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HomeMy WebLinkAboutTR-4600 -��- F ° � -�:'�y y mow"�` y' �► �..:.,�� �`d�` ..�F x '� �) ,:•,z� �-�e�7� ii• � ' �.�. V.:- �_axk'r7i.. .��%r ,:r """2.�C�r���� A' 1� �= —`� � a• a- .- w�n., i�" �� of�M1yr �y>^�' es a ' gV 's^r"SP"r � Board Of Southold Town Trustees ;w , a, SOUTHOLD, NEW YORK .,. PERMIT NO. DATE: � Ali .......:.�.�....... ...Ma ISSUED TO .......................James..-Deerkoski Pursuant to the provisions of Chapter 615 of the Laws of �» '•_ � the State of New York, 1893; and Chapter 404 of the Laws of the . :: State of New York 1952; and the Southold Town Ordinance en-}, titled "REGULATING AND THE PLACING OF OBSTRUCTIONS ��•: i • 4�! 1- i IN AND ON TOWN WATERS AND PUBLIC LANDS and the !ti; ' j REMOVAL OF r.\ SAND, GRAVEL OR OTHER MATERIALS FROM LANDS UNDER TOWN WATERS;" and in accordance with the Resolution of The Board adopted at a meeting held on ..May 22..... j p g y.... .. AJ 19.....9.6.., and in consideration of the sum of $......15.Q....00..... paid by M. alof ...............................................................................4.......... N. Y. and subject to the ' Terms and Conditions listed on the reverse side hereof, ' - aI.! of Southold Town Trustees authorizes and permits the following: .;I.! to construct a single family dwelling approx. 75' from wetlands. Hay bales must be placed 50' from the northwest ^; property line and no clearing shall take place within that 50' t all in accordance with the detailed specifications as presented in E � the originating application. IN WITNESS WHEREOF, The said Board of Trustees here- is by causes its Corporate Seal to be affixed, and these presents to to k ±;,..,.. be subscribed by a majority of the said Board as of this date. It .... ............. .. o ........ -0. o Ln ... ..... ............ ', =j 7��1 ��O �' ....... :. Trustees Albert J. Krupski,President „y �Gy Town Hall John Holzapfel, Vice President c 53095 Main Road `* _ P.O. Box 1179 Jim King �y • �� Southold,New York 11971 Martin H. Garrell . Peter Wenczel ��,( �'a� Telephone (516)765-1892 Fax(516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD May 23, 1996 James Deerkoski 32 .Pegs Lane Riverhead, NY 11901 Re: SCTM ##114-10-2 Dear Mr. Deerkoski: The following action was taken by the Board of Town Trustees during its regular meeting held on May 22, 1996 regarding the above matter: WHEREAS, JAMES DEERKOSKI applied to the Southold Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town of Southold, application dated April 15, 1996, and, WHEREAS, said application. was referred to the Southold Town Conservation Advisory Council for their findings and recommendations, and. WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on May 22, 1996, at which time all interested persons were given an opportunity to be heard, and, WHEREAS, the Board members have personally viewed and are familiar with the premises in question and the surrounding area, and, WHEREAS, the Board has considered all the testimony and documentation submitted concerning this application, and, WHEREAS, the structure complies. with the standard set forth in Chapter 37-18 of the Southold. Town Code, WHEREAS, the Board has determined that the project as proposed will not affect the health., safety and general welfare of the people of the town, NOW THEREFORE BE IT, RESOLVED, that the Board of Trustees grant a Wetland Permit to construct a. single family dwelling approx. 75' from wetlands i Haybales must be placed 50 ' from the north west property line and no clearing shall take place within that 501 , and, BE IT FURTHER RESOLVED that this determination should not be considered a determination made for any other Department or Agency which may also have an application pending for the same or similar project. Permit to construct project will expire two years from the date it is signed. Fees must be paid, if applicable, and permit issued within six months of the date of this notification. Two inspections are required and the Trustees are to be notified upon completion of said project. FEES: None. Very truly yours, Albert J. Krupski, Jr. President, Board of Trustees AJK/jmd cc: CAC o�oS�FFOL�coG Town Hall, 53095 Main Road U-1 T P.O. Box 1179 Telephone • (516) 765-1801 2P. ��' Southold, New York 11971 SOUTHOLD TOWN CONSERVATION ADVISORY COUNCIL . At the meeting of the Southold Town Conservation Advisory Council held Monday, May 20, 1996, the following recommendation was made: No. 1348 Moved by Robert Keith, seconded by Allan Connell, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH CONDITIONS of the Wetland Application of JAMES . DEERKOSKI 114-10-2 to build a single family 2-story dwelling with garage. 260 Deer Drive, Mattituck The CAC recommends approval if runoff is contained using hay bales, drywells, etc. and that there be no clearing within 75' of the wetlands. Vote of Council: Ayes: All Motion tarried. APR 18 '96 11 ©9AM SOUTHOLD TOWN HALL 516 765 1823 P.3 14•ts•4 i2/87)—Text 12 ,�� PROJECT I.D.NUMBER 617.Z1 SE0 Appendix C State Erivironmental Duality Review SHORT ENVIRONMENTAL" ASSESSMENT FORM For UNLIST413 ACTIONS Only PART [—PROJECT INFORMATION (To be completed by Applicant or Project slpbnsor) 1. APPLICANT/$PONSOR Z. PROJECT NAMIi 1, PROJECT LOCATION: Municipality 5001 m O C;b County a, PRECISE LOCATION(Street address and road intersections, prominent landmarks, etc.,or provide map) _ S. is PROP SED ACTION: r ew ❑Expanslon 0 Madiflastianlatteration 5. DESCRIBE P€CJECT BRIEFLY: , +V w 2 ?. AMOUNT OF LAND AFFECTED: s^ Initially e 30 acres Ultirnatoly 'U J acres 8. WILL PROPOSED ACTION COMPLY WITH EXISYING ZONING OR OTHER FXI�TING LAND U85 AEST810710NS? PY2s No If No,describe briefly " S. WtAj IS PRESENT LAND USe IN VICINITY OF PROJECT? asidantial c1ndustria11 Z Commercial Agriculture ❑Park/Fores Ocan apace ❑Other 10. DOES ACTION INVOLVE A PERMIT APPROVAL OR PUNDING,NOW OR ULTIMATELY PROM ANY OTHER GOVERNMENTAL AGENCY(FEDERAL, STATE OR LOCAL)? ffYes ❑No If yes, Ast agency(a)and perrniftordvals. It DOES ANY At3 ECT OF THE ACTION HAVE A CURRENTLY VAUD PERMIT OR APPFOVAL? ❑Yes /No, If yes,list agency name and permit/approval 12, AS A RESULT,OF PROPOSED ACTION WILL EXISTINC, PEAMITIAPPROVAL REouiAF-MODIFICATION? . Yes No I CEVi IFY THAT THE INPOSMATION PMOVIOtCD ABOVE Is TRUE TO THE BEST OF:MY KNOWLEdGE �L-S r� 'os� , �l<hW- preset -- I8 g Applicantld m pot+sor name: oat SignBturt; It the action is in the Constal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this aVessment OVER 1 APR 18 196 11:©9AM SOUTH'' T' TOWN HALL '516 765' 1823 P.2 PROOF OF MAILING OF NOTICE ATTACH CERTIFIED 14AIL RECEIPTS ' Name! y. Address STATE OF NEW PORK . CbUNTX OF SUF FOCC2�-� �!/�eU✓t/. residing--at Y being duly sworn egos�:s 'and. say that .on. t_ �? day of �// ,l9 , deponent, mailed a true copy of the-Notic�e set €ort in the Board of Trustees . Application, directed to each of the move named persons at the addresses set opposite there respective names; that-the addresses . set .opposite the names of -said s.person are. the address . of .said.. Persons as shown 'on the..currant assessment roll of .the Town. of Southold; -that si4d Notices wer Y mailed at the United States 'Post office at that said- Notices were mailed to each of said persons y (certified) registered) mail. ' Sworn to befo a me this � day of rig Notary Publio- JOSEFIH A. DEERKOS1�1 ; Notary Public, State of Nov 16�1 No. 6968126-Suffolk Oou"ItY Commission Expires Jan.31, 6 } Albert J. Krupski,President Town Hall John Holzapfel, Vice President =� ?� 53095 Main Road y z P.O. Box 1179 William G. Albertson Southold, New York 11971 Martin H. Garrell • Peter Wenczel ��j�l �a0� Telephone (516) 765-1892 Fax (516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Fry�-a� (� �5� Coastal Erosion Permit Application Wetland Permit Application y T - APR 1 5 Grandfather Permit Application Trustee Lands Permit Application Waiver ,�wi n,F Z,.i Received Application: Clerical Review: Completed A pli a on _ Incomplete A - SEQRA Classification: Type I Type II Unlisted Coordination: (date s t) CAC Referral Sent: Date of Inspection: y G eceipt of CAC Report: (da e) I Lead Agency Determination: Technical Review: (date) Public Hearing: (date) S" of Decision: Approved (Y/ date) Application Fee:$ GL//82 Name of Applicant Address �J� P�C-2S I--�9 Al I��V ,e a� rD 1�+ 1��0 1 Phone Number: (5h,) `72;7 ���7�'a 6 Suffolk County Tax Map Number: 1000 Property Location: 2-J-60 NEl DQ YE 1Voe-rti Sr of I00 i "N :o VV jqL (provide LILCO Pole #, distance to cross streets, and location) Agent: (If applicable) Address: Phone: 1 ird of Trustees Applicatic f GENERAL DATA rj Land Area ('in square feet) : 1 Q® '1 Area Zoning: P451 cet, f A L Previous use of property: V AC Ar M Intended use of property: Rest J1-_MCf Prior permits/approvals. for site improvements: Agency . Date No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? No Yes If yes, provide explanation: Project Description (use attachments if necessary) : New AO MC-_ 2- WI- 4 C,-AaA6�. 2 ' efa4nw.;.jE.="r.:a!':r.=tiaS�sa:.4+�;,._..,....::r•,',:zC;,�. ... ..:. _ ird of Trustees Applicatii ` r WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: 40-M J3k1PJC1Q_ otl) �ACA_Nll Lor Area of wetlands on lot:- square feet Percent coverage of lot: 0 o Closest distance between nearest existing structure and upland edge of wetlands: feet t�D—i 15 V AC A,' Closest distance between nearest proposed structure and upland edge of wetlands: - S' 1 feet Does the project involve excavation or filling? No Yes f�FbS�Y>9�iJJT' If yes, how much material will be excavated? 10U0 cubic yards How much material will be filled? CD cubic yards Depth of which material will be removed or deposited: feet 0 Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: 51N " 1 N Ee.I Pcf(F— POO wc)O f'10 YT. c�o-r 1 rV GS Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason os such proposed operations (use attachments if appropriate) : 6 14-16-2' ''37 6,17.21 Appendix A SEC: State Environmental Quality Review FULL ENVIRONMENTAL ASSESSMENT FORM Purpose: The full EAF is designed to help applicants and agencies determine, in an orderly manner, whether a projec or action may be significant. The question of whether an action may be significant is not always easy to answer. Frequent- ly, there are aspects of a project that are subjective or unmeasureable. It is also understood that those who determine significance may have little or no formal knowledge of the environment or may be technically expert in environmenta: analysis. In addition, many who have knowledge.in one particular area may not be aware of the broader concerns affecting the question of significance.The full EAF is intended to provide a method whereby applicants and agencies can be assured that the determinatior. process has been orderly, comprehensive in nature, yet.flexible to allow introduction of information to fit a project or action. Full EAF Components: The full EAF is comprised of three parts: Part 1: Provides-objective data and information about a given project and its site. By identifying basic project data, it assists a reviewer in the analysis that takes place in Parts 2 and 3. ?art 2: =ocuses on identifying the range of possible impacts that may occur from a project or action. It provides guidance as to whether an impact is like'y to be considered small'to moderate or whether it is a potentially large impact. The form.-also identifies whether an impact can be mitigated or reduced. Part 3: If any impact in Part 2 is identified as potentially-large, then Part 3,is used to evaluate whether or not the impact is actually important. DETERMINATION OF. SIGNIFICANCE—Type 1 and Unlisted ,actions Identify the Portions of. EAF completed for this project: ❑ Part 1 ❑ Part 2 ❑Part 3 Upon review of the information recorded on this EAF'(Parts 1 and 2 and 3 if appropriate), and any other supporting information, and considering both the magitude.and importance of each impact, it is reasonably determined by the lead agency that: ❑ A. The project will not result in any large and important impact(s) and, therefore, is one which will not have a significant impact on the environment, therefore a negative declaration will be prepared. ❑ B. Although the project could have a significant effect on the environment, there will not be a significant effect for this Unlisted Action because the mitigation measures described in PART 3 have been required, therefore a CONDITIONED negative declaration will be prepared.* ❑ C. The project may result in-one or more large and important impacts that may have a significant impact on the environment, therefore a positive declaration will be prepared. A'Conditioned Negative Declaration is only valid for Unlisted Actions Name of Action Name of Lead Agency Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(If different from responsible officer) Date --------------- - PART 1—PROJECT INFO' --AT10N Prepared by Project Sponsor NOTICE: This document is designed to assist in determining whether the action proposed may have a significant e- on the environment. Please complete the entire form', Parts A through E. Answers to these questions will be'consid as part of'the application for approval and may be subject to further verification and public revie%v. Provide any addit: information-you believe will be needed to complete Parts 2 and 3.. It is expected that completion of the full EAF will be dependent on information currently available and will not inv new studies, research or investigation. If information requiring such additional work is unavailable, so indicate and spe each-instance. NAME OF ACTION (� LOCATION OF ACTION (Include Street Address,Municipality and County) ITT 1__ l) NAME OF APPLICANT/SPONSOR BUSINESS TELEPHONE p` ADDRESS 62. S2 PcG--,. n_z_ CITY/PO I STATE- ZIP CODE v2 v �V1 I I O NAME OF OWNER(it different) BUSINESS TELEPHONE ADDRESS CITY/PO I STATE I ZIP CODE DESCRIPTION OF ACTION Please Complete Each Question—Indicate N.A. if.not applicable A. Site Description Physical setting*of overall project, both developed and undeveloped areas. 1. Present land use: ❑Urban ❑Industrial ❑Commercial Residential (suburban) ❑Rural (non-fa ❑Forest ❑Agriculture ❑Other 2. Total acreage of project area: Qq ,!� acres. APPROXIMATE ACREAGE PRESENTLY AFTER CONIPLETIO'N Meadow or Brushland (Non-agricultural) acres A acres Forested acres acres Agricultural (includes orchards, cropland, pasture, etc.) acres acres Wetland (Freshwater or tidal as per Articles 24, 25 of ECL) acres acres Water Surface Area acres acres Unvegetated (Rock, earth or fill) acres acres Roads, buildings and other paved surfaces acres acres Other (Indicate type) acres acres 3. What is predominant soil types) on project site? a. Soil drainage: ,Nell drained /©d 4a of site ❑Moderately well drained ?IS of site Poorly drained % of site b. If any agricultural land is involved, how many acres of soil are classified within soil group i through 4 of the N' Land Classification System? acres. (See 1 NYCRR 370). 4. Are there bedrock outcroppings on project site? ❑YesN0 a• V.hat is depth to bedrock? (in feet) 2 .. "3.•approximate percentage of Dostrd projoct'si[e with slopes: U-1( "� 0-1 S`JL _ ° ' ❑ 54„ ,,, greater °o 6. Is project substantially contiguous to, or co Eain a building, site, or district, listed on the State or the Nation Registers of Historic Places? ❑Yes No _ '. Is project substantially contiguous to a site li ted on the Register of National Natural Landmarks? ❑Yes ' 8. What is the depth of the water table? 2-0 (in feet) 9. Is site located over a primary, principal, or sole source aquifer? ❑Yes l 'o 10. Do hunting, fishing or shell fishing opportunities presently'exist in the project rea? ❑YesiNo 11, Does project site contain any species of plant or animal life that is identified as threatened or endangerea ❑YesJ0 According to Identify each species 12. Are there any unique or unusual land forms on the project site? (i.e., cliffs, dunes, other geological formationf ❑Yes Jal�o Describe 13. Is the projoc•.. si � presently used by the community or neighborhood as an open space or recreation area ❑Yes o If yes, explain f 14. Does the preseKt site include scenic views known to be important to the community? ❑Yes Intiguous o 15. Streams within or to project area: a. Name of Stream.and name of River to which it is tributary 16. Lakes, ponds, wetland areas within or contiguous to project area: a. Name TT ITO(A41 & u b. Size (In acres) 17. Is the site served by existing public utilities? *es to a) If Yes, does sufficient capacity' exist to allow connection? ❑YesNo b) If Yes, will improvements be necessary to allow connection? Yes CIN 18. Is the site located in an agricultA/N al district certified pursuant to Agriculture and iNvlarkets Law, Article 25-AA, Section 303 and 304? ❑Yes a 19. Is the site located in or substantialy contiguou to a Critical Environmental Area designated pursuant to Article 8 of the ECL, and 6 NYCRR 617? ❑Yes No 20. Has the site ever been used for the disposal o solid or hazardous wastes? ❑Yes N0 B. Project Description.. 1• Physical dimensions and scale of project (fill in dimensions as appropriate) a. Total contiguous acreage owned or controlled by project sponsor - �!57 acres. b. Project acreage to be developed: - acres initially; •45- acres ultimately. C. Project acreage to remain undeve!oped = Id acres. d. Length of project, in miles: (If appropriate) e. If the project is an expansion, indicate percent of expansion proposed f. Number of off-street parking spaces existing proposed g. Maximum vehicular trips generated per hour (upon completion of project)? h. If residential.." Number and type of housing units: One�Family Two Family Multiple Family Condominium Initially -) .L Ultimately 1 i. Dimensions (in feet) of largest proposed structure Zd height; fir width; 55' length. j. Linear feet of frontage along g a public thoroughfare project will occupy is? 7 ft. 3 2. How much• natural material (i.e., rock, earth, etc.) will be removed F-^m the site? �00 tonsjcub;c Nape 3. Will disturbed areas be r aimed? Ekes, ONO ❑N/A a. If yes, for what intendcc purpose is the site being reclaimed? b. Will topsoil be stockpiled for reclamation? Pes ONO c: Will upper subsoil be stockpiled for reclamation? J es ONO 4. How many acres of vegetation (trees, shrubs, ground covers) _will be removed from site? • acres. 5. Will any mature forest (over 100 years old) or other locally-important vegetation be removed by this project? Dyes N0 6. If single phase project: Anticipated period of construction months, (including demolition). 7. If multi-phased: a. Total number of phases anticipated (number). b. Anticipated date of commencement phase 1 month year, (including demolition .c. Approximate completion date of final phase month year. d. Is phase 1 functionally dependent on subsequent hales? Dyes ONO 8. Will blasting occur during construction? ' ❑Yes o 9. Number of jobs generated: during construction after project is complete 10. Number of jobs eliminated by this project 11. Will project require relocation of any projects or facilities? Dyes 4 o- If yes, explain 4,KL 12. Is surface liquid.waste disposal involved? ❑Yes DFNo a. If yes, indicate.type of waste (sewage, industrial, etc.) and amount b. Name of water body into which effluent will.be .discharged 13. Is subsurface liquid waste disposal,involved? Dyes ❑No Type 14. Will surface area of an existing water body indrease or decrease by proposal? Dyes ONO. Explain 15. Is project or any portion of project located in a 100 year flood plain? Dyes J4N0 16. Will the project generate solid waste? Dyes ONO a. If yes, what-is the amount per month tons' b. If yes, will an existing solid waste facility be used? Dyes Lle�'Na c. If yes,. give name ; location d. Will any wastes not go into a.sewage disposal system or into a sanitary landfill? ❑Yes ONO e. If Yes, explain 17. Will the project involve the disposal of solid waste? Dyes ( 4V0 a. If yes, what is the anticipated-rate of disposal? tons/month. b. If yes, what is the anticipated site life? years. 18. Will project use herbicides or pesticides? Dyes All 19.. Will project routinely produce odors (more than one hour per day)? ❑Yes �No 20. Will project produce operating noise exceeding'the local ambient noise levels? ❑Yes10 21. Will project result in an increase in energy use? Dyes 0 fNO J If yes , indicate type(s) �'JJ 22. If water supply is from wells, indicate pumping capacity gallons/minute. 23. Total anticipated water usage per day gallons/day. 24. Does project involve Local. State or Federal funding? ❑Yes o If Yes, explain 4 25. .Approvals Required: i Submittal TYPc Date City, Town, Village Board ❑Yes ONo City, Town, Village Planning Board ❑Yes ONo City, Town Zoning Board OYes ONo City, County Health Department ❑Yes ONo Other Local Agencies Dyes ONo Other Regional Agencies ❑Yes ❑No State Agencies ❑Yes ONo •Federal Agencies OYes ❑No C. Zoning and Planning Information 1. Does proposed action involve a planning-or zoning decision? ❑Yes o If Yes, indicate decision required: ❑zoning amendment ❑zoning variance ❑special use permit ❑subdivision _ Clsite plan Onewirevision of master plan ❑resource management plan ❑other 2. What is the zoning classification(s)of the site? RCS))l�rif'1 IC 3. What is the maximum) potential development of the site if developed as permitted by the present zoning? .4. What is the proposed zoning of 'the site? R-CS1 ►I S. What is the maximum potential development of the site if developed as permitted by the proposed zoning? /00� r 6. Is the proposed action consistent with the recommended uses in adopted local land use plans? es QN C 7. What are the predominant land use(s) and zoning classifications within a 1/4mile radius of proposed \action? • I�SI b��ry'31 >f4L 8. Is the proposed action compatible with adjoining/surrounding land uses within a '/ mile? � N'es C 9. If the proposed action is the subdivision of land, flow many lots are proposed? a. What is the minimum lot size proposed? 10. Will proposed action require any authorizations) for the formation of'9ewer or water districts? ❑Yes "RCN, 11 . Will the pr6posed action create a demand for any community provided services (recreation, education, police fire protection)? ❑Yes XN0 a. If yes, is existing capacity sufficient to handle projected demand? ❑Yes ONo 12. Will the proposed action result in the generation of traffic significantly g r y above present levels? ❑1'es c a. If yes, is the existing road network adequate to handle the additional traffic? Oyes o D. Informational Details Attach any additional information as may he needed to clarify yotir project. If there are or may be any adverse impacts associated with your proposal, plr,,se disc uss SUCK iml,acts aril the rnvasures which you propose to mitigate or avoid them. E. Verification I certify that tho information provided ',hok- is Irm. to the• hest of my knowledge. j ��pnhc.ant:slu,rrtior M1, ne J� �z. 1fK��u Date L�— Signature NWA/kt �fille If the action is in the Co. tal Ar;:::Vlr .ire a state .,I;ency, complete the Coastal Assessment Form hciore proceeding With Il,is assessment. g toe Part 2—PROJECT IMPACTS AND THEIR MAGNITUDE Responsibility of Lead Agency General Information (Read Carefully) • In completing the form the reviewer should be guided by the question: Have my responses and determinations been reasonable? The reviewer is not expected to be an expert environmental analyst. • Identifying that an impact will be potentially large (column 2) does not mean that it is also necessarily significant. Any large impact must be evaluated in PART 3 to determine significance. Identifying an impact in column 2 simply asks that it be looked at further. • The Examples provided are to assist the reviewer by showing types of impacts and wherever possible the threshold of magnitude that would trigger a response in column 2. The examples are generally applicable throughout the State and for most situations. But, for any specific project or site other examples and/or lower thresholds may be appropriate for a Potential Large Impact response, thus requiring evaluation in Part 3. • The impacts of each project, on each site, in each locality, will vary. Therefore, the examples are illustrative and have been offered as guidance.They do not constitute an exhaustive list of impacts and thresholds to answer each question. • The number of examples per question does not indicate the importance of each question. • In identifying impacts, consider long term, short term and cumlative effects. Instructions (Read carefully) a. Answer each of the 19 questions in PART 2. Answer Yes if there will be any impact. b. Maybe answers should be considered as Yes answers. c. If answering Yes to a question then check the appropriate box (column 1 or 2) to indicate the potential size of the impact. If impact threshold equals or exceeds any example provided, check column 2. If impact will occur but threshold is lower than example, check column 1. d. If reviewer has doubt about size of the impact then consider the impact as potentially large and proceed to PART 3. e. If a potentially large impact checked in column 2 can be mitigated by change(s) in the project to a small to moderate impact, also check the Yes box in column 3. A No response indicates that such a reduction is not possible. This must be explained in Part 3. 1 2 3 Small to Potential Can Impact Be Moderate Large Mitigated By IMPACT ON LAND Impact Impact Project Change 1 . Will the proposed action result in a physical change to the project site? ONO DYES Examples that would apply to column 2 • Any construction.on slopes of 15% or greater, (15 foot rise per 100 ❑ ❑ ❑Yes ❑No foot of length), or where the general slopes in the project area exceed 10%. • Construction on land where the depth to the water table is less than ❑ ❑ ❑Yes ❑No 3 feet. • Construction of paved parking area for 1,000 or more vehicles. ❑ ❑ ❑Yes ❑No • Construction on land where bedrock is exposed or generally within ❑ ❑ ❑Yes ❑No 3 feet of existing ground surface. • Construction that will continue for more than 1 year or involve more ❑ ❑ ❑Yes El No than one phase or stage. • Excavation for mining purposes that would remove more than 1,000 ❑ ❑ ❑Yes El No tons of natural material (i.e., rock or soil) per year. • Construction or expansion of a sanitary landfill. El El Yes ❑No • Construction in a designated floodway. ❑ ❑ ❑Yes El No • Other impacts ❑ ❑ ❑Yes El No 2. Will there be an effect to any unique or unusual land forms found on the site? (i.e., cliffs, dunes, geological formations, etc.)❑NO DYES • Specific land forms: ❑ ❑ ❑Yes ❑No 6 3rd of Trustees Applicatii County of Suffolk State of New York A BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH 'IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S) , IF GRANTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENTATIVES(S) , TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. ,nature. SWORN TO BEFORE ME THIS AdL DAY OF lg 9l� 94-1 o ry PUhW s JEFFREY F.KAYTIS Notary Public,State Of New York No. 62-4906947 Qualified in Suffolk County Commission ExpiresUaw*- 14; �3 3 Albert J. Krupski. President �p� �4G��, Town Hall John Holzapfel, Vice Presidents y� 53095 Main Road P.O. Box 1179 William G. Albertson y z Southold, New York 11971 Martin H. G acre I1 • Peter Wenczel 'fl�l �a0� Telephone (516) 765-1892 Fax (516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD � L 6L Office Use Only Coastal Erosion Permit Application ' Wetland Permit Application Grandfather Permit Permit Application +� APR 1 5 Trustee Lands Permit Application ' Waiver �`��1�b_ .y�'s' Received Application: ---- . UUIH ;' Clerical Review: Completed A pli a on Incomplete SEQRA Classification: Type I Type II Unlisted Coordination: (date s t) CAC Referral Sent: Date of Inspection: `1 G Receipt of CAC Report: (da e) Lead Agency Determination: Technical Review: (date) Public Hearing: (date) Decision: Approved (Y/N (date) Application Fee: $ �,��� C /i82 Name of Applicant jjA(Y)0!�- Address 3Z- P-F—(�'S - Phone Number : (57JC-) Suffolk County Tax Map Number: 1000 10 Property Location: a o NAP �Q�� , 0141TTrTV04. , N`1 N6Z—T+t 51 eve— 100 W To .(- 19 L >sa (provide LILCO Pole # , distance to cross streets, and location) Agent: ( If applicable) Address : Phone: 1 .L,.UP., nd so OTC -f COUNTY OF SuKaL I—Lb. ". D- - Lm P. W—ok".Lh. Real Prope"Tax Se A—%..-,P. :.#Is. W 4. - GwT n .—U-10 uATch LINE c MATCH DUE 4 Lw-- 61 &Z -1z DIOCESE OF LONG ISLAND SEE SM MOL W i Ar t-ft-r-4 -2-4en UNION F" e w. i+r SCHOOL TOWN OF SOUTHM.D LAW - 71AW 1.2 151.3hic) Otu."ewo L&MI a Ze— JL, 441", BEE SEC- MM 140 4:166. 14, 444d %IT % db 15 Is mm sm too. .141 2.4ow LoAtc! 5-1 SUFFOLK CO. HEALTH DEPT. APPROVAL i - wI N MAP OF QiEE�Q,PAQV- - rf :l: 1 1 t`4E aUFF. G: CLE{ 14-5 Q�'r E�� _—_-- _ _ ��c.. RVEYEL) k f'IL APR 1 5 �996 A5 T r 1 �i ��•P�Y� DFE R _• _.... STATEM�- I�°�O� INTENT } a ! I THE WATER SUPPLY AND SEWAGE DISPOSAL � ����_� - — �'� AT' ITU' ( SYSTEMS . FOR THIS RESIDENCE WILL CONFORM TO THE STANDARDS OF THE VPT1S --��- .�<.. '� '1�/''•L f>1 .�3c�LJ t .�-'C~ = ��I,Y i SUFFOLK CO. DEPT. OF HEALTH SERVICES. (S) APPLICANT I SUFFOLK COUNTY DEPT. OF HEALTH 1 _ . ----_. SERVICES - FOR APPROVAL i=0 Fc _ CONSTRUCTION ONLY DATE: jai 'i'j H. S. REF. NO. iS - -._ �.. I V 'f `1 'fJ f APPROVED: .19 17) 1 `1_, _ CO. A P DESIGNATION: SUFFOLK X MA r — _-----.-_� -•_- I DIST. SECT_ BLOCK PCL. PRUP, lz4 t n OWNERS ADDRESS: N 7, GA,Z I 1 ,� S . '.�. `� 32 PEGS LA I`F E' 21,5� iz. tZly f2 � !yY n9o9 ,1 I*)ts f( >..?Z 7-r-62713: , >?S� ` DEED: L..N;;JA P. } 11 �iC 1 TEST HOLE_ 1 STAMP Y/EI.Ll .>rL' tothiss�urvveeyi evlowm l 1'4 Section 7208 of the tWwYak SIM 1 - F'ducationLaw. i t w ~"\ '— Ccpies of this survey map not bea ft' . ' �' l \ a rand surveyors Inked seal or D2 IJC• _ _rr,.�� 4mbr,„sod teal shell not be CpMldelad •''� •o ee a valid trtie copy. ' ` r Dk 1 `9►+` - / ,'_ (. ..% 41\yam ,bernteo3inson odhanethesm . 'y'r,ihe aWnn personforwhomtlNtsaivpy �! cad,and on his behalf to dw � n,: �ovemmental a _ L -• / • _ �., t, ({/ }. V f � '' tiJn listed hereon t7ttd tc _cs of the lending lndl. tat noes are not trwEaraW I l ! }•"""� >, too dat t'ustaNionsweubaagtNal Sa' ! :1 owners J. SVACAtiiT� SEAS err . ... ; - .�. � xr��d. } t ' . � � '�. \. 2+ ;. to • REST-0-F s E' �� �Q. �QACKV,gN O AS aI "`1 ' Y,5-0 Mhn 13 1�}6 * Ax .RODE 1CK VAN TUYL P: '.• tiol} '• !¢26 0� j .. C s 250 cPOQG.. LICENSED.•LAND`SURVEYORS' FO1AND J. GREENP-OR-T NEW Y.ORK Tniiby 6 Pon N81329 i. i