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TR-4028 GF
0 �' b sv � ._n" r��,.�5'_�,t,�°; v.[Y{•�a1":�� 'c}_� �'�".z""''yet's �"S�°'�.�a''rR4 ,x'�or"r'"� �,t4�"^�'�,r""l`ai��i• %� .y j . 5 oar Out 0 Town Trustees \ V SOUTHOLD, NEW YORK e �,. PERMIT NO. . 4028. ... ........ DATE: ...G.lz6.L.92............ ISSUED T® .........fishers Island Development ............................. �s a ........... ............................... P. p 6 Agtl5{y} ��yqy �p®}�¢q�@.qq� o {�]Q� r ��1 �AWt ��6f+��G�r6aV�.A �48a°' Pursuant to the provisions of Chapter 615 of the Lays of the State of New York, 1893; and Chapter 404 of the Laws of the ,�> �`'�;�• "I State of Npw York 1952; and the Southold Town Ordinance on- title °' I d "REGULATING A�113 THE PLACING OF OBSTRUCTIONS s � IN AND ON TOWN WATERS AND PUBLIC LANDS and the . ' \ '1 REMOVAL OF SAND GRAVEL OR OTHER MATERIALS FROM ' - Rai LANDS UNDER TOWN WATERS;" and in accordance with the �� r „! Resolution of The hoard-adopted at a meeting held on .....61.2.5............. p , 11 19.R.., and in consideration of the sum of $....50.,.00 ...... paid by ........Do.cko...Inc.............P...O.......Box...421..... ... ................. ........................... ' � �•• of .......Mys.Flo......Conn.......Q.b.a.5�.:.................. 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: Grandfather permit for reconstruction of an �fa), P . existing fixed wood dock., as per application i�-z-iceived June 15, 1992. all in accordance with the detailed specifications as presented in the originating application. fi aye �k' r IN WITNESS WHEREOF, The said Board of Trustees here- by causes its Corporate Seal to be affixed, and these presents to } "al be subscribed by a majority of t said rd as of this date, ....... IE. i Ln ° ` x a ...... .. . .. ......... ... ................... � "n tees ��•. f ••,t �t .-�.Sr,J.°u�'c'�..4;.�✓Siu�uet.�a .�wr�._'.f r� rr•�s,�o a e r l,a:�.::�.iT' C'- i�a�r`J � ..yJ 4' - -i,.J•4P'.o'.�" �W i�Y F �rp �) � •` Be :, -1.�..; We�.�'..1 ��u.�..£�.�,.�.ati� 9�L�'.i...rS..•..d' �.a � .ec".�.r,,'.=�i t „q } 4 tr 3 mill .1 • W , 0 TRUSTEES SCOTT L. HARRIS John M. Bredemeyer, III, President �'!c.7; ` !' ,�� Supervisor Henry P. Smith, Vice President Albert J. ICcupski, Jr. Town Hall, 53095 Main Road P.O. Box 1179 John L. Bednoski, Jr. John B. Tuthill Southold, New York 11971 BOARD OF TOWN TRUSTEES Fax (516) 765-1823 Telephone (516) 765-1892 TOWN OF SOUTHOLD Telephone (516) 7654800 GRANDFATHER APPLICATION 1. Name of Applicant: Fishers Island :Development Corperation 2. Mailing address: Fishers Island, NY 06390, PO Drawer E Tel. No: 516 788 7251 3 . Address of Property: The property is shown on the attached tax map. 4 . Tax Map Number: 10 0 0- Private ROW Approx.yr.of construct: Pre 1971 5 . Prior owner if known: 6. Diagram of existing structures, including all dimensions, must be included with this application: See attached application drawings for overall Plan View of the area, Plan and Profile of the dock to be re-built, adjoining property owners and shoreline characteristics. The site is a portion of a private Right of Way between parcels 13 and 14 on Tax Map 1000-004 block 4 7. Indicate on attached map: Location, ie; reference point, telephone pole number, adjacent property owners, etc Signature of applican i Date: M2-- If -4!e47 * Please note, there is a one time fee of $5 .00 for filing t is application. Docko, Inc. P.O. Box 421, Mystic, CT 06355 (203) 572-8939 Fax: (203) 572-7569 May 29, 1992 LJKLIN 151992 Mr. John Bredemeyer, President fl Southold Board of Trustees PO Box 728 -�'OW�i9 OF ®UTH�pOILD Southold, NY 11971 Re: Fishers Island Development Corp Dock Reconstruction Permit Dear Mr. Bredemeyer: On behalf of our client, we request a "Grandfather" Permit for the reconstruction of an existing fixed wood dock of the Fishers Island Development Corperation on Fishers Island. We enclose the following documents in support of this permit application: - Two prints of application drawings titled: Project: "Dock Reconstruction" Waterway: East Harbor, Fishers Island Sound Location: Fishers Island, Town of Southold Suffolk County, New York Applicant: Fishers Island Development Corp Date: May 29, 1992 - Two copies of the Southold Board of Trustees "Grandfather" application, Corps and DEC applications, Tax Assessor's Map, location map and check in the amount of $50. I trust that you will find this application package complete and acceptable; please let me know if the need for more information arises. Yours truly, r DOCKO, INC. k Keith B. Neilson, PE Enclosures cc Fishers Island Development Company Fishers Island Country Club Jim Haggerty, CE Robert Green, DEC John Clavin, Fishers Island Harbor Master File 91-08-245 Docko, Inc. P.O. Box 421, Mystic, CT 06355 (203) 572-8939 Fax: (203) 572-7569 L A -u 'r,fir s: ABOVE: Aerial photograph from My 1990 showing the pre-hurricane conditions and and configuration from the south looking north at 500 feet. BELOW: Dock as it now exists showing the broken slab in foreground, which will be replaced with wood components, and other damage to be replaced. s e /► Docko, Inc. P.O. Box 421, Mystic, CT 06355 (203) 572-8939 Fax: (203) 572-7569 �i► t. 1 .« �,. � - � •• � w '�e r'_, r 1. F:�.i' Y . . L �4a 7 1 k' ABCYVE: Dock damage at the inter tidal zone including broken concrete slab, dislodged and damaged ramp, decking and stringers (March 1992) . BELOW: Outer one-half of the dock system showing the damaged stringers, ladders decking, etc. Photo taken at mean low water conditions looking west. t 4 S y,tlJV'D hSZXitDn FISHERS MI szr. xo:c uo:.: / / (. %a, Y' any 0.00 Mel 9sn 14 1.9• / " e.�• r . 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Box 421, Mystic, CT 06355(203) 572-8939 Fax: (203)572-7569 May 29, 1992 _iL1�1 1 5 1992 Mr. John Bredemeyer, President Southold Board of Trustees PO Box 728 OF SOUTHOLD Southold, NY 11971 Re: Fishers Island Development Corp Dock Reconstruction Permit Dear Mr. Bredemeyer: On behalf of our client, we request a "Grandfather" Permit for the reconstruction of an existing fixed wood dock of the Fishers Island Development Corperation on Fishers Island. We enclose the following documents in support of this permit application: - Two prints of application drawings titled: Project: "Dock Reconstruction" Waterway: East Harbor, Fishers Island Sound Location: Fishers Island, Town of Southold Suffolk County, New York Applicant: Fishers Island Development Corp Date: May 29, 1992 - Two copies of the Southold Board of Trustees "Grandfather" application, Corps and DEC applications, Tax Assessor's Map, location map and check in the amount of $50. I trust that you will find this application package complete and acceptable; please let me know if the need for more information arises. Yours truly, DOCKO, INC. Keith B. Neilson, PE Enclosures cc Fishers Island Development Company Fishers Island Country Club Jim Haggerty, CE Robert Green, DEC John Clavin, Fishers Island Harbor Master File 91-08-245 72 --------I------------- I - 56 _ I - ---- --- 70 f 30 _I 56 �'- - .East •. ... Clump•-, 1 Al 42' { O _ � �* .P'1,a lands Br 27 I In i(• -i dF Fong- 6 to-- 7 _ _ ��� r �- S:fir 0�:�`ll � �<�-� • 1' ---�=— lit �• '��. �- .�� ks-' 'Z`,ti .�- - .\,J �' � _-�_\ \\`/ .'" -�. J to d - +— - - _ � 1t "/,%�• ll �� __ �, tie: *. ZL 6 it CIO I, n d Po ,�/ * s VOCATION MAP ind - 76 1 >F b Project: DOCK RDOONSIIZUCTION !I OF SOLTI'fiOID I Location: FISHERS ISLAND, TOWN SUFFOLK COUNTY, NEW YORK C--\ Waterway: EAST HARBOR, FISHERS ISLAND SOUND ' �^2 Date: MAY 29, 1992 Applicant: FISHERS ISLAND DEVELOPMENT CORP " -- zt - y 6 79 \/l L 24 �J 96 C 1 7"70 46 220 0 39 8 R 20 ............... �Q --34 36 F1 6sec 55ft 17 t lump 14M BELL "ores 2 3 "Z asC 21 27 0 -25 ' 38 36 42............ ..........917o .......... I- - 1 BR �4 r6l ........... l7ousilip N"E �5LCMTIO" C)47um 1-5 Mr=AAf ILOW VV4FEe V�'e. 63 44 56 �8 2- rl&c- DATA Is rAtfr=h4 cRom 1,772- t4o4A 36 65 s 655 @ 38 8\ 11�37 58 Cable Area r1D6 TAP-,/-r=n,. '-42 34, //30 30 C"15 39 8 3 CR- 59 1 5 1 Youn 5 1 0 3 5. V6S1 PTI L)": 1� 16 .3 N ' " 351A-h46 CIS DouC- 26Co^ 5ro2U9r1oAj , 1f'j'-UDIfjC 4 18 IE 1 56 C"I 200 +/- LF OF FOOT wlc�s 1=1�cs Z) 6 Rk 0 i wooD Do--'e- YVITq / 'zs Foor Zz"a Ns -)6- �--4 A4P FO Z3�-fOR-�-= rd g- f3y F007 NIL AND -AVDSP-S. 26 BELL w"vr PLJQP056 B rky 0 23 31 23 To 4z WAI Acc,--sz FOR- '5 CAT 1 7 �er,-i2t-AT/O/,J4L WC -.0 Is o �d� Wreck 1 32 40 40 19 �5. L7*.--//:5 A (24ASS "D 5uRVF-\l 48 20 35 41 41. 44 FOR- PC-Amir 17- 1-3 A107' /A C OA15T��.UCTIO" Co^i1TF-ACT LO CA T-1 0" MAP C"AP-T ff-572 DOCUA46 I'J 7 tow 0 IC= .20czYAP- ' F-Is 1-4SR-5 f c:)uQT-) PZoj6CT- • EA 5 T • Row )E:�Rlzop&p-ry or �416 0. • F1Sk4EQS t-SZAAJr-) COU&J LUCILLC- 5ALCOXI rP-Y CLU PROJECT: 6 C0A/S 7-F-Ll cF/o, j LOCATION: FISH E R-2 l5l(-4&/10,T-ovl" o xr So VT.94 OL Z) -w yop-e- 51jr-'aot-k-, (=OuAjry, ive 1 '-C T, W ES74A/ / RaOoe) U DATE: M'A y 217) /??z APPLICANT: F: -qer2-5 I 5LAAJD boc 0. Dave-c-opmeur coepaeAr/otj • w-4 AGENT- SHEET OF DOCKO, INC. KEITH B. NEILSON, P.E. 9b -C,i -w 1- P.O. BOX 42 1. MYSTIC, CT 06355 0O 203 572 8939 FAX 572 7569 /"dZ6A5E RAMP r-��C�H T'►ICE e-rNE LENGTH U/'-TD 15, FOP- L4 nJc 2r 2 �i- )EePtAc.E 5EG-7/oN /31� ;-f/oyACE E P/LS WASHED AW Y t4r EC.9.S+4 �M��jjGG-ll22r,D4c.. PTH //Vs7'AGc- LEAD � v`D�RS�I Doer E^1o'g IL CA Ps 5 U 3TIDAL ZotJC f3o r/oM SA&JOY G2AVC-L ►W/1 80ULb&e-S 5L6 /S 2 x g fJ�t1i rco,P--M. �� T�EGC�NG- i� P/CE 5 AS SHo�.ViV ,¢ /::�ROF1 e—E /1DD�D(_EN,C 14 , /-�,2c-�/ ro 2AMP 5 00 ���\ 2oa+1 ,eAMP �\���1 pg cr pica 7-o ac /aap4Acex - /32u sH0 kc-) 0 0 (A7JD=P-oo � � ,� T.o � ��P1 CA G�a) .� FArN C�� '.l RLL) A v U � (QS5oYGD �y.STo2Jtils)p ATA�N T2 C> sjeoC6J Tb as eG-PCAc60 �2ocKy '�tl`a �° Qv/ e�T - D t3ouGDe�e. v 70 ,€3E ac-c,r.�a CaArTnvuovs ,4ND /NTEp-7'zAz- ?-o AJE ` , � � E•45l /�ael3o�e.. =/SN&,e5 /SG4n1V 4- AJ SouNa sC'4c.c i"= ¢o' A O 8 W V• PROJECT: DpCom-" 2ECQ�JST�UGr/OA/ LOCATION: F/SNEQs /gWIJ NEW Yo2 urHoc.D suFFoc.K CouAir WATERWAY:MAS1 HA1290 P- , F i BHEP-5 /54A,00 SO ua/D UX�Y`EIT ��• DATE: MAT 291 l9g7. CD v ,y; APPLICANT: P'l_S HEZS I S C.A ND Q C AGENT- SHEET /1 OF 2 'rs DOCKO, INC. r 068692'-\ ��or KEITH B. NEILSON, P.E. P.O. BOX 421, MYSTIC, CT 06355 203 572 8939 FAX 572 7569 TAX ASSESSOR'S NAP Project: DOCK RF0ONSMUCTION Location: FISHERS ISLAND, TOM OF SOUTHOID - SUFF�OLK COUNTY, NEW YORK 2 (• / Waterway FAST HARBOR, FISHERS ISLAND SOUND Date: l 29, 1992 FISHERS ISLAND DEVELOPMENT OORP• '•o SOU�YO Applicant: /S(q�,0 'r�•f, FISHERS —f`J- 0.80 no.e1 � /•'7 l tP 13 I O 4J , I I• l� •• I� ,r 1,• .IYd I t' a tfy LIItl♦ 1,kd i0• �~,' l•• iii u• r S ,w•I r � `•.•` � S ... ' I,.r1..M.1 ' ,ri41 •.. - ' w0 It l•1.1 .l ,,• 11 �, V ;tip a J<I I,•[n I.w•[..•r[. l•w01 / C•�� .. i 0� !zl o fit ,:• , e•• jO,Zti-fEFNY A 1, �, ,:,• l Sri` w ae wo .>o \M w•.vt oo.fo.•.cr ref• 1 ( _ ISLAND �SOUNO -- __ _ 1•a••d _ © COUNTY OF SUFFOLK !o..n SOUTH0L0 •r. ., t0 .i,e.... .. Real Properly Tax Service Agency— —� .—�_ .... ...-....� „ I" ... •uy.crw _... 004 , _ c.... c....< 1000 — �i..,A•od,I 1,Nw-Y.rl PIA%lair �I Docko, 'Inc. P.O. Box 421;Mystic,CT 06355(203)572-8939 Fax:(203)572-7569 May 29, 1992 Mr. Robert Green NYS DEC, Regulatory Affairs i Building 40, SUNY Stony Brook, NY 11790-2356 Re: Fishers Island Development Corp Dock Reconstruction Permit Dear Mr. Green: On behalf of our client, we request a Tidal Wetlands Permit, including Water Quality Certifications, as necessary, for reconstruction of a fixed dock of the Fishers Island Development Corperation on Fishers Island, New York. We enclose the following in support of this permit application: - Four prints of application drawings titled: Project: "Dock Reconstruction" Waterway: East Harbor, Fishers Island Sound Location: Fishers Island, Town of Southold Suffolk County, New York ' Applicant: Fishers Island Development Corp Date: May 29, ,1992 -Four copies of the DEC Joint Application, including the Short Environmental Assessment Form, SAAF, site photographs, Tax Assessor's Map, location plan and check in the amount of $210. I trust that you will ; find this application package complete and acceptable; please let me know if the need for further information arises. Very truly yours, DOCKO, INC. OKW• jaJj Keith B. Neilson, P.E. Enclosures cc: Fishers Island Development 'Company Fishers Island Country Club Jim Haggerty, CE John Bredemeyer, Town of Southold John Clavin, Fishers Island Harbor Master File 91-08-234 95-19-3(8/89)-7e DEC APPLICATION NUMBER NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION JOINT APPLICATION FOR PERMIT U.S.ARMY CORPS OF ENGINEERS APPLICATION NO. Please read ALL instructions on back before completing this application. Please type or print clearly in ink.Attach additional information as needed. El ARTICLE 9,TITLE 1,ARTICLE 43 6NYCRR 646(LAKE GEORGE RECREATION ZONE) ❑ARTICLE 15,TITLE 3(AQUATIC PESTICIDES CONTROL) ❑6NYCRR 327(AQUATIC VEGETATION) 06NYCRR 328(FISH) ❑6NYCRR 329(INSECTS) S ❑ARTICLE 15,TITLE 5 6NYCRR 608(PROTECTION OF WATERS) T ❑ A for the construction, reconstruction,or repair of a DAM or other impoundment structure. T ❑For the disturbance of a STREAM BED OR BANKS or excavation in or fill of NAVIGABLE WATERS. Ej�401 WATER QUALITY CERTIFICATION E? ❑ARTICLE 15,TITLE 15 1:16NYCRR 601 (WATER SUPPLY) 1:16NYCRR 602(LONG ISLAND WELL) ❑ARTICLE 15,TITLE 27 6NYCRR 666(WILD,SCENIC AND RECREATIONAL RIVERS) ❑ARTICLE 24 6NYCRR 662,663(FRESHWATER WETLANDS) ®ARTICLE 25 6NYCRR 661 (TIDAL WETLANDS) ]ARTICLE 34 6NYCRR 505(COASTAL EROSION) ------------------------------------------------------------------------------------------------------------------------------------------------ F ®SECTION 10(RIVER AND HARBOR ACT OF 1899)for structures and work in navigable waters of the U.S. ❑COASTAL CONSISTENCY CERTIFICATION. E ❑SECTION 404(CLEAN WATER ACT OF 1977)for disposal of dredged or fill material in waters of the U.S. D ❑SECTION 103(MARINE PROTECTION, RESEARCH AND SANCTUARIES ACT)for the transportation of dredged materials for dumping into ocean waters. 1. LIST PREVIOUS PERMITIAPPLICATION NUMBERS AND DATES(If any) None Known 2. APPLICANT IS A/AN ®Owner ❑Operator El Lessee ❑Municipality/Governmental Agency (Check as many as apply) 3. NAME OF APPLICANT(Use Full Name) Fishers Island Development Co ration MAILING ADDRESS TELEPHONE(Where can be reached during day) PO Drawer E (516 ) 788 7251 POST OFFICE STATE ZIP CODE Fishers Island NY 06390 4. NAME OF El Owner ®Agent/Contact Person (Check one) Docko Inc. Keith B. Neilson PE MAILING ADDRESS TELEPHONE(Where can be reached during day) P.O. Box 421 (203 ) 572-8939 POST OFFICE STATE ZIP CODE Mystic 5. PROJECT/FACILITY LOCATION(Mark location on map, see Number la on reverse side) County Suffolk I Town or city Southold Village Fishers STREET ADDRESS(If different from applicant) Private Road POST OFFICE STATE ZIP CODE Fishers Island NY 06390 6. NAME OF STREAM OR BODY OF WATER East Harbor 7. HAS WORK BEGUN ON PROJECT? If YES, attach explanation on starting work without permit, include dates. 8. WILL PROJECT UTILIZE STATE LAND? ❑Yes ®No Show work on map and/or drawings. El Yes ®No 9. PROPOSED USE: Private 10. PROPOSED STARTING DATE: 11. APPROXIMATE COMPLETION DATE: 12. FEE OF(NYS Permit Only) L'J ❑ Public ❑ Commercial October 1992 1 January 1993 $ 21 0 Enclosed 13. PROJECT DESCRIPTION: "(e.g.quantity and type of material to be excavated,dredged or used for fill or rip rap, location of disposal sites: type of structure to be installed; height of dam;size of impoundent; capacities of proposed water sources;extent of distribution system;etc.) Dock reconstruction, including 200±LF of 9 foot wide fixed, wood dock, with associated ramp and ladders. 14. WILL THIS PROJECT REQUIRE ADDITIONAL FEDERAL, STATE AND/OR LOCAL PERMITS? M Yes ❑ No If yes, please list: US Army Corps of Engineers Nationwide !'-en.eral.Permit Town of Southold, "Grandfather" Permit and Coastal Frosion Permit 15. CERTIFICATION: I hereby affirm that under penality of perjury that information provided on this form and all attachments submitted herewith is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Law. Further, the applicant accepts full responsibility for all damage, direct or indirect, of whatever nature, and by whomever suffered,arising out of the project described herein and agrees to indemnify and save harmless the State from suits, actions, damages and costs of every name and description resulting from said project. In addition, Federal Law, 18 U.S.C. Section 1001 provides for a fi not more than$10,000 or imprisonment for not more than five years, or both, wheer-e�an applicant knowingly and willfully falsifies eats, v p a mat rial fac,or k o 'ngly makes or uses a false,fictitous or fraudulent statement L'J I hereby authorize the agent named in Nu b 4. ab bmit this pli ati oe-mV belhalf. Z DATE SIGNATURE VTITLE PLEASE READ ALL INSTRUCTIONS ON REVERSE SIDE PERMIT ADMINISTRATOR - I I 14-16-4(2/87)—Text 12 PROJECT I.D. NUMBER 617.21 SEAR Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I—PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT/SPONSOR 2. PROJECT NAME Fishers Island Development Co ration Dock Reconstruction 3. PROJECT LOCATION: Municipality Fishers Island Town of Southold County Suffolk 4. PRECISE LOCATION (Street address and road intersections,prominent landmarks,etc.,or provide map) The site is located on a private road at the easterly end of Fishers Island. See attached Tax Assessor's Map 1000L004 Block 4, the private right of way between parcels 13 and 14. 5. IS PROPOSED ACTION: ❑New ❑Expansion ®Modification/alteration 6. DESCRIBE PROJECT BRIEFLY: Dock reconstruction, including 200±LF of 9 foot wide fixed, wood dock, with associated ramp and ladders. 7. AMOUNT OF LAND AFFECTED: Not applicable this is a dock reconstruction project. Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? [N Yes ❑No If No,describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? ❑Residential 0 Industrial ❑Commercial ❑Agriculture Park/Forest/Open space ❑Other Describe: There are two residential properties immediately adjacent to the site to the east; the club grouds and golf course lie to the south. 10. DOES ACTION INVOLVE A PERMIT APPROVAL,OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY(FEDERAL, STATE OR LOCAL)? Yes ❑No If yes, list agency(s)and permit/approvals US Army Corps of Engineers, Nationwide General Permit Town of Southold Board of Trustees, "Grandfather" Permit and Coastal Erosion Permit 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑Yes ®No If yes,list agency name and permit/approval Not Known 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION? ❑Yes ®No I CERTIFY THAT THE INFORMATION PROVID D ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE n 7R Applicant/spons name: /A / �Ue ^�• Date: vv �992 Signature: �1ci 4"If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER 1 PART II—ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.12? If yes,coordinate the review process and use the FULL EAF. ❑Yes ❑No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR,PART 617.6? If No,a negative declaration may be superseded by another involved agency. ❑Yes ❑No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING:(Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion,drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural,archaeological, historic,or other natural or cultural resources;or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish,shellfish or wildlife species,significant habitats,or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially adopted,or a change In use or intensity of use of land or other natural resources?Explain briefly. C5. Growth,subsequent development,or related activities likely to be induced by the proposed action? Explain briefly. I C6. Long term, short term,cumulative,or other effects not identified in C1-05?Explain briefly. C7. Other impacts(including changes in use of either quantity or type of energy)? Explain briefly. D. IS THERE,OR IS THERE LIKELY TO BE,CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑Yes ❑No If Yes,explain briefly PART III—DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above,determine whether it is substantial,large,important or otherwise significant. Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability Iof occurring; (c) duration; (d) Irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. ❑ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. ❑ Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse i environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: 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 2 FICC 95:-20-7(10/90) 5/29/9245 /29/92 New York State Department of Environmental Conservation Supplement to Application for Permit STRUCTURAL—ARCHEOLOGICAL ASSESSMENT FORM (SAAF) PART 1 — APPLICANT COMPLETES Applicant Information 1 . Applicant Name Fishers Island Development Corperation 2. Applicant Address Fishers Island, NY 06390. PO Drawer E Project Information 3. Project/Facility Name Dock Reconstruction 4. Project/Facility Location East Harbor, Fishers Island, NY 5. Is the proposed project adjacent to, or does it contain a building or structure listed in the State or National Register of Historic Places? Yes No x 6. Are there any buildings or structures built prior to 1940 adjacent to or within the proposed project area? Yes x No If the answer to question 5 and/or 6 is yes, provide the following information for each building and structure (use attachments if necessary) : a. name of structure Two homes former y the East Harbor Coast Guard Station and boathouse b. location A private road near the easterly end of Fishers Island. c. type of structure (ex: house, outbuilding, barn, bridge, dam, ruins) House d. approximate age or date of construction 1935 7. Might the proposed project have any impact (physical/visual) upon any buildings or structures listed in the State or National Register of Historic Places or built prior to 1940? Yes No x This project is reconstruction of an existing dock. If yes, describe briefly (use attachments if necessary) : 8. Provide photographs of every building and structure that may be impacted by the project as described in number 7, above. The following standards are recommended: o minimum of two photographs o minimum size 4" x 4" prints from negatives preferred; polaroid photos are acceptable o photos must be clear and focused o clearly label photos so it is obvious what is being illustrated; key photos to map or plan, if possible o photo 1: show both the entire front and side of the structure in a single shot from as close to the building as possible.' Be sure the structure is not partially or fully blocked by trees or other obstructions o photo 2: show relationship of building or structure to roadway or surroundings I 9. Has the land within the proposed project area been previously disturbed or altered (excavated, landscaped, filled, utilities installed)? Yes x No If yes, describe briefly, including depth of disturbance (use attachments if necessary): A dock has existed at this site for many years, prior to 1970. 10. Approximate percentage of proposed project area with slopes: Not Applicable 0-10% % 10-15% % 15% or greater % 11. Approximate percentage of proposed project site-with the following drainage characteristics: Not Applicable well drained % moderately we rained % poorly drained % Prepared by Doc o, Inc.. Keith B. Neilson. PE Date May 29, 1992 SAAFI.LK/G 10/90 FICC 91-08:-�-245 5/29/92 STRUCTURAL—ARCHEOLOGICAL ASSESSMENT FORM (SAAF) PART 2 — DEPARTMENT OF ENVIRONMENTAL CONSERVATION (DEC) COMPLETES Applicant/Project Information 1 . Applicant Name' Fishers Island Development Corperation 2. Project/Facility Name Dock Reconstruction 3. DEC Number Buildings and Structures 4. Might the proposed project have any impact (physical/visual) upon any buildings or structures listed in the State or National Register of Historic Places or built prior to 1940? Yes No If yes, DEC must consult with the Office of Parks, Recreation and Historic Preservation (OPRHP) . The DEC must request a determination of eligibility for the State Register of Historic Places and/or comments regarding project impact. Include information supplied by the applicant in response to questions 5, 6, 7 and 8 of Part 1 of this form. Archeological Sites 5. Does the proposed project area coincide with a circle, square or stippled area on OPRHP's Statewide Archeological Inventory Map? Yes No 6. Is the proposed project area outside of a circle or square, but one for which information has been provided (ex: documented reports of known sites) that suggests the area is archeologically sensitive? Yes No If yes, what is the nature and source of information? 7. Is the proposed project area apparently undisturbed? Yes No 8. Will the proposed action include a physical disturbance of the project area? Yes No 9. Is the slope in the area characteristically less than 15% (unless on limestone/flint escarpments)? Yes No 10. Is the proposed project area characteristically moderately, well or well drained? Yes No If the answers to 5, 7-10 are yes, an archeological survey should be performed by the applicant. Provide the applicant with aicopy of Report Format for Cultural Resource Investigations and list of archeological consultants. I If the answers to 6-10 are yes, DEC must consult with OPRHP before requiring that the applicant perform an archeological survey. Results of Evaluation No buildings, structures or archeological sites identified at the project location (SHPA-1) 1 Buildings, structures or archeological sites identified, but no impacts will occur, no survey required. No further cultural resources review required (SHPA-2) Consultation by DEC with OPRHP required structures archeology Archeological survey required Prepared by Date i SAAF2.LK/G 10/90 FICC 5/29/g 1 of pages APPLICATION CHECKLIST NOTE: APPLICATION MUST INCLUDE: X 1. STANDARD FORMS - Appropriate Application for Permit. Short Environmental Assessment Form, Structural Assessment Form. NOTE: For all projects requiring Wild, Scenic & Recreational Rivers Permits and for commercial, industrial or multi-residential pro- jects, submit a long Environmental Assessment Form. $2102. APPLICATION FEE: Refer to enclosed fee schedule $10.00 minimum, Check or Money Order payable to NYS DEC. You will be notified of additional fees, if ,any. X 3. Authorization letter from the owner where the applicant is not the owner. X 4. Staking and labeling of the seaward/wetland side of the proposed structure or fill area. X 5. Photographs of the staked project area mounted on a separate and labeled page. X 6. County Tax Map Numbers: Photo of Tax Bill will suffice. Suffolk: Dist. Sect. Blk. Lot Nassau: Sect. Blk. Subblock Lot X 7. Project Plans (four ,copies) - Plans must clearly show the pro- posed project and include all appropriate dimensions, elevations and must be at a scale of 1" to 100' or larger. X 8. Address of project location (if vacant land; telephone pole # or other identifying landmark) . MINIMUM PLAN REQUIREMENTS (FOUR COPIES REQUIRED) PROJECT: Alterations and/or Extensions 1, 3, 5, 6, 7, & 8 New House Construction 1, 3, 5, 6, 7, & 8 Accessory Structures 1, 3, 5, & 6 Repairs to Existing Structu,res 2, 3, & 4 Dredging 2, 3, 4, 5, & 6 Catwalks and Docks 2, 3, 4, & 5 Subdivisions 1, 2, 3, 5, & 6 Bulkheads . 1, 2, 3, 4, 5, •6, 9, & 10 Groins and Jetties 2, 3, 4, 5, 9, & 10 Filling 1, 4, 5, & 6 KEY: 1. Stamped Sealed Survey 2. Plot Plan 3. Location Map: 4. Sectional View 5. Wetland Line or Mean High Water, as appropriate 6. Fill and Clearcut Area 7. Sanitary System Location 8. Test Hole and Data 9. Profile View 10. Distances from fixed structures NOTE: IF YOU WISH CONFIRMATION OF RECEIPT OF YOUR APPLICATION, PLEASE SUBMIT A SELF-ADDRESSED, STAMPED POSTCARD. NOTE: THE PERMIT PROCESS TAKES AT LEAST EIGHT (8) WEEKS. T Docko, Inc. P.O. Box 421, Mystic,CT 06355 (203)572-8939 Fax:(203)572-7569 May 29, 1992 Mr. Jim Haggerty, Regulatory US Army Corps of Engineers Jacob Javits Federal Building, Room 1937 New York, NY 10278-0090 Re: Fishers Island Development Corp Dock Reconstruction Permit Dear Mr. Haggerty: On behalf of our client, we request a Department of the Army Nationwide General Permit for reconstruction of a fixed dock of the Fishers Island Development Corperation on Fishers Island, New York. We enclose the following in support of this permit application: - Two prints of the application drawings titled: Project: "Dock Reconstruction" Waterway: . East Harbor, Fishers Island Sound Location: Fishers Island, Town of Southold Suffolk County, New York' Applicant: Fishers island Development Corp Date: May 29; 1992 - Two copies of Corps of Engineers, Town and DEC Application Forms - Two copies of site photos, Tax Assessor's Map, and location map. I trust that you will- find this application package complete and acceptable; please let me know if the need for further information arises. Very truly yours, DOCKO, INC. � AJ ` Keith B. Neilson, P.E. Enclosures cc: Fisher Island Development Corperation Fishers Island Country Club Mr. Robert Green, NYS DEC John Bredemeyer, Town of Southold John Clavin, Fishers Island Harbor Master File 91-08-245 APPLICATION FOR DEPARTMENT OF THE ARMY PERMIT OMB APPROVAL NO. 0702-0036 (33 CFR 325) Expires 30 June 1992 Public reporting burden for this collection of information is estimated to average 5 hours per response for the majority of cases,including the time for reviewing instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information. Applications for larger or more complex projects,or those in ecologically sensitive areas,will take longer. Send comments regarding this burden estimate or any other aspect of this collection of information,including suggestions for reducing this burden,to Washington Headquarters Services,Directorate for lolormation Operations and Reports,1215 Jefferson Davis Highway,Suite 12D4,Arlington,VA 22202-4302;and to the Office of information and Regulatory Affairs,Office of Management and Budget,Washington,DC 20503. The Department of the Army permit program is authorized by Section 10 of the Rivers and Harbors Act of 1899,Section 404 of the Clean Water Act and Section 103 of the Marine,Protection,Research and Sarmctuaries Act These Laws require permits authorizing activities—n-or affecting navigable waters of the United States,the discharge of dredged or fill material into waters of the United States,and the transportation of dredged material for the purpose of dumping it into ocean waters. Information provided on this form will be used in evaluating the application for a permit Information in this application is made a matter of public record through issuance of a public notice. Disclosure of fhe information requested is voluntary,however,the data requested are necessary in order to comrrwnicate with the applicant and to evaluate the permit application. If necessary information is not provided,the permit application cannot be processed nor can a permit be issued. One set of original drawings or good reproducible copies which show the location and character of fhe proposed activity must be attached to this application (see sample drawings and instructions) and be submitted to the District Engineer having jurisdiction over the location of the proposed activity. An application that is not completed in full will be returned. 1. APPLICATION NUMBER(To be assigned by Corps) 3. NAME,ADDRESS.AND TITLE OF AUTHORIZED AGENT Docko, Inc., Keith B. Neilson, PE PO Box 421 Mystic, CT 06355 Telephone no.during business hours 2. NAME AND ADDRESS OF APPLICANT Fishers Island Development Corperation AIC( ) (Residence) PO Drawer E A/c(203) 572-8939 (Office) Fishers Island, New York 06390 statement of Authorization: I hereby designate and authorize Attention: Mr Thomas Doherty, Manager Docko, Inc. to ad in my Telephone no.during business hours behalf as my agent in the processing of this permit application and to lur ' ,upon r uest, ntal inl mation in support of the appr Atior, A/C( ) (Residence) r DATE ac(51 6) 788 7251 (Office) iA19Z 4. DETAILED DESCRIPTION OF PROPOSED ACTIVITY 4a. ACTIVrrY Dock reconstruction, including 200' of 9 foot wide fixed, wood dock with associated ramp and ladders. 4b. PURPOSE The dock is privately owned and is used for recreational boating. The aged facility was irreparably damaged by Hurricane "BOB" and must be completely re-built. 4a. DISCHARGE OF DREDGED OR FILL MATERIAL Not Applicable ENG FORM 4345, Aug 89 EDITION OF APR 86 IS OBSOLETE. (Pru{xxwrd: CECW-ON) 5. NAMES AND ADDRESSES OF ADJOINING PROPERTY OWNERS,LESSEES.ETC.,WHOSE PROPERTY ALSO ADJOINS THE WATERWAY East: West: Ms. Lucille Balcom Fishers Island Development Corperation c/o Fiduciary Trust PO Drawer E Mr. Francis Shepherd Fishers Island, NY 06390 2 World Trade Center New York, NY 10048 6. WATERBODY AND LOCATION ON WATERBODY WHERE ACTIVITY EXISTS OR IS PROPOSED The dock system is in East Harbor. 7. LOCATION ON LAND WHERE ACTIVITY MUSTS OR IS PROPOSED ADDRESS; The site is located on a private road at the aesterly end of Fishers Island. STREET,ROAD,ROUTE OR OTHER DESCRIPTIVE LOCATION Suffolk NY 06390 COUNTY STATE ZIP CODE Southold Board of Trustees LOCAL GOVERNING BODY WITH JURISDICTION OVERSITE 8. Is any portion of the activity for which authorization is sought now complete? ❑ YES IN NO If answer is'yes'give reasons,month and year the activity was completed. Indicate the existing work on the drawings. The project is the reconstruction of an existing dock. 9. List all approvals or certifications and denials received from other federal,interstate,state or local agencies for any structures,construction,discharges or other activities described in this application. ISSUING AGENCY TYPE APPROVAL IDENTIFICATION NO. DATE OF APPLICATION DATE OF APPROVAL DATE OF DENIAL NYS DEC Tidal Wetlands Pending May 29, 1992 Pending Water Quality Certificate Southold "Grandfather" Pending May 29, 1992 Pending Board of Coastal Erosion Trustees 10. Application is hereby made for a permit or permits to authorize the activities described herein. I certify that I am familiar with the information contained in the application,and that to the best of my knowledge and belief such information is true.complete,and accurate. 1 further certify that 1 possess the authority to undertake the proposed activities or 1 am acting as the duly authorized agent of the applicant. 7" � �Z J�40S 5 29 92 SIGNATURE OF APPLICANT DATE SIGNATURE OF AGENT DATE Docko, Inc., Keith B. Neilson, PE The application must be signed by the person who desires to undertake the proposed activity(applicant)or it may be signed by a duly authorized agent if the statement in block 3 has been titled out and signed. 18 U.S.C.Section 1001 provides that Whoever,in any manner within the jurisdiction of any department or agency of The United States knowingly and willfully falsifies,conceals,or covers up by any trick,scheme,or device a material fact or makes any false, fictitious or fraudulent statements or representations or makes or uses any false writing or document knowing same to contain any false fictitious or fraudulent statement or entry,shall be fw*d not more than$10,000 or imprisoned not more than fare years,or both.