SEP-0849-2021 4 Office Use Only
SEPTIC VARIANCE Permit#:
APPLICATION Permit Fee:$ —
Town cA CLccns%rur.
Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.aueensbury.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 Own er(s)�r4ALa) ` - L-:oIC, Owner's Agent: 1 `���lhila 1Z
Address: J7-Co Address: c1a6
L.L>t�11C�hiV 1G L.4 GYcb�� 1�1 TbIr1 2Y� t N-1, `ZO(O
Phone#: a(aG --Ij Z,1j — 74=>17 Phone#: �'J 1$ -57Ce--�� 5`5
EmaiLeri®.6�. cica.gW�1 tGGd a►�tb1i'e*►ht. Email: c9+- l sro 9API
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Site Information:
Site Address: `52 �d���1 Tax ID#: Z.Z<o� 19 —1-41
Directions to Site: A-yo t�tzy ; 1 -2:s `+wplmy Lta `1�-5
Distance from well on property to septic system (if applicable) 0y feet
Is it possible to install a conforming septic system on this property? ❑Yes No n�
If YES,please explain and attach a diagram: ng IE C E U 1wJ E
NOV 3.0 2021
Does the proposed system meet setback requirements for distance from wells set ' t@1n€��E"W-Mg
properties? ®Yes ❑ No If NO, please explain: B ILDING&CODES
is the proposed system to be installed under a parking area? ❑Yes ® 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.):
80 ,
Septic Variance Application Revised September 2021
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 \.t] iL.C.®
Address
Tax Map ID
South Name
Address
Tax Map ID
East Name TA 1 C.—f,4F_-I—
Address
TaxMaplD
West Name JE F CRWVG��a 0 cnty4 4db53a4ti-L�
Address Z2Z lLsa V_E'��'-kk0,A`f
Tax Map ID ZZG_ IC9 — I —E53 n l —
OWNER STATEMENT
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 eaching syste less than the required 100 feet
from the sw4ym We1A.- may increase the risk of pollution.
Owner—Print Name: . �;
Owner—Signature: , Date: 11 -`5'Z l
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-5ignature: Date:
Septic Variance Application Revised September 2021
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: aiy��Ql�—(`� G�y�-LJ t G
Designates:',.��� �s agent regarding the Septic Variance for VInZAeK. 12;,
Site Address: '5 o'Z.
Tax Map#: I H 1
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 to the
submission requirements and completed checklist:
OWNER—PRINT NAME: A30 GXc
OWNER-SIGNATURE: DATE:
AGENT-PRINT NAME: -4N 1 SnG Cat`
AGENT-SIGNATURE: DATE:
Septic Variance Application Revised September 2021