2024-0166 SEPTIC VARIANCE Office Use Only
Permit#:- - r)-ip
APPLICATION Permit Fee: $ 1(FJ "-
Town of Qoccn sbury
Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Approvals:
Submittal: 1 (one) original & 8 copies of the completed application package
PLEASE PRINT L-EGIB_LY OR TYPE;PLEASE-'INCLUDE AN EMAIL
Section 1: ) ?
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Contact Information: U I�
p y Gregg Nolte = . i .r-F `�'Owner'sAgent: Environmental Design Partnerhsip Property Owner(s): !"��f1lV [= '� u� b`3� 9
PI1,1_7I!,i'�_�'µ_e.::!t COD
Address: 10 Apple Blossom Lane Address: 900 Route 146
Albany, NY 12205 Clifton Park NY, 12065
Phone#: 518-858-0537 Phone#: 518-371-7621 x 138
Email: gnolte60@gmail.com Email: cdemyer@edpllp.com
Section 2:
Site Information:
Site Address: 35 Assembly Point Rd Tax ID#: 239.12-2-10
Directions to Site:
Section 3:
Distance from well on property to septic system (if applicable) n/a 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 setback requirements for distance from wells &septic systems on neighboring
properties? ■❑Yes ❑ 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 100 ft.): V-1 : Use of Holding Tanks
Septic Variance Application .Revised December 2021
Section 8:
i
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 Jeffrey Handles
Address 42 Assembly Point Rd
Tax Map ID 239.12-2-11
South Name Raymond Shirvell
Address 31 Assembly Point Rd
Tax Map ID 239.12-2-9
East Name Harold D. Gordon
Address State Route 9L
Tax Map ID 239.12-2-94.1
West Name Collier FarmRevLivTrust
Address 28 Old Assembly Point Rd
Tax Map ID 239.12-2-5
Section 9:
OS61NER.STTEMEENT
I/We do hereby relieve the Town of Queensbury from any liabilities on the plumbing and septic system located at:
35 Asseinbly Point Rd . 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.
Owner—Print Name: . �T{' �'`
i
Owner—Signature: / ,A, Date: .`I )� 740 a`r
Section 10:
NEIGHBOaORTENANTBELEASESTATEMENT( 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 December 2021
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: 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:
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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: C C)c)
Designates: Environmental Design Partnership as agent regarding the Septic Variance for Nolte Residence
Site Address: 35 Assembly Point Road
Tax Map#: 239.12-2-10
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: e-
OWNER—SIGNATURE: DATE; L } 2\W
AGENT—PRINT NAME: Connor DeMyer
AGENT—SIGNATURE: ,a .r'� DATE: 4/2/24
Septic Variance_Aonlication Revised December 2021
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