENS FALLS,NY 12801 QUEENSBURY,NY 12804
Phone 518-796-6524 Phone 518-796-2515
Directions to Site: BIG BAY ROAD TO PALMER DRIVE -5 PALMER DRIVE
Distance from well on property to septic system(if applicable) 100 feet
Is it possible to install a conforming septic system on this property? ✓ Yes No
If YES, please explain and attach diagram: SEE ATTACHED PLAN
Does proposed system meet setback requirements for distance from wells &septic systems on neighboring properties?
Yes ✓ No If NO,please explain: SEE ATTACHED PLAN
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):
136-7 A-REQUEST RELIEF OF 85 FT TO INSTALL A NEW DRILLED WELL 65 FT FROM A SEEPAGE PIT ON THE
PARCEL TO THE NORTH WHERE 150 FT OF SEPARATION IS.REQUIRED.
136-7 A-REQUEST RELEIF OF 55 FT TO INSTALL A NEW DRILLED WELL 95 FT FROM A SEEPAGE PIT ON THE
PARCEL TO THE SOUTH WHERE 150 FT OF SEPARATION IS REQUIRED.
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A�Town of Queensbury Building&Codes Septic Variance Application ZG 1 L O� 518-761-8256
.i 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: RRIAN HAYWARD
Designates: HUCTHINS ENGINEERING as agent regarding Septic Variance for
Tax Map ID: 316.17-1-4
OWNER'S SIGNATURE: Date: 02/19/2020
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.
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: BRIAN HAYWARD
SIGNATURE OF OWNER:
DATE: 02/19/2020
PRINT NAME OF AGENT: THOMAMNTER,PE HUTCHINS ENGINEERING
SIGNATURE OF AGENT:
DATE: 02/19/2020
Town of Queensbury Building&Codes Septic Variance Application 518-761-8256
Short Environmental Assessment Form
Part 1 -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 maybe 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
BRIAN HAYWARD
Name of Action or Project:
HAYWARD WELL VARIANCE
Project Location(describe,and attach a location map):
5 PALMER DRIVE,QUEENSBURY
Brief Description of Proposed Action:
INSTALL A NEW WELL LESS TAHN 150 FT FROM NEIGHBORING SEEPAGE PITS.
Name of Applicant or Sponsor:
Telephone: 518-796-6524
BRIAN HAYWARD
E-Mail:
Address:
21 STODDARD STREET
City/PO: State: Zip Code:
GLENS FALLS NY 12801
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:TOQ BOH WELL VARIANCE
3.- a.Total acreage of the site of the proposed action? 0.26 acres
b.Total acreage to be physically disturbed? 0.26 acres
c.Total acreage(project site and any contiguous properties)owned
or controlled by the applicant or project sponsor? 0.26 acres
4. Check all land uses that occur on,are adjoining or near the proposed action:
5. ❑Urban ❑ Rural(non-agriculture) ❑ Industrial ❑ Commercial 0 Residential(suburban)
❑Forest ❑ Agriculture ❑ Aquatic ❑ Other(Specify):
❑Parkland
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14. Identify the typical habitat types that occur on,or are likely to be found on the project site.Check all that apply:
[]Shoreline 0 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? _ ❑
16. Is the project site located in the 100-year flood plan? NO YES
❑✓ E
17. Will the proposed action create storm water discharge,either from point or non-point sources.9 NO YES
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: ❑
_L9._ 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: ❑ El
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: Rl ❑
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF
MY KNOWLEDGE
Applicant/sponso e: THOMAS CENTER,PE,HUTCHINS ENGINEERING, Date:2/1912020
Signature: Title:PROJECT ENGINEER
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