SEP-0052-2022 SEPTIC VARIANCE officeuse only
j Permit#: c -'60`�2 •ZeZZ
APPLICATION Permit Fee:$
Invoice# :61 bbb
742 Bay Road,Queensbury,NY 12M
P:51846142S6 www.wueensbunr.net Approvals:
Submittal: I (one) original &8 copies of the completed application package
PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
Section 1•
Contact Information:
Property Owner(s): Richard and Linda Shuren Owner's Agent: Rucinski.Hall Architecture
Address: 3 Chestnut Road Address: 134 Dix Ave, Glens Falls NY 12801
Lake George NY 12645
Phone M 609-865-8094 Phone#: ,5.18-741-0268
Email: lindashuren@aol.corh Email: ephall@nycap.rr.com .
Section 2•
Site Information:
Site Address: 3.Chestnut.Road Tax ID#: 289.13-1-6
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 propertyto septic system(if applicable) feet
Section 4c
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 setback requirements for distance from wells&septic systems on neighboring
properties? EZYes ❑No If No,please explain:
Section 6.
Is the proposed system to be installed under a parking area? ❑Yes No -
Section 7•
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 106 ft.j: SEE FOLLOWING PAGE ATTACHED
Septic Variance Application Revised December 2021
RUCIHSKI HALL ARCHITECTURE
Ronald Richard Rucinski °�
�a
Ethan Peter Hall
134 Dix Avenue
Glens Falls NY 12801
Voice 516 7410268
Fax 518 7410274
Email ephall@nycap.rr.com
3 Chestnut Road-Shuren 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.) Relief(ft.) '
1 Property line Disposal field 91-01' 10' min.. II-V
2 Property line Disposal field 8'-11". 10' min. ?4"
3 Residence Disposal field 13'-9" . 20'min. 64"
4 Garage Pump station 614 10' min. 3-8"
5 Garage Fujiciean 7'-1" 10' min. .
6 Residence Pump station 7'-0" 10'min.
7 Residence Fujiclean T-0" 10' min. 3=0n
1
Section 8:
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 Drahushuk;'Michele.Novak
Address. . 1 Chestnut Road
Tax Map ID 289.13-1-5-
South Name Steve and Tracey Bureau
Address 5 Chestnut Road_
Tax Map ID 289.13-1-7
GLEN LAKE ;
East Name .
Address .
Tax Map ID
West (Name AndreW DoAiley
Address Glen Lake Road (vacant)
Tax Map ID 289.13-1-41
Section 9•
OWNER STATEM ENT
I/We do.hereby relieve the Town of Queensbury from any liabilities on the plumbing and septic system located at:
3 GheSknu-� . I/We realize that putting.the well,septic tank or leaching system less than the required I O feet
from the P L•� ����� caG�rA_ iay increase the risk of pollution.
Owner—Print Name: . Richard Shuren
Owner—Signature: Date:. ..02/22/22
Section 16:
NEIGHBOR OR TENS°RT 11 E STATEAd1MT Jifarp pL-cVsm)
if/We do hereby relieve the Town of Q,ueensbury from' a.nV liabilities on the plumbing and septic systern located at:
J G�1�-4-K1�f1- d/We realize that puiting, the vaell,sel is tarsi;or leaching,system less than the required_Q_feet
from the P—M—Q?�-1�-+ �iVNP- may increase-the risk of PDllub n.
Ti-acey Bureau
Neighbor/Tenant—Print Name:
Neighborfr'enant Signature: R Date:20-219 99
Sepik Uk same Ap0imt%sn Revised Dem-nbu 2?1
PLEASE ATTACK 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.)
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!
U4I_rI!A$MIA
Septic Variance Application Revised December 2021
Section 11:
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: Richard and Linda Shuren
Designates: Ethan P. Hall _ as.agent regarding-the Septic Variance for
Site Address: 3 Chestnut Road
Tax Map#:
289.13=1-6
Eneineerine Fee Disclosu_re: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.Meetink 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:
Richard J.Shur-en
OWNER—PRINT NAME:
OWNER—SIGNATURE: . . lole
'� ` DATE: 02/22/22
AGENT—PRINT NAME:
AGENT®SIGNATURE:. DATE:: . -
Septic Variance Application Revised December 2021
RUCINSKI HALL ARCHITECTURE
Ronald Richard Rucinski
Ethan Peter Hall
134 Dik Avenue
Glens FaIISr NY 1,2801
Voice 618 741:-'0268
Fax 518 741-0274
Email ephallQnycap-rr.com
Memo
To: John O'Brien—Code Enforcement Officer—Town of Queensbury
From: Ethan-Hall
D4te 25 February, Z=
Re: Shuren Residence—3 Chestnut Road—Glen Lake—Septic variance
John,
As A clarifidation to-our-submission,for the Shureh Residenc6seplic variance,-thp.,cadjoi.ing property
owner at 1 Che
stnut fttid, IE-inds-n\f of.Drahushuk:draws,water from'n the lakd. The Wat f line is
shown on:their-septic variance submission (drawing C1 00 attache
d). if.there are any a, ditional
questions,.please let me know.
Regards,
Ethan P..Hall
Architect
YAShuren Residence--Glen Lake\Memo 25 SB 2&2.doo
I
:, ^�_ .? r9Kt�l�.:a '• es'�°'::•, .. _
ma® ®® f.,9+'
_ �', �','ryl'c�, t
`h�-.Y• c.•• R+If�.r•jF�.:J;'f�'I�lJ '���tn�f�f
L I1.1 1 1 r, II,/I ` , �./..,8, a a ':.; ..,-•,�'�ia' : 't .r: �`V
1 pa. . flfllt���1
06
J,j I l "' I.,•jl :Ada�.o:� ....o
fro• I 1 °/ �I 1 f /I'J L w '� J� 106
°s.. ._...�®.
.. �"" �'®mo ��.„>. t G I I ) ,,J'> I,Y .,.•�l 141 � mm®�,�I,®mo...l.m
a
M—I v
I' - - ----T"_I• ® w - L'O o0 maw o® ..®�m�0.°w
®'R°m° mMlmaa.
.�4va_
Yw°y.m�.,m�..v.�mlw
I �1mw®
_ aarrwe
HM a m ®• ��_m e'� � �� ____II I ®' m! _ ... wooufrn ®®ol®e vrt.YwW� >
EEO"uii
--
r�
aF.EEM FAQ
ww,:,u°n er a¢mrc�mm rn.n w,ip mv>.> u� mwnw ' '
..�> .'. AXM SEPfiC'SY'4TDF R
\ _ ��� >'m+R'•='""`�^'� ��Lwn PREP EDFOR
• ,�>o. e• %r�i"w w':u.aa ,row a,w¢xaugv asrov.t MICV�LE MIiJSlUM
T ia...a ma'"o.ove f
'm� row ®® mp TAx unP �9.tsl-s
�ra°o":..... cNEESSNt�UUii ROAD
L. T J OUEENS w,NY M"
ip� �11 I — ""' COUNTY F WARREN
\ �. c_ - r--�Pw .•t- PUMP&CONTROL.NOTES:
.� ;mr.„•;..m.. r�rr,.m. , I�no ui...'nmm.u,.wwn n.v.. ma�raw.
SANITARY PUMP DESIGNS"..""' t.�.a ' I r.. `®®p1 New York
EI ECTRICAl^NOTES a v,e•'e."ma.'x
800.082-7982
m vm
,1.500 GALLON POMP STATION NO-=..n...m.� ' Clog
i.
� J
=I
RESOLUTION APPROVING RICHARD AND LINDA SHUREN'S
APPLICATION FOR SANITARY SEWAGE DISPOSAL VARIANCES
RESOLUTION NO.: BOH 22,2022
INTRODUCED BY: Mr.Timothy McNulty APP p 29022
WHO MOVED ITS ADOPTION
TOWN O C,UB`N
P�SB
SECONDED BY: Mr.Anthony Metivier BUILDING&CO URYSR
WHEREAS, Richard and Linda Shuren(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 9' from the property line in lieu of the required 10' setback;
2. Disposal field to be 8'11"from the property line in lieu of the required 10' setback;
3. Disposal field to be 13'9"from the residence in lieu of the required 20' setback;
4. Pump station to be 64"from the garage in lieu of the required 10' setback;
5. Fuji Clean system to be 7'1"from the garage in lieu of the required 10' setback;
6. Pump station to be 7' from the residence in lieu of the required 10' setback;and
7. Fuji Clean system to be 7' from the residence in lieu of the required 10' setback;
on property located at 3 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 concerning the
variance requests on March 21",2022,and
w
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 Richard
and Linda Shuren 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 9' from the property line in lieu of the required 10' setback;
2. Disposal field to be 8'11"from the property line in lieu of the required 10' setback;
3.. Disposal field to be 13'9"from the residence in lieu of the required 20' setback;
4. Pump station to be 6'4"from the garage in lieu of the required 10' setback;
5. Fuji Clean system to be 7'l"from the garage in lieu of the required 10' setback;
6. Pump station to be 7' from the residence in lieu of the required 10' setback;and
7. Fuji Clean system to be 7' from the residence in lieu of the required 10' setback;
on property located at 3 Chestnut Road in the Town of Queensbury and bearing Tax Map No: 289-
13-1-6.
Duly adopted this 21 St day of March,2022,by the following vote:
AYES Mr.Metivier,Mr.Freer,Mr.Ferone,Mr.McNulty,Mr. Strough
NOES None
ABSENT: None
SEPTIC DISPOSAL PERMIT office Use only
APPLICATION Permit#: Ste' 0052 -Z02Z
Town ofQueensbury D I� C l�+ g V E Permit Fee:$
Invoice#: q�b--x)
742 Bay Road,Queensbury,NY 1280 APR 0 2022
P:518-761-8256 www.gueensburv. e Septic Variance? ® N
TOWN OF
BUILDIN G EEENSBURY Flood Zone? Y
ODES Wetlands? Y N Reviewed B�
i
Project Location: 3 Chestnut Road i
Tax Map #: 289.13-1-6
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) ❑ X
1981-1991 130 Spa or Hot Tub Yes No
1992-Present 110 2 110 1 .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 540* 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: Bottomless Sand Filter
Holding Tank System Total required capacity? ; tank size
# of tanks
* FujiClean tank proposed: 540 gallon capacity with 500 gallons per day hydraulic load
Septic Application Revised April 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): Richard and Linda Shuren
Mailing Address, C/S/Z: 13 Powderhom way, Allentown NJ, 08501
Cell Phone: 609-865-8094 Land Line:
Email: lindashuren@aol.com
• Primary Owner(s):
Name(s): Richard and Linda Shuren
Mailing Address, C/S/Z: 13 Powderhom way, Allentown NJ, 08501
Cell Phone: 609-865-8094 Land Line:
Email: lindashuren@aol.com
❑ Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): Ellsworth &Sons Excavating
Contractor Trade: General Contractor
Mailing Address, C/S/Z: 10302 Route 149 Fort Ann NY 12827
Cell Phone: 518-361-1993 Land Line: 518-792-9246
Email: digging@ellsworthexcavating.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-Arrc/hitect\Agent for the Applicant
SIGNATURE: / DATE: 7 Apr 2022
Septic Application Revised April 2021
Sip— c�o52-- 2-02� i
SERVICE CONTRACT
FOR THE
FUJI CLEAN TREATMENT TECHNOLOGY
Ellsworth &Son Excavating, Inc. has been contracted by Fuji 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
local regulations.
This contract, entered into between Ellsworth&Son Excavating, Inc.and Richard and Linda Shuren shall be binding
upon both parties in accordance with the conditions and terms set forth below:
Contract Date: May 2022
Term of Contract: 2 years
Location of Technology:property address: 3 Chestnut Road,Lake George,NY 12846 r
Model: Fujlclean CE5
Maintenance and Other Services shall consist of.
a. Inspection,Maintenance,and Operation:Service Provider agrees to 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: . i
- 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;
- check the sludge depth to determine the need for pumping; j
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
l operation; '
b. Service Calls:Service Provider will provide services calls within two business days. Service Provider will
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 manufacturer's 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,vamishes,thinners,waste oils,photographic solutions, pesticides and excessive
amounts of household chemicals into the system.The owner acknowledges that violation of these terms will void the
manufacturer's warranty and may be
in violation of state law.
rr,,i- '!
Homeowner: � � .�L Date
Service Provider: Date q d
(AuttXrizid Agent)
Please sign and return to the Service Provider whose name and address appear below:
Ellsworth&Son Excavating,Inc 2 D C JE 0 V E
10302 State Route 149 L�
Fort Ann,NY 12827
FEB 0 6 2023
TOWN OF QUEENSBURY
BUILDING P. CODES
RUCINSKI HALL ARCHITECTURE
Ronald Richard Rucinski
Ethan Peter Hall
134 Dix Avenue
Glens Falls NY 12801
Voice 518 741 0268
Fax 518 741 0274
Email ephall@nycap.rr.com
Shuren Residence—3 Chestnut Drive—Glen Lake
8 June 2022
Town of Queensbury Building Department FEB 0 7 2023
742 Bay Road TOWiV
Queensbury NY 12804 OF BUILOF Q &ECOpESRy
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 bottomless sand filter bed prior to backfill. This installation is
acceptable to this i". ece are any questions please contact our office to discuss.
Regard �� ,};.
V A - .
Et n eter aU��
eY.S":w
Architect 6 °
s
AS 8
1
COMMONWEALTH ELECTRICAL INSPECTION SERVICE,INC.
Main Office 176 Doe Run Road-Manheim,PA 17545
MUNICIPAL CERTIFICATE - ELECTRICAL APPROVAL
Permit 22.Cert.N o 50073 Cut-in Card No...................................
....................
Owner.................../A .}?.!?!w...........S1 .vx.t... ................................................................................
Location...................3.......G_kesi nu?.l'.1, .................................. ..............
InstallationConsisting of..................................................................................................................................
...............................J.�n/)74kC........../Q.4.M.10......s/s./..G zn=................................................................
.................................................................................................................................................................................
InstalledBy............r.�.......,1. arn.. .................................Lie.No................................................
The conditions following governed the issuance of this certificate,and any certificate previously issued i
cancelled:-
This certificate only covers the electrical equipment and installation conditions as of date. Upon th
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 ii
rules are violated,the Company shall have the right to revoke this certificate.
Date........... ............. INSPECTOR............ ........................P'..................................................
C�olM—h N FP A_I_A_FJ_