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HomeMy WebLinkAboutTR-1757 ALL :i0ORI\GS A\D STAKES ciCJ I' DISPLAY VISi3LE MOORING :�C::Bc'.RS ALL DOCKS AND BULKHEADS MUST DISPLAY VISIBLE PERMIT NUMBERS SI -�a• "-' `' war�X"``!.'�'T'�' "';Q•w!'r [� S•,�w.►= � ``. " ,�, t � "1l• ';�, � '`ate` �• �.. �3��: h�S�?'?i� �, d' P•. -••`�• \� � n�,,y •,• ,� a �'�)fir L d •f 4VAl- /^ .Cr''ti '•� 'ii ry ii 7_' :r_�= �. -ii �J':._.i-•�'. .y- ii_a,^,-•"i'x`'�:'-v:`Y'." - 'C��^S.7 .�`.4.: � �L�.S.��l�..JL.!_f:.Y•��:. �i..P'•_ ..g.r:1L• -•1' i\ _ Board Of Southold Town .Trustees ,,' SOUTHOLD, NEW YORK a' -�.=��• ::t '• S`, Mooring # 1757 DATE• ' Oct. 31 1983 PERMIT NO. ......... .. . .. �., 1 ° � ISSUED TO .........Ron...Dgbert.......................................................................................... AV Pursuant to the provisions of Chapter 615 of the Laws of s ,1 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 IN AND ON TOWN WATERS 'AND PUBLIC LANDS and the :'i�" REMOVAL OF SAND GRAVEL OR OTHER MATERIALS FROM LANDS UNDER TOWN WATERS;" and in accordance with the / 'sue -:: .-�F• C.� Resolution of The Board adopted at a meeting held on ....... . ........ . S' Syr bct 11_ �.. 19...8. ..., and in consideration of the sum of $.....5..00......... Paid by .� ................:.......................... of ..........Ma.tt.UV.Q.k.............................................. N. Y. and subject to the ,I Terms and Conditions listed on the reverse side hereof, of Southold Town Trustees authorizes and permits the following: Application approved to construct a catwalk in '.r a' gutter off of James Creek, ;Mattituck. r all in accordance with the detailed specifications as presented in the originating application. r-`' IN WITNESS WHEREOF, The said Board of Trustees here- by causes its Corporate Seal to be affixed, and these presents to be subscribed by a majority e said Board as of this date. ;, y�;_ •d _ } .. . .� 11 If V� i �w«�� � �. �`ti 0��1 �• ... .•.tea`/••li".�c,.�.... .......................................� �.� -�. Trus;e� ' :�: yam{ �•7�q�: - �.•. +'t � � �. � �_ ...�.•�/.'�iW i..,'.'w�!��� w� ��6.���_� �.-1... *j.��r \1 'Acr.. ;COY' I r �.'..�.. :. •-� .�.(• . � �t ..�� ��, '.may: � . ,�,,, A� �" 11'-. ,�, .;^�. •,^� ���6�y?°`°�" r� a '���,� .. 70 � ed Please tear off and return to the Trustees Board Of Soulho; d Tov,111 T rusreED- s Grandfather SOUTHOLD NEW Y D E� KiIE-ADS , Clause ALL vim::-„� it" 14coRI_:c No. nI5PL f VISIBLE PERtAli I`-U;v►BcRS PERMIT NO. 1.757 DATE: Oct'. 31 , 1983 TO Rob Dobe_rt I� ce==if; that the wor}: as author i=ed ' in thus per it has teen ccmplec=d and is now read•, fcr your in--=ec- t'_c::. Also, the nun'^e- required on t!::., p_oiec- is clew=�y visible. I f• rthe= urde stand this perm_, :s •^•ot � `.. Until this tear sheet Y L TERMS and CONDITIONS The Permittee Ron Dobert residing at 31 Southoer Blvd. , East Patchogue, N. Y., as part of the consideration for the issuance of the Permit does understand and prescribe to the fol- lowing: 1. That the Southold Trustees Permit must be prominently displayed on the premises effected% thereby during the period of That the said Board of Trustees and the Town of Southold are released from any and work t? all damages, or claims for damages, of suits arising directly or indirectly as a result of any oiler- unde 13tion performed pursuant to this permit, and the said Permittee will, *at-his or her own expense, the- defend any and all such suits initiated by third parties, and the said Permittee assumes full liability Permi G with respect thereto, to the complete exclusion of the Board of Trustees of the Town of Southold 3., That this Permit is valid for a period of 19 mos. which is considered to be the sufficient time required to complete the work involved, but should circumstances warrant, request for an extension may be made to the Board at a later date. 4.; That this Permit should be retained indefinitely, or as long as the said Permiree wishes to maintain the structure or project' involved, to provide evidence to anyone concerned that auth- orization was originally obtained, - 5: That the work involved will be subject to the inspection and approval of the Board or its agents, and non-compliance with the provisions of the originating application, may be cause for revocation of this Permit by resolution of the said Board. 6. That there will be no unreasonable interference with navigation as a result of the work herein authorized. 7. That there shall be no interference with the right of the public to pass and repass along the beach between high and low water marks. 8. That if future operations of the Town of Southold require the removal and/or alterations in the location of the work herein authorized, or if, in the opinion of the Board of Trustees, the work shall cause unreasonable obstruction to free navigation, the said Permittee will be required, upon due notice, to remove or alter this work or project herein stated without expenses to the Town of Southold. 9. Thac the said Board will be notified by the Permittee or the completion of the work auth- orized. (See tear off sheet. ) 10. That, the Permittee will obtain all other permits and consents that may be required sup- plemental to this permit which may be subject to revoke upon failure to obtain same. it TELEPHONE (516) 765-1892 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall, 53095 Main Road P.O. Box 728 Southold, New York 11971 October 13 , 1983 Mrs. Judith T. Terry Southold Town Clerk Southold Town Hall Main Road Southold, New York 11971 Dear Judy: Transmitted herewith is the action taken by the Board of Town Trustees at a regular meeting held on October 11 , 1983 : RESOLVED to recommend to the Southold Town Board APPROVAL of the Wetland Application #167 for Ron Dobert to construct a 250 ' x 3 ' catwalk in James Creek, Mattituck. Very truly yours, Board of Town Trustees Paul Stoutenburgh President PS:ip y; � Town Hall 53095 Main Road P.O. Box 728 Southold, New York 11971 JUDITH T.TERRY TELEPHONE TowN CLERK (516)765-1801 REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD NEGATIVE DECLARATION NOTICE OF NO SIGNIFICANT EFFECT ON THE ENVIRONMENT Dated: November 2, 1983 Pursuant to Article 8 of the Environmental Conservation Law State Environmental Quality Review and 6NYCRR Part, 617, Section.. _ 617.10 and Chapter 44 of the Code of the Town of Southold, notice is hereby given that the Southold Town Board, as lead agency for the action described below, has determined that the project , which is unlisted will not have a significant effect on the environment . DESCRIPTION OF ACTION Application of Ron Dobert for a wetland permit . Permission is requested for construction of catwalk at James Creek on Ole Jule Lane, Mattituck, New York. The project has been determined not to have a significant effect on the environment for the following reasons: An environmental assessment has been submitted which indicated that no significant adverse effect to the environment_ are likely to occur should the project be implemented as planned. Because there has been a response. from the Board of Southold Town Trustees and Southold Town Conservation Advisory Council indicating that this project would not have a significant effect to the environment. Because there has been no response in the allotted time from the New York State Department of Environmental Conservation and the Southold Town Building Department , it is assumed that there are no objections nor comments from those agencies. Further information can be obtained by contacting Mrs. Judith T. Terry, Southold Town Clerk, Southold Town Hall , Main Road, Southold, New York 11971. Copies to: David DeRidder, DEC, Stony Brook Commissioner Williams, DEC, Albany Southold Town Building Department Southold Town Trustees,,-- Southold Town Conservation Advisory Council Town Clerk' s Bulletin Board Ron Dobert cn 4 � rn TELEPHONE (516) 765-1892 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall, 53095 Main Road : ... . _ . = P.O. Box 728 Southold, New York 11971 October 4, 1983 '�`. -=f .w rii�--9 .'a_`ti.':� .-���"�,P7g.�'_`-_,-M`1 �. '�.-�.'�iuwg;•`�C yw, �^t _ �"s..-- xr:' - ,r �^;:.-�'�-:.. .L "- -�`�-�_�` - .�'�e�.-�flur'=•can{versation today, with Trustee Stoutenburgh, I have �c.� ��1 �����fn�:Ynu�'�catzdal�c..�-=.Y �.�::--;:.�..�,::s�... •-- • �� � _ Please fill it out and return to this office along with a $5.00 filing fee, so that your---application can--be acted upon at the earliest possible date. I have made copies of your work plan, map of property to help make this more convenient for you. Very truly yours, Board of Town Trustees c0izW.'00 eo"IA�j Ilene Pfifferlin Clerk to Trustees Attachment 10 )z) '.. P/1 Rev414 .,Lt. DOC 'S 'AND BULKHEADS MUST BOARD OF TOWN TRUSTEES JISPLXY VISIBLE PERPAIT NU�MSERS Torn of. Southold plain Road ALL to OMINGS AND STAKES (MUST Southold, New York ]19 i 1 DISPLAY VISIBLE MOORING HiMBERS NOTICE OF ACTION — NOT A PERMIT To: .................Ron..Dobert.............................._................................................................................ 1. Your application, dated .......�.Q/.11/83 .. ........... ....... .............................. has been reviewed�� ... by this Board, at a meeting of the Trustees held on 10/11/83 .................................. and resulting in the action, as indicated below: OCXXXXIX Application approved. ............) Application denied. ............) Application tabled. 2. Comments and remarks: Application approved to.... construct a catwalk in a gutter off of James Creek, Mattituck. 3. I li aN n i - ,,. A PERMIT FEE to the orCer of the Board of ve ��`'rrr"t--r'z is now due and should be mode payable the.ScheGul Southold Town Trustees. This fee is computed below accerdin to a1d with of R$tcs s set forth in the In�trucrion ghee 11c rm I/1 This p in 0 days or re—applying and ac�di�iona� fee Wilgus` e If the Permit Fee is acid in person to the Secretary of the Board, The Permit will be cb;ainc;,le at the some time. If the fee is paid by mail, the n e necessa: permit will b_ moiled in reply. Computation of Permit Fee: ALL DOCKS AND BULKHEADS MUST . DISPLAY VISIBLE PERMIT NUMBERS Total Fee for this application ............... .............................. $ ......5: 0... • Signed ........... Pros. Board of Southold Town Truste s. by .. .. . . . ..... . . G`'"G� o'`r ALL DOCKS AND BULKHEADS MUST' ' i1h:L CF C• E:C T�.y�3 G•c°�E.4� r DISPLAY VISIBLE PERMIT NUMBERS BOARD OF T07v'ti TRL'STELS y Town Of Southold ,lain Road D j Southold, New York 11971 APPLICATION FOR FIXED and/or F L 0ATI:1-,G DOORS � �l 1. Applicant's name and address: .....�,a .-,„�--� Br.LT• .j/ �o�'��!•�.e�.v BC�/Q . ........... .................................................`ram..28-�•;/003 2. Contractor's name and address- ............................................................................................................... .............z e ........................... 3. Briefly explain the purpose of this application: 7.e./GT .................. l'f�TGoAL�---•��...��T/�,eo �yt'r�E'TG�-.eJl> � .................................. !����TJ� G'•s?, .o....ar�...�. !�« ...�! .........'=..��Es��.✓.eT o C. • '. T�.� o u �.P...�E�Tf;....................................................................................................... 4. After issuance o= a Permit, Work Must be co,":pleted wi th - r, one yea„ $. LrRGE - Secure the correct Area Map from the C1er : of this Bcard, and by using a A CIRCLE indicate as close, as S \ e of L is y pes�ibie the lo-.., ion of ,his dock. On the. reverse site of this mcp, provide a SCALE DRAWING which will show Ordinary Hig;-i Water the shcoe oral size of the dock and any sucplemental pilings which are needed to hold a ficc-:r.e d„�;� r i71 Y orTtie-uo a boat. Give all dimensions necessary to determine the aroc of the H C- t;.__ -- E';_E_ DS O FS H OP.E from the O. H. W. M If dj a . cent property owne- -- surface a docks, specify Location and length to scale. rs have- 6. Will any portion of this construction extend offshore into Town `;Voters beyond an imegin:ry line or boundary farmed by other similar structures along the area's shoreline? YES or Nia— If it does extend bevond this so-called dock; line indicate by how for, epproximatcly,-........ 7. Provide the following documents: (a) A Licensed Engineer's Survey of the property involved. (b) A copy of the Contractor's PI cns and SPOZifiz_otions. Short Environmental Assessment Form. _�%8. Wi�l thetccnsa�ct�cn�r lui�t to n Fill ing ling of on,/ lard offshore of the Crdinary High Water Mark or the Dredging of any material from Town Londs under water? YES cr NQ If it does Form A/4 (Application for Dredc in Filiin e cppl icaticn. 7�' g, mutt b crrnpleted cnc o—cched as part of thi:; 9. In requesting approval of this application., I submit that: the rnfcrn- ition .rose ,is true cnd correct to the best of my ';no; led:,_ and belief; I cm the r.?-_-cn nt.�d h=r�i r the performance of the w cccuntccie for p or in cccardance wrri� trr� plans and Specific:tic:ns cit�zhed; I h--ve read ar cm fcmiiicr wiry ti provi;ion, cf any Sou;:,oid Tc,. n' C _, ,c:ncr ..c..T;r,;:nt ts t^= wOrK involved; and further, I intend to achere to and ai:ije by the Terms cr.d C:,nniticns of the Permit, when and if issued to me. 10. To expedite finding specific location f r inspect by using a temporary marher:> ..�on, indicate _.. .. A/'::Rev. 2/82 � _ 7� •I r� f •r R� 1J Q 14 t r ���., �� • A O R I L - j \ Al RD Cl) dam X w Creed IL DR. R LL P pECONIC Y B D. 21. I C-74 VA" GREA T PECONIC . BA Y NEW YORK DEPARTMENT OF ENVIRONMENTAL CONS11 RVA BUREAU OF MARINE HABITAT PROTECTIb BLDG. 40 - STATE UNIVERSITY OF NEW STONY BROOK, NEW YORK 11794 (516) 751-7900 NOTICE OF VIOLATION Mr . Ron Dobert 31 Southern' Blvd . November 23 , 1987 • East Patchogue , NY 11772 Date of Violation : September 11 , 1987 Location: Ole Jule Lane , James Creek , Mattituck Permit Number (if applicable) : 10-83-1193 Dear Mr . Dobert : Records of this Department indicate that you are in violation of the environmental Conservation Law ( ECL) : Article 15 , Protection of Waters , Section 15-0501 . 1 , 503 . 1 , 0505 . 1 X Article 25 , Tidal Wetlands , Section 25-0401 . 1 in that you caused, or permitted to be caused : Construction of 26± if of timber catwalk in non-compliance with issued permit in that structure i� not located a minimum of 3 ' over grade, construction of a 41x8 ' platforr, in intertidal marsh and additional 18 ' of catwalk constructed with permit . A violation of this/these Articles of ECL is a misdemeanor and is punishable by a fine of not more than $3 , 000 and/or $8 , OOD . You are , hereby , advised to cease your operation at the referenced location immediately . Please contact this office at once so that we may attempt to resolve this matter . A failure to contact this office within 30 days will result in this matter being referred to the Department ' s Regional Attorney for legal action . Very truly yours , Charles T . Hamilton Chief, Marine Regul.ator. y Section CTH : dr ECO Obenauer. Southold Town Trustees m �-c• . ���� ice,. i v Town Hall, 53095 Main Road o� P.O. Box 728 1 Southold, New York 11971 JUDITH T.TERRY TELEPHONE TowN CLERK (516)765-1801 REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD September 28, 1983 p j ebqn Mr ., Paul Stoutenburgh, President Board of. Southold Town Trustees Southold Town Hall Southold, New York 11971 Dear Mr. Stoutenburgh: Transmitted herewith is application no. 167 for a wetland permit submitted by Ron Dobert . Please prepare a written report of findings and recommendations with respect to this application. Very truly yours, Judith T. Terry Southold Town Clerk Attachment •; q:J— - S 1 ATF; -J THE WATER SU?LY .,:�i:= SYSTEMS FO',- TH15 ' .RYZSIb XC 5 CONFORM TO -FI• E STAKDAF-}i,S OF. SUFF0 _K' CO. DEFT. OF idEAL;`-i-4 `��r?'✓ ' l APi'i_I CA:-IT ti.r C1 SUS FOLK CC1t3b�TY C`r;.f'7. Or klz SERVICES — FOR :id�PROVA COINSTRI.;CT10N 0INI—Y �'O `7�/ l �. •�.. () DATE:- \ H.. S. REF. NO. q APPROVED. SU FOLK CO. TAX MA7r *3%a1f' { ' i L:1: 0 Owi,iE'.RS A7.0i E'; 5: AeAJ 4, 1 - m. y' �i�,�Gf G A4 ,TFS h0 L i..: 8' y� 3 6 ' $Z,la fi$ � utj& :li(�ixTrgN CS UCT!^M 7J J OP TM{iFW YG3, S1 f 4 �r:.1rt:LJ: COP!,5 OF T?i15 SI RY I'l.'1Y ?S_A7:S+4At1,*h77 r!CUittl: �*• .- _ 'G S:A YAILUTI iNUE CCYY. GUA2ANTF:GWLat=4 Itfi�Gh*3Y.x;. R:p L r• R Tri: Th., ;c0 i"A K 5 +u G(rrGnrc�U �i f-;c rf: ,ur-. r r,^l� C1,rlrf r trr1� ;;ad �JI 5111'Ve:•(f,•'+'d ...ji J'•!c� ,i.f7.1�.�I RODERICK VAN TUYL, P.C.- r �. C- �: LICENSED LAND SURVC..Y05tS GREEN?ORT NE YORK i '-_-1--^-^ �O" �dfarneta•om f Ili £R[Eliip'TiocJ � O �:F E w[ar F � e P � • � : �ie>v�toGhwPt�. O drio VAJ 0 • �\y z moo, \ � • AAA40E'r g ®AJ ��e ci.�s'r� �,to%►,to T� !'�jetp,v� �o G.Ar.�syey /ti } ryl.a�o� s� d�s7T�--E' Go aiarTJ' os S'v�FoGiC we. i �T.rr� - /IE�M j�.p G.E'�/6'E /9P�C/C'.9tT"ioieJ aY wear �'v®f�T i © eTo11,V A a►r9[3X'/ r• f --. _ r -1 71 ihN el , SUP- -- ---- + ; -?-- t - _. r{atir J r� �• '` �F�. ac t- 1 r" tr f' TOWN OF • SOUT-HOLD SHORT ENVIRONMENTAL ASSESSMENT FORM INSTRUCTIONS : (—a-F In order to answer the -questions in this short EAF it is assumed that the preparer will use currently available information concerning the project and the likely impacts of the action . It is not expected that additional studies, research or other investigations will be undertaken . (b) If any question has been answered Yes the project may be . significant and a completed Environmental Assessment Form is necessary . (c ) If all questions have been answered No it is likely th-t this project is not significant . (d) Environmental Assessment 1 . Will project resu t in .a large physical change to the project site or physically alter more than 10 acres of land? . . . Yes Z- N . 2 . Will there be a major change to any unique or unusual land form found on the site? . . : . . . :. Yeso 3 . Will project alter or have a large effect on existing body of water? . . . . . . . . . . . . . . . . . . . . . . . YesLNo 4. Will project have a potentially large impact on groundwater quality? . . . . . . . . . . . . . . . . . . . . . . . Yes_k o 5 . Will project significantly effect drainage flow on adjacent sites? . : . . . . . . .. . . . . . . . . . . . . . . . Yes No 6 . Will project affect any threatened or endangered plant or animal species? . . . . . . . . . . . Yes No 7. Will project result in a major adverse effect on air quality? . . . . . . . . . . . . . Yes {l'*"No' 8 . Will project have a major effect on visual character of the community or scenic views or vistas known to be important to the community? Yes !/ No 2 . Will project adversely impact any site or structure of historic, prehistoric or paleontological importance or any site designated as a critical environmental area by a local agency? . . . . . . . . . . : . . . . . . . . . . . . . Yes �No 10 . Will project have a major effect on existing or future recreational opportunities? . . . . . . . . . Yes /No 11 . Will project result in major traffic problems or cause a major effect to existing transportation systems? . . . . . . . . . . Yes �No 12 . Will project regularly cause objectionable odors, noise, glare, vibration, or electrical disturbance as a result of the project ' s operation? . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . : Yes INo 13 . Will project have any impact on public health • or . safety? . . . . . . Yes' ll"Na 14. Will project offecttheexistingcommunityby directly causing a growth in permanent population of more t-han -5 percent over a one- year period or have a major negative effect on the character of the community or / neighborhood? . . . . . . * * * * * . . . . * * " Yes d No 15 . Is there public controversy concerning the / project? . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . .. Yes y No PREPARER ' S SIGNATURE — REPRESENTING_ - DATE �' �3 o o ` T r Town 6f Southold f Town Clerk's Office Southold, N. Y. R C SEP 2 7 1933 Tovin C' .,-k- 5cul'OoH APPLICATION FOR WETLANDS PERMIT Application No. ......... .��.......... Date of Application ..........Z L./................... Identityof Applicant ............./.L:.�.'v.... . ....................................................................................... Address of Applicant ... .uTh�`.e.U...BG.ay.... TC•s�aG,v`..... :. .�i»Z INSTRUCTIONS FOR PERMIT A. This application is to be completely filled in by typewriter or ink and submitted to the Town Clerk in quadruplicate, accompanied by written permission from the owner of the property if not the some as the applicant. B. Pilot Plan must be drawn to scale on the reverse Eide of this application showing the location of property, the names and locations of owners of adjoining properties, and a detailed description of proposed project. (Note: Copies of the Pilot Plan may be made by a copy machine and attached to the Permit Application.') . C. No operation shall be initiated by the applicant until all permits that are required are issued. D. A detailed statement of the rehabilitation and proposed condition of the premises after the work is completed must be given, including a survey if required. E. If permit is being sought for a more sizeable excavation than the .construction of a private single dock or jetty, then this application must be accompanied by a survey and topographical map certified by a registered land survey or Professional Engineer. The horizontal control of survey shall be based upon an approval local coordinate system. The vertical control for elevation and sound- ings shall be based upon United States Coast and Geodetic Survey and/or United States Geological Survey datum. F. A statement must accompany the application describing any known prior operations conducted on the premises in question and whether any prior licenses or permits have been issued to erect structures or to dredge or deposit fill on said premises and whether any such permits or licenses were ever revoked or suspended by a governmental agency. G. A filing fee of $25.00 shall accompany the application. This filing fee includes one inspection; there is a $5.00 fee for each additional inspection. i H. ?he Town Board wor, rer;�iest7 of �h% applic cnt fo.- c, �-P.rnit, mr;y i wcive in ^ ir,Iir .-c , :, lnrh the provisions of Auricle I i, Section subdivisions (b and (Or where it finds that nature of the proposed operations are such that 'the requirements of such provisions are not necessary for a proper consideration of a permit application. I. Upon approval of this application the Town Clerk will issue a permit to the applicant. Such permit shall be available for inspection at any time, upon request. y 1 Examined .... .4ga.................... 19. . �3 Approved ...... ..,��.•. ... ,,7 ... Disapproved ........................................................... Cnnraitions,. ?f any! ...�.. ........ . .... . . .�.,. �....... ,< .....,.�,«...........................:.. .................................................................................................................................................................. .................................................................................................................................................................. Examining Body ........ .. ......... ........... .. .................. :.....:.:. ::Q`.. ::................... Signature of Chairman . . .� . .............. ... APPLICATION IS HEREBY MADE to the Town Board of the Town of Southold, Suffolk County, New York, for the issuance of a permit pursuant to the Laws, Ordinances and Regulations govem- ing the Coastal and Interior Wetlands, Flood Plains and Drainage Areas of the Town of Southold: Permit requested to ..l v .r'0GG. . .9 .. .9Td�°� . .Ivr9G•E� .....�•uO.. y.. ��q.�X /o. Gs�ri•vc./ G'•�,�o i.v c x 5 .►�G ��P�9i.uAG�= 6ZO lTc .................................................................................................................................................................. Location of property for which permit wanted.....�!..�-'............' ..��de '.� .................... .................................. fir.>..T...G000......1•�ci.�z�......:8e�5�.............�..1.:`il�T.✓ci-.......:v:.'J....................... Home address of permit applicant if different from aforesaid location ....................................... .................................................................................................................................................................. Creek, Bay or Harbor fronting property ../,P... ........v'r�.. f��S„ .................................................................................................................................................................. Size of proposed work: Length ..... ......d............... Width :......................................................................................................................... .................. HeightAbove High Water ......Z.......................................................................................................... DepthBelow Low Water ......................................................................................................................... Yardsto be Excavated ........................................................................................................................... Yardsto be Filled ................................................................................................................................... Width of canal, creek or bay fronting property...... Ar :e... ..... ........ ..................................... Depthat Low Tide .......Z..................................... . .... .................................................................... AverageRise in Tide .........z...........................................:..................................................................... Is this for private or business use? :;�, ,�`o-0=............... ...................................................................................... Area Zoning ^�J..s' Manner in which material will be removed or deposited . — .......... ....................................................................................................................................................... Intendeduse of property ......................................................................................................................... ......................................I....................................................................... Written consent of owner of property, if not the some as the applicant ....................................... . ................................................................................................................................................................ ..... ................................................................................................................................... COUNTY OF SUFFOLK ) STATE OF NEW YORK ) SS: ................. �� ......./ '.. .................................................. being duly sworn deposes and says that he is the applicant for the above described permit, and that all statements contained herein are true to the best of his knowledge and belief; that the work will be done in the manner set forth in this application and as may be approved by the Town Board of the Town of Southold. The applicont agrees to hold the Town of Southold and the Town Board harmless and free from any and all damages and claims arising under or by virtue of per it, if aranted. .............................ez;ze�..............................................:..... Signature of Applicant Sworn to before me this .., .................. day 'of c. . .... ..... ................ 19..V2. ... . . .�......... ..... Notary Public N. PETER RATHVON JR. NOTARY PUBLIC,State of New Yaj* No.52-3210931, Suffolk Cou"W Term Expires March 30,19.5')