SEP-0053-2022 SEPTIC VARIANCE Affice Use Only ..
Permit#: ' 60r6- 2oZ2
APPLICAnoN Permit Feb:$ �5
*of
Invoice M
742 Bay Road,Queensbury,NY 12804
P:SW761-8256 www.etueensburv.net_ Approvals:
Submittal: l (one) olriginal 8e 8 copies of the completed application package
PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
Section 1:
Content Information:
Property Owner's): Steve:and.Tracey Bureau Owner's Agent: Rucinski Hall Architecture
Address:5 Chestnut Road, Address: .134 Dix Ave .
Lake George NY 12845 Glens Falls NY.12801
Phone#: 518-280-3177 Phone#: 518=741-0268.
Email: tbureaufitfun@gmaiLcom EMail:' .8Phall@riycap.rr.com.
Section 2•
Site Information:
Site Address: 5 Chestnut Road . Tax ID#: 289.13-1-7
Directions to-Site:-.-Chestnut-Road-is.off-of Glen-Lake.-Road or Birch road-(off of glen.lake road-as-well). -
Section 3•
Distance from well on property to septic system(if applicable) feet
Section 4: .
Is it possible to install a conforming septic system on this property? ❑Yes ®No
If YES,please explain and attach a diagram:
Section 5:
Does the proposed system meet setbackrequirements for distance from wells:&_septic systems on neighboring
properties? ®Yes E]No If NO,please explain:
Section 6:
Is the proposed system to be installed under a parking area? ®Yes 0 No
Section 7:
Section of the Sanitary Sewage Ordinance frorn-which you are seeking the variance(i.e.leaching system will be 89 ft.
from well in lieu of required 100 ft.): SEE FOLLOWING PAGE ATTACHED
Septic Variance Application Revised December 2021
RUCINSKI HALL ARCHITECTURE
Ronald Richard Rucinski
Ethan Peter Hall
134 Dix Avenue QJ-
Glens Falls NY 12801
Voice 518 7410268
Faic 518 741 0274
Email ephall@nycap.rr.com
5 Chestnut Road-Bureau Residence
18 February 2022
Continuation of Section 7:
Section of the sanitary sewage ordinance from which you are seeking the variance
Variance# Location.1 Location 2 Proposed (ft.) Required (ft) T Relief(ft.)
1 Property line., Disposal field : 4'-9 10'min. 5'_3"..
2 - Property line Disposal.field 3'-0" 10'min. 7=0"
3 Property,line Disposal field 2'-3" 10' min. W"-
4 Property line . Force main 2'-7" .10' min. 7'
5 Property line Force main 1'-00_ 10'..
0'min. 9'=.0"
6 Adjoining garage Force-main V-10" - 10'min. 4=2"
7 Adjoining residence Force main 3'-8" 10'min. 6'-4"
8 _ Property line Pump station. 5'-8" 10'min. 4'-4" .
- - - - 9 ---- -Adjoining residence- Pump station_ - 6'-10"-.-- - 10'-min- - .3 V:= -
10 Residence Pump station 5'-5" 10'min. 4=7"
11 Adjoining residence . Fujiclean 7'-0" 10'min. 3=0"
12 Property line Fujiclean 5'-9" 10'.min. 4':3"
13 Residence Fujiclean 5'-9" 10'min. 4'-3"
1
f
Section S•
List the names, parcel addresses,and.tax map numbers of all adjoining property owners. You may obtain this
information from the Town of Queensbury's Assessor's Office: -
North Name: _ Richard Shuren
Address : 3 Chestnut Road -
Tax Map ID 289.13A-6. '
South Name James M Whitaker
Address 7 Chestnut Road
Tax Map ID 289.13-1-8.,
East Name
GLEN,LAKE
Add ress
Tax Map ID .
West Name _Andiew'Rougrey_
Address ., Glen Lake.Road (vacant)
Tax Map ID 289.13-1-41-
Section 9•
OWNER STATEMENT
I/We,do hereby relieve the Town of Queensbu,r 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 10-feet
1iv,er
from the emick C-C Prb • may increase the risk of pollution. .
racey Bureau
Owner—Print Name:
Owner—Signature: Date: :2/22/2022
NgGH OR Ok TEN MT REi MESTATEM (it re)
/We do heeyby relieve the Town&Qvgensbuay from any Ileb711ties on the plumbling and septic system located at=
CAOr cJh-j,, 1' _P/We realize that putting the well,septic tank or leaching system less thm t(he required 10 feet
fFrore the ralcdice, o 6LmWay Increase the ei5k of pollution..
I NJ
Neighbor/Tenant--- Pdnt Name; Fidler'Souren�.+
N'6ghbOrf f'rl rp -5 19ture: l� Date: 02122/22
�ap7ic fila��nce�IIra6iara ! � �2�Y@
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: I inch=40 feet
c. Location gC 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.)
f. Location of all wells and septic systems on neighboring properties
g. Adjacent ownerships. -
h. All properties.within 500.feet
A sample plot plan and location are shown below;
_�
ht
Septic Variance Application Revised December 2021
Section 11:
AUTHORIZATION AND SIGNATURE PAGE .
This page includes the Authorization to Act.as Agent fdrm;engineering fee disclosure,authorization for site
visits, other permit responsibilities and agreement to provide documentation required.
Complete the following if the OWNER is using a6 Agent:
Owner's Name. Steve and Tracey Bureau
Designates: Ethan P. Hall as agent regarding the Septic Variance for
Site Address: 5 Chestnut Road.
Tax Map#: 289.134-7 .
Engineering Fee Disclosure:Applications maybe 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/ 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 subsequentto approval by -
the Town Hoard 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 to the
submission requirements and completed checklist: .
Tracey.Bureau
OWNER—PRINT NAME:
OWNER—SIGNATURE: " DATE: 2/22/2022
AGENT—PRINT NAME:
AGENT—SIGNATURE: DATE:
Septic Variance Applicatlon Revised December 2021
v _
rr- U E
D
APR 0 8 2022
TO13UILD NG&CODES Y
RESOLUTION APPROVING STEVE AND TRACEY BUREAU'S
APPLICATION FOR SANITARY SEWAGE DISPOSAL VARIANCES
RESOLUTION NO.: BOH 23,2022
INTRODUCED BY: Mr.Anthony Metivier
WHO MOVED ITS ADOPTION
SECONDED BY: Mr.George Ferone
WHEREAS, Steve and Tracey Bureau(Applicants) have filed an application for variances
from provisions of the Town of Queensbury On-Site Sewage Disposal Ordinance, Chapter 136 to
install a replacement wastewater treatment system with its components proposed to be located as
follows:
1. Disposal field to be 4'9"from the property line in lieu of the required 10' setback;
2. Disposal field to be 3' from the property line in lieu of the required 10' setback;
3. Disposal field to be 2'3"from the property line in lieu of the required 10' setback;
4. Force main to be 27'from the property line in lieu of the required 10' setback;
5. Force main to be P from the property line in lieu of the required 10' setback;
6. Force main to be 5'10"from the adjoining garage in lieu of the required 10' setback;
7. Force main to be 3'8" from the adjoining residence in lieu of the required 10'
setback;
8. Pump station to be 5'8"from the property line in lieu of the required 10' setback;
9. Pump station to be 6'10" from the adjoining residence in lieu of the required 10'
setback;
10. Pump station to be 5'5"from the residence in lieu of the required 10' setback;
11. Fuji clean system to be 7' from the adjoining residence in lieu of the required 10'
setback;
c i
12. Fuji clean system to be 5'9" from the property line in lieu of the required 10'
setback;and
13. Fuji clean system to be 5'9"from the residence in lieu of the required 10' setback;
on property located at 5 Chestnut 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 conceming the
variance requests on March 21",2022,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 Steve and
Tracey Bureau for variances from the Sewage Disposal Ordinance to install a replacement
wastewater treatment system with its components to be located as follows:
1. Disposal field to be 4'9"from the property line in lieu of the required 10' setback;
2. Disposal field to be 3' from the property line in lieu of the required 10' setback;
3. Disposal field to be 2'3"from the property line in lieu of the required 10' setback;
4. Force main to be 27'from the property line in lieu of the required 10' setback;
5. Force main to be 1' from the property line in lieu of the required 10' setback;
6. Force main to be 5'10"from the adjoining garage in lieu of the required 10' setback;
7. Force main to be 3'8" from the adjoining residence in lieu of the required 10'
setback;
8. Pump station to be 5'8"from the property line in lieu of the required 10' setback;
9. Pump station to be 6'10" from the adjoining residence in lieu of the required 10'
setback;
10. Pump station to be 5'5"from the residence in lieu of the required 10' setback;
11. Fuji clean system to be 7' from the adjoining residence in lieu of the required 10'
setback;
12. Fuji clean system to be 5'9" from the property line in lieu of the required 10'
setback: and
13. Fuji clean system to be 5'9"from the residence in lieu of the required 10' setback;
on property located at 5 Chestnut Road in the Town of Queensbury and bearing Tax Map No: 289-
13-1-7.
Duly adopted this 2 1"day of March,2022,by the following vote:
AYES Mr.Freer,Mr. Ferone,Mr.McNulty,Mr. Strough,Mr.Metivier
NOES None
ABSENT: None
SEPTIC DISPOSAL PERMIT office Use only
APPLICATION Permit#:
T. ofCZi�censhtu.Y Permit Fee:$ f)FD
Invoice#:
742 Bay Road,Queensbury,NY 12804 ,6�^^Vk 2_,) 20 22
P:318-761-MG www.aueensbury.net Septic Variance? UY N d�
Flood Zone? Y 45-0
Wetlands?
V_
Project Location: 5 Chestnut Road D -
Tax Map M 289.13-1-7 AIR 0 2-22
RESIDENCE INFORMATION: TOWN OF QUEENS BURY
Year-Built Gallons #of bedrooms: X gallons per =total daily flow BUILDING &CODES
bedroom Garbage Grinder Yes No
1980 or older 150 Installed? (choose one) X.
i0si-1991 130 Spa or Hot Tub Yes No
1992-Present 1110 2 110 220 Installed? (choose one) ❑. _
PARCEL INFORMATION:
Topography ❑ Flat Rolling ®Steep Slope %Slope
Soil Nature ® Sand ❑ Loam ❑Clay ❑ Other, explain:
Groundwater At what depth? not encountered
Bedrock/Impervious material At what depth? not encountered
Domestic Water Supply ❑ Municipal ❑Well ®Lake
(if well or lake, water supply from any septic system absorption is
ft.}
Percolation Test Rate: 1-5 per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED_SYSTEM INFORMATION:
Tank size 540t 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: H-20 Infiltrator Absorpt. bed (under parking)
Holding Tank System Total required capacity? : tank size
#of tanks
*FujiClean tank proposed: 540 gallon opacity with 500 gallons per day hydraulic load
Septic Application Revised April 2021
CONTACT I�ORMAJQbLPLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): Steve and Tracey Bureau
Mailing Address, C/S/Z: 5 Chestnut Road, Lake George NY 12845
Cell Phone: 518-260-3177 Land Line:
Email: tbureaufitfun@gmail.com
® Primary.Owner(s):
Name(s): Steve and Tracey Bureau
Mailing Address,C/S/Z: 5 Chestnut Road, Lake George NY 12845
Cell Phone: .518-260-3177 Land Line:
Email: tbureaufitfun@gmail.com
❑Check if all work will be performed by property owner only
• Contractor:
Contact Name(si. Ellsworth & Sons Excavating
Contractor Trade: Genreal Contractor
Mailing Address,C/S/Z:10302 Route 349 Eort NY 12827
Cell Phone:518-361-1993 Land Line: _ _
9246
Email:.diggiLnAellclNnrthe=auating.com
**Workers'Comp documentation must be submitted with this application**
• Eneineer(s):
Name(s): Rucinski Hall Architecture
Mailing Address, C/S/Z: 134 Dix Ave,.Glens Falls NY 12801
Cell Phone: Land Line: 518-741-0268
Email: ephall@nycap.rr.com
Contact Person for Compliance in regards to this project: Ethan P. Hall
Cell Phone: 518-260-2888 Land Line: 518-741-0268
Email: _ephall@nycap.rr.com
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.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: Ethan P. Hall -Arcchiite gent for the Applicant
SIGNATURE:-- DATE:8 Apr 2022
Septic Application Revised April 2021
COMMONWEALTH ELECTRICAL INSPECTION SERVICE,INC.
Main Office 176 Doe Run Road-Manheim,PA 17545
MUNICIPAL CERTIFICATE - ELECTRICAL APPROVAL
�� °� Z�y2 N° 50069
Permit No........................................Cert. Cut-in Card No....................................
Owner................................5l4.a.S✓........
Location.......................s7...... 1?:i7 v cots.�: 2. .......................................... .
InstallationConsisting of...................................................................................................................................
...................................5.=�?..!`. � .......v.. n .......S .S.i. m...:.............................................................
.
...................................................................................................................................................................................
InstalledBy....... -......z' ....................................Lic.No.................................................
The conditions following governed the issuance of this certificate,and any certificate previously issued is
cancelled:-
This certificate only covers the electrical equipment and installation conditions as of datc. Upon the
introduction of additional equipment or alterations,application shall be promptly made for inspection.
Inspectors of this Company shall have the privilege of making inspections at any time, and if it:
rules are violated,the Company shall have the right to revoke this certificate.
Date............6n..�:.�a................ INSPECTOR .. ??.............................................................
Mnmho.N G P A I A F I
'GP
SERVICE CONTRACT
FOR THE
FUJI CLEAN TREATMENT TECHNOLOGY
f-
Ellsworth&Son Excavating, Inc. has been contracted by Full Clean USA and their Authorized Distributor to provide
you with the first two years of service,maintenance,and operation as well as any warranty service should it be required.
This contract has been paid in full on your behalf. This contract is provided In accordance with applicable state and r
local regulations.
I
This contract,entered into between Ellsworth&Son Excavating,inc.and Tracey&Steve Bureau shall be binding upon
both parties in accordance with the conditions and terms set forth below:
Contract Date: May 2022 i
i
Term of Contract: 2 years I
i
Location of Technology:property address: 5 Chestnut Road,Lake George,NY 12845
Model: Fujiclean CE6
I
Maintenance and Other Services shall consist of:
a. Inspection,Maintenance,and Operation:Service Provider agrees td inspect, maintain and operate the Fuji
Clean treatment system per the TN DEC and manufacturer's requirements.This includes but is not limited
to the following:
two service visits per year (6-month Intervals). Service visits will include performance of
operation and maintenance activities detailed In the Operation and Maintenance manual, j
check the sludge depth to determine the need for pumping;
inspection of the final effluent to determine proper operational performance;and
test the process parameters including but not limited to DO,pH,and turbidity to maintain proper
�. operation;
b. Service Calls:Service Provider will provide services calls within two business days. Service Provider will I
apply a charge for labor,travel time and shipping for any necessary replacement parts unless covered by
the manufacturer's warranty.
c. Completed inspection form will be submitted to local and state authorities as required.
d. Contract is transferable in the event of sale of the home.
i
The owner of the system agrees to use the system as outlined in the owner's manual.The owner also understands that
any abuse of the system may void the manufaoturers warranty.
Owner acknowledges that the following items can overtax the biological process of the system and shall avoid
introducing dental floss, disposable diapers,kitty litter,sanitary napkins,tampons,cigarette butts,condoms and other
items of similar nature.Owner acknowledges that the following can destroy the biological process and agrees to not
introduce chemicals such as paints,varnishes,thinners,waste ails,photographic solutions, pesticides and excessive
amounts of household chemicals Into the system.`P owner acknowledges that violation of these terms will void the
manufacturer's w y and may be in vi ation of state w.
Homeowner. Date a� --
Service Provider. Date /nfUiloi ,
Autho ed gent) /"
Please sign and return to the Service Provider whose'name and address appear below:
Ellsworth&Son Excavating,Inc D � (' 1f ��
r
10302 State Route 149
Fort Ann, NY 12827 FEB 6 2023
TOWN OF
BU�LDliVGUEENSBURy
CODES
I
RUCINSKI HALL ARCHITECTURE
Ronald Richard Rucinski
Ethan Peter Hall
134 Dix Avenue �JG
Glens Falls NY 12801
Voice 518 741 0268
Fax 518 741 0274
Email ephall@nycap.rr.com
Bureau Residence—5 Chestnut Drive—Glen Lake E U
D
8 June 2022 FEB 0 7 2023
Town of Queensbury Building Department TOWN®1=QUEENSBURY
742 Bay Road BUILDING&CODES
Queensbury NY 12804
Re: Installation of Replacement Sewage Disposal System
At the above referenced project location this office observed the installation of the FujiClean OWTS
tank, effluent pump chamber and infiltrator& stone bed prior to backfill. This installation is
acceptable to'this off :eke are any questions please contact our office to discuss.
D
Regar
Ethan Peter `5f �
Architect
Y a®A,
�s
L
1