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FORM NO. TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHO LD, N. Y. V b byBUILDING PERMIT /1GE' (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) W 20092 Z Date ............ ............1...�1.................. 19.7./ plc 1 /-1 Permission is hereby granted to: ...•. ... r �. ...... .. .... .� ti.��� !/ to ......... .. ..............Q .. .......Z..16 ,r.....�0. ... ..... ......... . . .......�/.,�l............ .. . ... . .. . . .. .. atpre2iises located at .....C,l .. .......... ........... ........... . ........ . . ` .yP...... . ........ .. ..... �I..�,...... �e��"Y�, �... .. ..... ..... ..... ............................................................................................................................................................ :... County Tax Map No. 1000 Section ...............G�....... Block ....... ........... Lot No. .....l..:S ..... pursuant to application dated .......... .. ..... .........�..�f....... 19.OV/ and approved by the Building Inspector. Fee 5.J27X,1-111el.4� .. Building Inspector Rev. 6/30/80 BOARD OF HEALTH . . . . . . . . . . . . 3 SETS OF PLANS . . . . . . . . . . . . FORM NO. 1 SURVEY . . . . . . . . . . . . . . . . . . . . . TOWN OF SOUTHOLD CHECK . . . . . . . . . . . . . . . . . . . . . . BUILDING DEPARTMENT SEPTIC FORM . .. . . . . . . . . . . . . . . TOWN HALL SOUTHOLD, N.Y. 11971 NOTIFY TEL.: 765-1802 CALL . . . . . . . . . . . . . . . . . . . . . : Examined . . . . . . . . . . . . . . . .. 19 . . . MAIL TO 17/ Approved 19 A i - Permit No. . Disapproved a 7c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Building Inspector) APPLICATION FOR BUILDING PERMIT Date . . . .�". 19 INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector,with 3 sets of plans,accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli- cation. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issued a Building Permit to the applicant. Such permit shall be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupancy shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described. The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in building for necessary inspections. . . . . . . . . . . . . . . . . (Signature of applicant, or name, if a corp ation) . . . . . . . . . (Mailing address of applicant) C, State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . r Name of owner of premises . . . . . . . o. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (as on the tax roll or latest deed) If applicant is a corporation, signature of duly a?)horized officer. . . . (Name an . . . . . . . �FtitlZcof corporate officer) Builder's License No. . . . . . . . . . . . . . . . . Plumber's License No. . . . . . . . . . . . . . . . . . Electrician's License No. . . . . . . . . . . . . . . . . Other Trade's License No. / w./11"e A . . . . . . . . . . . . . 1. Location of land on which proposd work will be done. . . . . . . . . . . . . . . . . . . . . . . . . . / . . . . . . . . . . .allul� 4 Lg-a,2,-�- House Number Street HamletCounty Tax Map No. 1000 Section . . .��4Z . . . . . . . . . Block . . . . . . . . . . . . . . . Lot . . . . 16 . . . . . . . . . . . Subdivision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Filed Map No. . . . . . . . . . . . . . Lot . ... . . .. . . . . . . . . . (Name) 2- State existing use and occupancy of premises and intended LISe and ocCLIpanc.y of proposed construction: a. Existing use and occupancy . . . . . . . . . . . . . . . . . . . . . . . . . . b. Intended use and occupancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Nature of work (check which applicable): New Building . . . . . . . . . . Addition . . . . . . Alteration . . . . . . . . . . Repair . . . . . . . . . . . . . . Removal . . . . . . . . . . . . . . Demolition . . . . . . . . . . . . . . Other Work . . . . . . . . . . . . . . . (Description) n 4. Estimated Cost . . . .G �U .4 . . . . . . . . . . . . . . . . . . . . . . Fee . . .viD.D© . . . . . . . . . . . . . . . . . . . . . . . . . . . . (to be paid on filing this application) 5. If dwelling,number of dwelling units . Number/'of dwelling units on each floor . . . . . . . . . . . . . . . . Ifgarage, number of cars . . . . ?-e. �` . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. If business, commercial or mixed occupancy, spec y nature and extent of each type of use . . . . . . . . . . . . . 7. Dimensions of existing structures, if any: Front . . . . . . Rear . . . ..` Depth Height . . . . . . . . . . . . . . . Number of Stories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dimensions of same structure with alterations or additions: Front . . . . . Rear . . . . . . . . . . . . . . . . . . Depth . . . . . . . . . . . . . . . . . . . . . . Height . . . . . . . . . . . . . . . . . . . . . . Number of Stories . . . . . . . . . . . . . . . . . . . . . . 8. Dimensions of entire new construction: Front . . . . Rear . . . . . . . . . . . . . . . Depth . . . . . . . . . . . . . . . Height . . . . . . . . . . . . . . . NumberofStories . . . . . . . . . . . .. .. . . . . . . . . .,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. Size of lot: Front . . . . . . . . . . . . . . . . . . . . . . Rear . . . . . . . . . . . . . . . . . . . . . Depth . . . . . . . . . . . . . . . . . . . . . . 10. Date of Purchase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Name of Former Owner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. Zone or use district in which premises are situated . . .%l�?,�c �c • • , , , . , , • . . . . . . . . . . . . . . . . . • . • . , . • . • 12. Does proposed construction violate any zoning law, ordinance or regulation: . -'. . . . . . . . . . . . . . . . . . . . . . . . . . 13. Will lot be regraded . . . . ./;�-O . . Will excess fill be removed from premises: Yes 14. Name of Owner of premise / Address��•�1 ��, •Phone No. Name of Architect . Address . . . . . . . . Phone No. %. Name of Contractor 4� �. �° « Address �c0�lo. ��. Phone °3 15 . Is this property located within 300 feet of a tidal wetland? -YES . . . .NO. . . . *If yes , Southold Town Trustees Permit may be` required. PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and.indicate all set-back dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEW YORK, S.S COUNTY OF . . . . . . . . . . . • �``�` • • • • • • • • . . . . . . . . . . . . . . . . being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) above named. He is the . . . . . . . . . . . . . . �e (65htractor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his knowledge and belief;and that the work will be performed in the manners orth in the application filed therewith. Sworn to bef �ee this . . . . . . .day of . . . . . ., l9? Notary Pub Ti , . l . . . . . . . . . . . . . . . . . . . . County Wwry Public State of New yor<J , . . . . . . . N9,4906559 Quant ou in Suffolk county (Signature o applicant) Term Explrts 12/310C— M 111"114n i 0CC�CCo Inc. AD2 Box 420A.Stafford St., Mystic,CT 06355 (203)572.6939 t• JUM11; 2 ® IN June 20, 1991 John gredemeyer III, PresidentOF t Southold Board of J own 'Trustees ao Box 1179 iouthold, NY 3.1971 Re... BalccM Property, Fishers island Boat Lift Installation Bear Mr. BredeMYer: J am writing at Jill's sugge[stioLutcoillev&•ticom,ise the shown on attached rd of Trustees Map004 s � ork proposed at the property of rt: a boat s Block 4, Lot 15. The scope of work is to drive four piles to support lift which will enable the Bale tl's to raise their boat out of the water other alterations to the between uses for safety and ed ase Of this accessl have prepared a sketch showing hxisting facilities are proposed the extent of the project foryour referencea£ t existing rstruct�''reSi,l] Hofer the limits o f. Work are within the pe-ri.met - It kOuld l:)e helpful if you could advise us as to the acceptability of this project within the permit program standards for the Town of southold. Your assistance, as always, is appreciated. yours truly, UOC}CO r Inc. Keith B. Neilson, PE ' �ftulUyuC�S cc: Dick Hale Ms. Lucille Baler File 91-04-21.0 I L4 -,aAAA "Cx4r /SLAN4D /V&W a OAT 61pr (4 y db— —rrp )V&W PLC—Typ ryp ago SAND' P-)0 L V ff 1:1 S SA-4,Dy BOffOM 9 d-Ll,A to R�cA rL (MNW WN Al-oNr>MeA) PLAAi VISW FiAN AND Nor r4 spa NSW 0(:)AT- &IP7- /Aj ICI SH EW5 /SLAND tO U e4 I-(A)z AT f uL4ND M4 OF'5(!>UrH0t2> WI (o A Sp ICOC-A-- COCJOQ New ye)ge- APPLICANT.' LUCIA(-ff )9ALC.0,tl Z>ATG : Jud 20, 11791 A--sN r W<c. r. 69 My.5T'c �GT 20?) 572 6934 ti DEPARTMENT OF THE ARMY `\ NEW YORK DISTRICT CORP;; OF ENGINEERS \ JAC0E3 K. JAVITS FEDERAL BUILDING NEW YORK, N.Y. 10278-0090 REPLY TO ; ATTENTION Of j CENAN-OP-RH 1 ' a IMPORTANT i This letter must be completed and mailed to the Harbor Supervision & Compliance Section at the above address prior to commencement of any work authorized under the permit. Permittee: Lucille Balcom Permit No. 16173 Date Permit Issued: July 24, 1991 Expiration Date: None Waterway: Fishers Island Sound, East Harbor y City & State:_ Fishers Island, New York a d Type of Work: Install 4 piles to support a boat lift. Work will commence on or about: July 26, 1991 (duration- 2 days, Max. ) Name, Address & Telephone Number of Contractor: Gwenmor Marina 203 536 0281 a , 4 PO Box 375 '. Mystic, CT 06355 a a b Docko, Inc.- Agent July 26, 1991 Signature of Permittee Date I ' 2 ' p a c; j' --------------------------------------- -------------- ------------- - d----- 07-25-91 02: 38PM FRL)M 0 e -- -� CENAN-OP � r a l i a I�� �.- �'��• �•;'� P 0 2 DEPARTMENT OF THE ARMY NEW YORK DISTRICT CORPS OF ENGINEERS JACOB K. JAVITS FEDERAL EUILDINO NEW YORK, N.Y, 10278-0090 REPLY TO A'rrLNTiONOF July ?4 , 1991 Operations Division Regulatory Branch SUBJECT: Department of the Army Permit No. 7.6:173 Ms,. Lucille Balcom C/o Mr. Keith B. Neilson, P.E. Docko, Inc. P.O. Box 421 Mystic, CT. 06355 Dear Ms. Balcom: We have completed our review of -Application Number 91-0612-L2. Pursuant to Section 10 of the Rivers and Harbors Act of 1899 (33 USC 403) , you are hereby authorized by the Secretary of the Army: WORK: Install four piles to support a boat lift. WA'T'ERWAY: song Island Sound LO•,^'ATION: Fishers Island, Suffolk County, New York Kindly display the enclosed notice of authorization sign at the project site. The activity authorized herein must be completed within three years of the date of this permit, and is subject to the enclosed conditions. You are required to submit to this office the dates of commencement and completion to the authorized,' activity. Enclosed please find two forms for your use in submitting the required dates. Notice is hereby given that the permittee should recognize that a possibility exists that the structure permitted herein may be subject to wave wash from passing vessels. The issuance of this permit does not relieve the permittee from taking all proper steps to insure the ' integrity of the structure permitted herein and the safety of boats moored thereto from damage by wave wash and the permittee shall not hold the United States liable for any such damage. The authorized activities must be performed in accordance with the enc:ldsed plans. If any material changes in the location or plans of the subject work are found necessary, revised plans should be submitted to �the District Engineer. These plans must receive the approval required by law before work begins, incerel rRt dDa ie1 n el, co ps of Engineers Enclosures ict Engineer TRUSTEES �� John M.Bredemeyer,III,President ® F�.;�a ' f SUPERVISOR � N' Henry P. Smith,Vice President �: ;, '�, SCOTT L.HARRIS Albert J.Krupski,Jr. ` " John L.Bednosld,Jr. �® a��� Town Hall John B.Tuthill 53095 Main Road P.O.Box 1179 Telephone(516)765-1892 BOARD OF TOWN TRUSTEES Southold,New York 11971 Fax(516)765-1823 TOWN OF SOUTHOLD June 21, 1991 Keith B. Neilson Docko, Inc. RD2, P.O. Box 420A ._� Stafford Street -C3F Mystic, CT 06355 't0 .� RE: Balcom Property, Fishers Island Boat Lift Installation Dear Mr. Neilson: Trustee President John M. Bredemeyer reviewed the application submitted for the above referenced property to install a boat lift. As this structure is proposed for Fishers Island Sound, which is beyond the jurisdiction of Chapter 97 of the Town Code "Wetlands" at this time the Board, will have no jurisdiction in this matter. All other approvals that may be applicable should be secured prior to the commencement of the project. Very truly yours, John M. Bredemeyer, III President, Board of Trustees JMB: jt cc: Building Dept. 1416-2 (2/87)-7c 617.21 SEQR Appendix A 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 project 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 environmental 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 determination ,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. Part 2: Focuses on identifying the range of possible impacts that may occur from a project or action. It provides guidance as to whether an impact is likely 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 1 J 14.16.4(2/87)—Text 12 PROJECT I.D. NUMBER 617.21 SEAR Appendix C a 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 Ms. Lucille Balcom _ New Boat Lift 3. PROJECT LOCATION Municipality Fishers Island County Suffolk 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc, or provide map) The project site is located on a private road on the north shore of Fishers Island atthe west end of East Harbor, adjacent to Fishers Island Sound. 5. IS PROPOSED ACTION, ------------- - -------— -----------------RNew [I❑Expansion Modillcation/allelnlion Modification of an existing dock system. 6. DESCRIBE PROJECT BRIEFLY. — Install four new piles to support a boat lift system. 7. AMOUNT OF LAND AFFECTED - Initially _=Qarros Ultimately —C— aeras 8. WILL PROPOSED ACTION COMPL`!WITH EXISTING ZONING 011 OTHER EXISTING I AND USE RESTRICTIONS? MYes tJ No If No, doscrll,(; bllully 9, WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT') 13Residential ❑Industrial ❑Commercial � I AOncullure Ll Park/Forest/Open space ❑Other a Describe: e 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY(FEDERAL, STATE ItOR LOCAL)? t J Yes No II yeas, list n(I(!n(y(;;) and pannI1/appn,v.lI!, 11. DOES ANY ASPECT OF IHE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVALS 12Yes I—I No If yos, INN a(101)(y name and pclnutlapproval The existing dock was built in the early 1900's and preexists state and local permit programs; the structure is considered 'grandfathered" by the Corps of Engineers. . 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION') ❑Yes No Not Applicable I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name Lucille Balcom Z --- — - - ----- - - - — ------- Date: �- Signature: 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 EAR. ❑Yes ❑No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR,PART 617.6? If No,a negative declaration a 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. 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. S 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 ft'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 of 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 environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: Name of Lead Agency Print or Type Name of Responsible Ofticer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(If different from responsible officer) Date 2 Docko, Inc. RD2 Box 420A,Stafford St.,Mystic,CT 06355 (203)572-8939 Jjl "'^".�=rte 'iwt•z' ' �;K•�'x^.`'�'v - - 4 Above - Boat House looking west; Boat Lift to be at north end of east dock ; Below - East Dock looking north; Boat Lift to be located at far end ZA tar z-► _� YT el •1•]08 ry 1 r•' ... L.>,°� •-Ie-er 1 .,on 0 lap /•SL AND •' •v+er r r r vT .er ,L.SOUND SOUNo ISLAND I 4 me) FISHERS I s[E sic No uD 'Vfe s[E scc xo i]o 000 RO 81 ed fEa 9 E5 0 <F' 4 e]• ']'yN e�8z •o• e�'C •,er o Pe Y I •' L ,+ 3. sq ,ar �• �-.� � 9.1 le, Y6• le•l,l+a , ' \\ 4� 3 I] ♦ 5 ]•• v ].. le• T,i Z, Cam a. 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SOUTHOLD _ •D}I•r;e•EEP•It v"'•'•• .�L•+._ _ ]+4.,....Lww --- r L.q °^ •r--°—_ ,.Y,`� --- ...D...,.IL.. --•-- ..,.,.D..,.,L�_O_. ,.D�.._ Real Properly Tax Service A enc D. 004 Dy 9 y ND 10 _00 Pwlo,.•M1..n1,wN P. el-LLL. _--- e.a o•.Lrt�.. __. .. ;] .. , x111 IM COu 1 C."', a�" '° Rlverheod,l 1,Nr.v Yo,4 PROYFRIY MAY REMITTANCE ADVICE 51-7014 DOCKO INC. 211' D/B/A DOCKO MANAGEMENT RD 2, BOX 420A. STAFFORD ST MYSTIC. CT 06355-9744 112 8 203%572-8939 PAY '7—tj-)0 h`i�.y7��Zc-7�` .� ��crz� DOLLARS DATE I TO THE ORDER OF DESCRIPTION CHECK AMOUNT q �N v�lznN mc�--�� �Zyr�c_TiaiV -- COASTAL SAVINGS BANK FSB NEW LONDON, CONN 0001128111 1: 2 1 1 1 70 L4 31: 049 70 L 5 2 511' 95.19.3(8/89)-7e D1( A1'I'l ICA]ION NUMIII R NEW YORK STAT( DIPARIMINI 01 1NVIRONAtt'NIAI c ()Ntil1<VA11ON — '" ' JOINT APPLICATION FOR PERMIT U S ARMY CORPS Of INGINFERS APPLICATION NO Please read ALL Instruction%on baLk'bcfore completing this apphc.cluai PIeau• IYpe of print Llea(ly in Ink.Attach additional information as needed. ❑ARTICLE 9,TITLE 1,ARTICLE 43 6NYCRR 646(LAKI (.I ORW RI CRLAI ION ZONI) ❑ARTICLE 15,TITLE 3(AQUATIC PESTICIDI S CONTROL) ❑6NYU:R 327(AQUA11C VI GI IAT ION) 06NYCRR 318(-ism ❑6NYCRR 329(INSECTS) S ❑ARTICLE 15,TITLE 5 6NYCRR 608(PROTECTION OF WATT RS) T+ • A El 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 0401 WATr.R QUALITY CERTIFICATION E? ❑ARTICLE 15,TITLE 15 ❑6NYCRR 601 (WATT R SUM']Y) ❑6NYCRR 602(]ONG IS]AND W111) '- ARTICLE 15,TITLE 27 6NYCRR GGG(WILD, SCI NIC AND RI CKLArIONAI LIVI RS) ❑ARTICLE 24 6NYCRR 662,663(FRESHWATER WrTLANDS) I ❑ 0 ARTICLE 25 6NYCRR 661 (TIDAL WETLANDS) ARTICLE 34 6NYCRR 505(COASTAL LROSION) -------------------------------------------------------------------------------------------------------------------------------------------------- F ®SECTION 10(RIVER AND HARBOR ACT OF 1899)for structure%in(]work in navigable waters of the U S ❑COASI AL CONSIST ENCY 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 PFRMIT/APPLICATION NUMBI RS AND DAI l S(If any) None Known; the site was once i_I US Coast Cuard Station boat house and dock system. 2.,nPPLIcnNr IS nlnN ••�� 0Ownvr ❑Operaln( I I oxen I IMI11111 gialdylGmvennnonlal Agr•n(y (Che(k a%many ns apply) 3. NAME OF API'LICANI (Use Full Name) Lucille Balcom MAILING ADDRESS TELEPHONE(Where can be reached during day) C/o Fiduciary Trust, Mr. Francis Shepherd, ( ) POST OFFICE STATE ZIP CODE 2 World Trade Center, New York, NY 10048 4. NAME OF 1:1 Owner ®Agent/Contact Person (Check one) Docko, Inc. , Keith B. Neilson, PE I MAILING ADDRI SS — T I1 I.I PI ION[ (Where can he reached(luring aay) PO Box 421 (203) 572 8939 POST OFFICE STATE ZIP CODE Mystic CT 06355 5. PROJECTIFACILITY LOCATION(Mark location on map, see Number 1a on reverse side) County Suffolk I Town or city Southold I Village Fi shers Island STREET ADDRESS(If different from applicant) Private Road POST OFFICE STATF ZIP CODE Fishers Island NY 06390 6. NAME OF STREAM OR BODY OF WATER Fishers Island Sound, East Harbor 7. HAS WORK BEGUN ON PROJECT? If YES, attach explanation on starting work without pernut, Include dates 8 WILT.PROJECT UTILIZE STATE LAND? 11 Yes MI N. Show work on map and/or drawings ❑Yes NNo 9. PROPOSED USE, ® PROPOSED SIARTING DArL 11 APPROXIMATE COMPLETION DATE 12 FEE OF(NYS Permit Only) ® Private Immediately July 15,1991 y 11 Public El Commercial g $210 Enclosed 13. PROJECT DESCRIPTION (e g quantity an(] type of material to be excavated,diedgmi or u%Vd for fill or rip rap, location of disposal sites;*type of 1, structure to be installed, height of dam,size of i mpoundent, capacities of propose(]water%ources,extent of distribution system, etc) I, Install four new piles to support a boat lift. I 'r 14. WILL THIS PROJECT REQUIRE ADDITIONAL FEDERAL, STATE AND/OR LOCAL PERMITS? Lit Yes ❑ No If yes, please list: US Army Corps of Engineers, Nationwide General Permit Southold Board of Town Trustees 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, (tired 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 5 C Section 1001 provides for a fine of not more than 810,000 or imprisonment for not more than five years, or both, where an applicant knowingly and willfully falsifies,conceals,or covers up a matonal fact,or knowingly makes or uses a false, fictitous or fraudulent statement. �I Ise authorrz the agent named In Number ove to submit this application my behalf � h 01--- em D T IGNATUI2 a TITLE PLEASE READ ALL INSTRUCTIONS ON REVERSE SIDE d , Docko, Inc. RD2 Box 420A,Stafford St.,Mystic,CT 06355 (203)572-8939 June 21, 1991 Ms. Christine Costopoulos NYS DEC, Regulatory Affairs State Campus, Building 40, Roan 219 Stony Brook, NY 11794 ,,. Re: Lucille Balcom Property Boat Lift Permit Application Dear Ms. Costopoulos: Pursuant to our discussions today, and on behalf of our client, Ms. Lucille Balcom, we request a Wetlands Permit, for a new pile supported boat lift at her propoerty on Fishers Island. We enclose herewith the following in support of this permit application: - Two prints of a plan titled: "New Boat Lift" In: Fishers Island Sound, East Harbor At: Fishers Island, Suffolk County, New York Applicant : Lucille Balcom Date: June 20, 1991 - Two copies of the DEC Joint Application, including location maps, site photographs, Short and Full Environmental Assessment Forms, Structural-Archeological Assessment Forms and Tax Assessor's Map. I trust that you will find this application .package complete and acceptable; please let me know if the need for further information arises. Your early review and °approval of this application would be greatly appreciated by Ms. Balcom. We have been advised that the Southold Board of Trustees will have no jurisdiction in this project. Very truly yours, Docko, Inc. -Keith B. Neilson, P.E. Enclosures cc: Lucille Balcom James Haggerty, CE Tan Law, Sandy McGugan File 91-04-210 l- A CXP .9_- Docko, Inc. RD2 Box 420A,Stafford St.,Mystic,CT 06355 (203)572-8939 June 21, 1991 Mr. James Haggerty, Regulatory US Army Corps of Engineers 26 Federal Plaza, Roan 1937 New York, NY 10278-0090 Re: Balcon Property Boat Lift Permit Application Dear Mr. Haggerty: On behalf of our client, we request a Department of the Army Nationwide Permit for a new pile supported boat lift at property of Mrs,. Lucille Balcom on Fishers Island. We enclose herewith the following in support of this permit application: - Two prints of a plan titled: "New-,Boat Lift"' In: Fisher's Island Sound, East Harbor At: Fishers Island, Town of Southold Suffolk County, New York Applicant: Lucille Balcom Date: June 20, 1991 = - Two copies of Corps of Engineers and DEC Application Forms - Two copies of the Short and Full Environmental Assessment Forms, Structural-Archeological Assessment Forms ,= 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. Your early review and approval of -this information would be greatly appreciated by Ms. Balcom. Very truly yours, XeithB. Neilson, P.E. Enclosures cc: Lucille Balcom Christine Costopoulos, DEC Tan Law, Sandy McGugan File 91-04-210 APPLICATION FOR DEPARTMENT OF THE ARMY PERMIT OMB APPROVAL NO. 0702=0036 (33 CFR 325) Expires 30 June 1989 The Department of the Army permit program is authorized by Section 10 of the River and'Harbor Act of 1899,Section 404 of the Clean'Water Act and Section 103 of the Marine,Protection, Research and Sanctuaries Act. These laws require permits authorizing activities in 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 the information requested is voluntary;however,the data requested are necessary in order to communicate 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 i0t of original drawings or good reproducible copies which show the location and character of the proposed activity must be attached to this application (see sample drawings and instructions) and be submitted to the District Enginger 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 2.NAME ANO ADDRESS OF APPLICANT Telephone no.during business hours Lucille Balcom ( ) 6 c/o Fiduciary Trust, Mr. Francis ShepherdA/C (Residence)A)c(203 ) 572 8939 2 World Trade Center (orrice) New York, NY 10048 Statement of Authorization: I hereby designate and authorize Docko, Inc. to act in my behalf as my Telephone no.during business hours agent In the processing of this permit application and to furnish,upon request. Contact Harold Cook, Cilda Construction supplemental Information in support of the application. (Residence) SIGN E OF APPLICANT DATE A/C"( 515788 7321 (orf«) 4,DETAILED DESCRIPTION OF PROPOSED ACTIVITY 4a.ACTIVITY Install four piles to support a boat lift. F � 4b.PURPOSE ) I The proposed boat lift will be for the use of the Balcoms; private recreational boating. a 4c.DISCHARGE OF DREDGED OR FILL MATERIAL Not Applicable. i ENG FORM 4345,Apr 86 EDITION OF APR 83 IS OBSOLETE (Proponent: 0AEN-CW6-N) t r� 5.NAMES AND ADDRESSES OF ADJOINING PROPERTY OWNERS, LESSEES, ETC,WHOSE PROPERTY ALSO ADJOINS THE WATERWAY East: Ms. Kim K. Campbell West: Fishers Island Development Corp 257 Dunbar Raod PO Drawer E Palm Beach, FL 33480 Fishers Island, New York 06390 6.WATERBODY AND LOCATION ON WATERBOOY WHERE ACTIVITY EXISTS OR IS PROPOSED The site is located in waters of Fishers Island Sound at the west end of East Harbor. 7, LOCATION ON LAND WHERE ACTIVITY EXISTS OR IS PROPOSED r AODRFSS: T1,,'e Balcom's property is located on the north shore of Fishers Island on a private road identified additionally as the Boat House for the old East Harbor Coast Guard Station. STREET,ROAD,ROUTE OR OTHER DESCRIPTIVE LOCATION Suffolk County Now York 06390 COUNTY STATE ZIP CODE LOCAL GOVERNING BODY WITH JURISDICTION OVER SITE 8. Is any c,ortlon Of tits activity for which authorization is souuht now complete) 0 YES XXNO If answar Is"Yes"give reasons,month and Veer the activity was completed. Indicate the existing work on the drawings. 9.List all approvals or eartlfiutlons and denials received from other federal,interstate,state or local agencies for any structures,eonmuetion, discharges or other activities described In this application. ISSUING AGENCY TYPE APPROVAL IDENTIFICATION NO. DATE OF APPLICATION DATE OF APPROVAL DATE OF DENIAL NY DEC Wetlands Pending June 20, 1991 Pending Permit 10.Applici,tion is hereby made for a permit or permits to authorizo the activities described herein I certify that I am familiar with the information contained in this so)lication,and that to the bast of my knowledge and belief such information Is true,complete,and accurate I further certify that I possess the authority to undertake the proposed activities or I am acting as the duly authorized ogent of the applicant //e*,W/�' z �z ® ne 20, 1991 gIGtTATURE OF APPLICANT OATt SIGNATURE OF AGENT DATE Harold Cook for Lucille Balcom PcVrer of Attorney 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 i/the statement in Block .3 has been Pilled out and signed 18 U.S.C.Section 1001 provides that. Whoever, in any mariner within the jurisdiction of any department or agency of The United Statex, knowingly and willfully falsifies, conceals,or covers up by any trick,scheme, or device a material fact or makes any false, fictitious or fraudr.lent statements or representations or makes or uses any lalse writing or document knowing same to contain any false fiCtitioua or fraudulent statement or entry, shall be fined riot more than $10,000 or unpnsoned not more than five years, or both. Do not send a permit processing fee with this application The appropriate fee will be assessed when a permit is issued. ,1' PART 1-PROJECT INFORMATION Prepared by Project Sponsor NOTICE: This document is designed to assist in determining whether the action proposed may have a significant effect on the environment Please complete the entire form, Parts A through E. Answers to these questions will be considered as part of the application for approval and may be subject to further verification and public review. Provide any additional 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 involve new studies, research or investigation. It information requiring such additional work is unavailable, so indicate and specify each instance. NAME OF ACTION Install new boat lift. LOCATION OF ACTION(Include Street Address, Municipality and County) Fishers Island Sound, Eases Harbor at hte old East Harbor Coast Guard Boat House. - NAME OF APPLICANT/SPONSOR _ BUSINESS TELEPHONE Lucille Balcom ( ) ADDRESS c/o Fiduciary Trust, Mr. Francis Shepherd, 2 World Trade Center CITYIPO - STATE ZIP CODE New York, NY 10048 NAME OF OWNER(If different) BUSINESS TELEPHONE ADDRESS CITY/130 STATE ZIP CODE DESCRIPTION OF ACTION The project will consist of driving four wood piles to support the boat lift, as shown in the application drawings. Please Complete Each Question—Indicate N.A. if not applicable s A. Site Description Physical setting of overall project, both developed"and undeveloped areas. 1. Present land use: ❑Urban ❑Industrial ❑Commercial MResidential (suburban) ❑Rural (non-farm) ❑Forest ❑Agriculture ❑Other 2. Total acreage of project area- 150+/— SF acres APPROXIMATE ACREAGE PRESENTLY AFTER COMPLETION Meadow or Brushland (Non-agricultural) NA acres acres Forested NA acres acres Agricultural (Includes orchards, cropland, pasture, etc.) NA acres acres Wetland (Freshwater or tidal as per Articles 24, 25 of ECL) NA acres acres Water Surface Area 150+/—SF ,acres 150+/—SF acres Unvegetated (Rock, earth or fill) NA acres acres Roads, buildings and other paved surfaces NA acres acres Other (Indicate type) NA acres acres -3. What is predominant soil type(s) on project site? Not Applicable a. Soil drainage: ❑Well drained % of site ❑Moderately well drained % of site ❑Poorly drained % of site b. If any agricultural land is involved, how many acres of soil are classified within soil group 1 through 4 of the NYS Land Classification System? acres. (See 1 NYCRR 370) 4 Are there bedrock outcroppings on project site? ❑Yes ®No a. What is depth to bedrock? (In feet) Z 5. Approximate percentage of proposed project site with slopes. X010% % ❑10-15% % Ell 5% or greater % 6. Is project substantially contiguous to, or contain a building, site, or district, listed on the State or the National Registers of Historic Places? LNYes ❑No 7. Is project substantially contiguous to a site listed on the Register of National Natural Landmarks? ❑Yes CR:No 8. What is the depth of the water table? NA (in feet) 9. Is site located over a primary, principal, or sole source aquifer? ❑Yes (2No 10. Do hunting, fishing or shell fishing opportunities presently exist in the project area? IRYes ❑No 11. Does project site contain any species of plant or animal life that is identified as threatened or endangered? Dyes IRNo According to _ visual inspection; common aquatic shoreline plants. Identify each %pvciv-, --- ---____-- 12. Are there any unique or unusual land forms on the protect site? (i e, cliffs, dunes, other geological formations) ❑Yes I-3No Describe Rocky shorefront and sandy bottom sediments with boulders. 13. Is the project site presently used by the community or neighborhood as an open space or recreation area? Dyes L4No If yes, explain 14. Does the present site include scenic views known to be important to the community? ❑Yes 12 No 15. Streams within or contiguous to project area Not Applicable a. Name of Stream and name of River to which it is tributary 16. Lakes, ponds, wetland areas within or contiguous to protect area Shoreline fringe growth only. a. Name Not Applicable b. Size (In acres) 17. Is the site served by existing public utilities? XJYes ❑No a) If Yes, does sufficient capacity exist to allow connection? Yes ❑No b) If Yes, will improvements be necessary to allow connection? Yes ❑No 18. Is the site located in an agricultural district certified pursuant to Agriculture and Markets Law, Article 25-AA, Section 303 and 304? [:]Yes 'R 19. Is the site located in or substantially contiguous to a Critical Environmental Area designated pursuant to Article 8 of the ECL, and 6 NYCRR 617? ElYes ❑No All of Fishers Island is designated a CEA 20. Has the site ever been used for the disposal of solid or hazardous wastes? ❑Yes ®No 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 2+/— acres. b. Project acreage to be developed: 150+/— acres initially; acres ultimately. c. Project acreage to remain undeveloped NA acres. d. Length of project, in miles: NA (If appropriate) e. If the project is an expansion, indicate percent of expansion proposed 5.5 %; f. Number of off-street parking spaces existing 3-5 ; proposed no change g. Maximum vehicular trips generated per hour NA (upon completion of project)? h. If residential: Number and type of housing units: Not Applicable One Family Two Family Multiple Family Condominium Initially Ultimately i. Dimensions (in feet) of largest proposed structure 10'MLW height; 13 width; 12 length. j. Linear feet of frontage along a public thoroughfare project will occupy is? NA ft. 3 2. How much natural material (i e, rock, earth, etc.) will be removed from the site? None tons/cubic yards 3. Will disturbed areas be reclaimed? ❑Yes ❑No ANN/A a. If yes, for what intended purpose is the site being reclaimed? _ b. Will topsoil he stt�( kpilf-d Im w( lanialum' I IYes I INO c. Will upper subsoil he stot kpilt,tl loi rt-( Iamauo W I IYes I ]No 4. How many acres of vegetation (trees, shrubs, ground covers) will be removed from site? NA acres. 5. Will any mature forest (over 100 years old) or other locally-important vegetation be removed by this project? ❑Yes ®No 6. If single phase project: Anticipated period of construction 1 months, (including demolition). 7. If multi-phased:Not Applicable 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 phases? Dyes ❑No 8. Will blasting occur during construction? Dyes Flo 9. Number of jobs generated: during construction 2 ; after project is complete O 10. Number of jobs eliminated by this project None 11. Will project require relocation of any projects or facilities? Dyes ®No If yes, explain 12. Is surface liquid waste disposal involved? Dyes ZING 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? ❑Yes ®No Type 14. Will surface area of an existing water body increase or decrease by proposal? ❑Yes ®No Explain 15. Is project or any portion of project located in a 100 year flood plain? IlYes ❑No 16. Will the project generate solid waste? []Yes 12No Only left over lumber -in minimal amounts. a. If yes, what is the amount per month tons b. If yes, will an existing solid waste facility be used? ❑Yes ❑No c. If yes, give name location d. Will any wastes not go into a sewage disposal system or into a sanitary landfill? ❑Yes 12 No e. If Yes, explain 17. Will the project involve the disposal of solid waste? 13Y- es ❑No Probably z ton or less of a. If yes, what is the anticipated rate of disposal? tons/monAFrap lumber, one time only. b. If yes, what is the anticipated site life? years. 18. Will project use herbicides or pesticides? ❑Yes :fiNo 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? ®Yes ❑No 21. Will project result in an increase in energy use? Dyes ®No If yes , indicate type(s) 22. If water supply is from wells, indicate pumping-capacity NA gallons/minute. 23. Total anticipated water usage per day NA gallons/day. 24. Does project involve Local, State or Federal funding? ❑Yes ®No If Yes, explain 4 25: Approvals Required: Submittal Type Date City, Town, Villdge Board ICYes C]No Letter Authorization June 20, 1991 see attacheresponse City, Town, Village Planning Board ❑Yes ❑No City, Town Zoning Board ❑Yes ❑No City, County Heath Department ❑Yes ❑No Other Local Agencies []Yes ❑No Other Regional Agencies ❑Yes ❑No State'Agencies ❑Yes ❑No _ Federal Agencies Yes []No Nationwide General Permit June 20, 1991 C. Zoning and Planning Information 1 . Does proposed action involve a planning or zoning decision? LJYes 19N If Yes, indicate decision required ❑zoning amendment ❑zoning variance llspecial ww permit FJsubdivision ❑site plan ❑new/revision of master plan ❑resource management plan FJother 2. What is the zoning classification(s)of the site? Residential 3. What is the maximum potential development of the site if developed as permitted by the present zoning? Single Family Residential 4. What is the proposed zoning of the site? Residential 5. What is the maximum potential development of the site if developed as permitted by the proposed zoning? Single Family Residential 6. Is�the proposed action consistent with the recommended uses in adopted local land use plans? JaYes ❑No 7. What are the predominant land use(s) and zoning classifications within a Y4 mile radius of proposed action? Single Family Residential and a golf course. 8. Is the proposed action compatible with adjoining/surrounding land uses within a '/ mile? , E'es ❑No Y 9. If the proposed action is the subdivision of land, how many lots are proposed? a. What is the minimum lot size proposed? 10. Will proposed action require any authorization(s) for the formation of sewer or water districts? ❑Yes nNo 11 . Will the proposed action create a demand for any community provided services (recreation, education, police, fire protection)? ❑Yes ®No a. If yes, is existing capacity sufficient to handle protected demand? ❑Yes ❑No 12. Will the proposed action result in the generation of tiaff,c significantly above present levels? ❑Yes 30No a. If yes, is the existing road network adequate to handle the additional traffic? ❑Yes ❑No t D. lhformational Details Attach any additional information as may be needed to clarify your protect If there are or may be any adverse imparts associated with your proposal, please discuss such impacts and the measures which you propose to mitigate or avoid'them. E. Verification i certify that the information provided above is true to the best of my knowledge. A Applicant/Sponsor a Lucille Baof l ef7DateA2Y Signature Tale If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment. 5 Hale -95-2B-7(10/90) 91-04-210 June 20, 1991 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 Lucille Balcom 2. Applicant Address c/o Fiduciary Trust, Mr.Francis Shepherd 2 World Trade Center, NY, NY 10048 Project Information 3. Project/Facility Name Install New Boat Lift 4. Project/Facility Location Fishers Island Sound, East Harbor 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 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 The site of the new lift is the dock system for the East Harbor Coast Guard Station Boat House. b. location The Boat House is located on a private road on the north tshore of Fishers ^ Island's east end. - °' Tf,eeboatshouse rias(beenhconv�rt°ecbirito tae bacr n�cb ridge, dam, ruins) d. -approximate age or date of construction Approximate age: 80 years 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 If yes, describe briefly (use attachments if necessary) : Hale - Cont'd 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 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) : The project site was originally disturbed when the dock system was originally built; the proposed work will be similar in nature, although far less in scope. 10. Approximate percentage of proposed project area with slopes: Not Applicable 0-10% % 10-15% % 15% or greater % J e 11. Approximate percentage of proposed project site-with the following drainage characteristics: Not Applicable well drained % moderately weTl cTrained % poorly drained % Prepared by Docko, Inc., Keith B. Neilson, PE Date June 20, 1991 SAAFI.LK/G 10/90 STRUCTURAL-ARCHEOLOGICAL ASSESSMENT FORM (SAAF) PART 2 - DEPARTMENT OF ENVIRONMENTAL CONSERVATION (DEC) COMPLETES Applicant/Project Information 1 . Applicant Name Lucille Balcom 2. Project/Facility Name New Boat Lift 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 x 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? s 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 x 8. Will the proposed action include a physical disturbance of the project area? Yes Minor No At the project site,__the0ground is ten feet under water. Hale - Cont'd 9. Is the slope in the area characteristically less than 15% (unless on limestone/flint escarpments)? Yes x No 10. Is the proposed project area characteristically moderately well or well drained? Yes No x If the answers to 5, 7-10 are yes, an archeological survey should be performed by the applicant. Provide the applicant with a copy of Report Format for Cultural Resource Investigations and list of archeological consultants. 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) x 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 Docko, Inc. , Keith B. Neilson, PE Date June 20, 1991 SAAF2.LK/G 10/90 I of- 2. pa gol.; AI'I'I,1 l'A'1'I ON ('11ECKI,I ST NOTE: APPLICATION MUST LNr�1,IJD1?: X L . STANDAND PORMS - Apl,r op, 10, a :111,I r c•�rl. i on I or 1'�:tori t Shur t Env.i roranrenLa I Assessment F.)rm, SL r uct.ura 1 Assessment. Porm. NOTE: For all projects requirinq Wild, Scenic & Recreational Rivers Permits; ,:and tot commoicial , indu:,t rial or mult- r --resident. ial pro- jec;Ls , stibmr L a long Environmunt.al AssessmenL Porm. $200_2 . APPLICA'T'ION ['Lls: Ruler to enclosed Lee schedule $10 . 00 minimum, Check or Money Order payable Lo NYS DEC. You will be notified of additional fees , if any . NA-.3 . AULhor a ration I et t er t rant t he owner where the appl i cant i s not the owner . X 4 . Staking and labeling of L,h.e seaward/wetland side of the proposed sLrucLure or fil1. area . X 5 . Photographs of t he :,t aked prn je -I- irea mounted on a separate and r labeled page . X 6 . County Tax Map Numbert, : Photo of Wax Bill will suffice . Suffolk : Dist .1000_ Sect . 4 B I k . 4 Lot 15 Nassau: Sect B] k . SUL1)1 uck 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 ] " Lo 100 ' or larger . X 8 . Address of project, location ( t f vacant land; L- el eptaone 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 Structures 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 , _& 1.0 Groins and Jetties 2 , 3 ,_4 , 5, 9 , & 1-0 Filling 1 , 4 , 5 , & 6 KEY: 1 . Stamped Sealed Survey -- 2 . P1oL Plan 3 . Location Map 4 . Sectional View 5 . Wetland Line or Mean High Water , as appropriate 6 . P'i 1 1 and Cl earcuL Area 7 . Sanit-ary System Location 8 . Test Hole and Data 9 . Profile View 10 . Dist.anoes from fixed SLructures NOTE: IP' YOU WTSH CONPYRMATION OP RECEIP'1' OF YOUR APPLICATION, PLEASE SUBMIT A SELF-ADDRESSED, STAMPED POSTCARD. NOTE: THE PERMIT PROCESS TAKES A`1' 1,EAST EIGH`1' ( 8) WEEKS. APPROVEID,AS NOTE® GATE: B.P.# �® Z F=EE: BY: F,OTIFY BUILDING DEPARTMENT AT 765-1802 S AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE ROUGH - FRAMING & PLUMBING INSULATION FINAL - CONSTRUCTION MUST 13E COMPLETE FOR C.O. .ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE N.Y. STATE CONSTRUCTION & ENERGY. 'ODES. NOT RESPONSIBLE FOR . GFSIGN OR CONSTRUCTION ERRORS OCCUPA Cy OR USE IS UNLAWFUL WITHOUT CERTIFICATE OF OCCUPANCY Top P�64M , F/SNE�25 I � ,SO&, soc�N� tiEW ,5oAT t-lFr CILADLE C3EAi�� 6l31� _ .r 7;)oua41N-TYP I — - i��; 147' Ec. 5.8+i I N _ ' MHW EL 2.s fiw PLC TYP. ±' C64SS"'B"'M#4 M(-W EL Oa Pies-IYP Rock- OM ZEDW - Cl. �� CurOFF •'1 SAO-40Y Bo oM .Saga K//Pouc.VEtzs _ rr��,ouc. s I R V Q u i 1 U uy l n u v ■ ■ i v „ v i v IVER o nVIA 007 • I DECK - oo 1 s- �• �Ar TYELy .�� r-N APPRox rM4t IDES r DBn K.� n7 O wIATEQ L/NC-5 - HIAC..L AWNS FAC. ) F'-AN AND )7-'P-OF/Lc N 4 IrV(EtLA� &OAT (-li=r < +�'�; du� ' /N• E{F'15tfER'Sy/SGANDWUND j EA 5T E_ 44 'S�fSc.AND, c w" OF' o; Ur 101� 'SuFFOCx Coc1u��NEw yDI�. igPPLICrgN1-: LUCILL6 8ALGDrI Z.JA.M : J vtis 20, i9q I 7)cx�o, PVC. ���12 6F Z aax.�oN,P6 M�STic ,CT 203 572 6g3q