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HomeMy WebLinkAboutTR-10024A Glenn Goldsmith,President O�I if so Town Town Hall Annex A. Nicholas Krupski,Vice President h 54375 Route 25 P.O. Box 1179 John M. Bredemeyer III Southold,New York 11971 Michael J.Domino G • Q Telephone(631) 765-1892 Greg Williams �0 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE 4-1891C Date: December 6, 2021 THIS CERTIFIES that the installation of an I/A OWTS septic system; . At .440 Sunset Way, Southold Suffolk County Tax Map #1000-91-1-8 Conforms to,the application for a-Tru'stees Permit heretofore fled in this office Dated November 5; 2021 oursuant to which"Trustees Administrative•Permit,#10024A Dated November 17, 2021,was issued-and conforms to,all - f the requirements and conditions of the applicable provisions,of law. The project for which this certificate is being issued is for the installation of an UA OWTS septic system. The certificate is issued to Michael Jensen 8c Donna La Manque owners of the aforesaid property. 4 - Authorized Signature Glenn-Goldsmith,-President -- -- OF SU�jy - -- - -- Town Hall-Annex--- -------- - - -- V� 54375 Route 25 A. Nicholas Krupski,Vice President P.O.Box 1179 John M. Bredemeyer III Southold, New York 11971 Michael J.Domino G Q Telephone(631) 765-1892 Greg Williams �O Fax(631) 765-6641 UNT`I,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION. . � r � � l�, C INSPECTED BY. C12/-t LA.,k-�� / Ch. 275 -Ch. 111 INSPECTION_SCHEDULE Pre-construction, haybale-line/silt, boom/silt curtain 1St day of construction % constructed Project complete, compliance inspection COMMENTS: CERTIFICATE OF COMPLIANCE: Glenn Goldsmith,President �0� so(/Ty Town Hall Annex A. Nicholas Krupski,Vice President ,`o ��� 54375 Route 25 III P.O. Box 11 79 John M. Bredemeer Y � � Southold, New York 11971 Michael J.Domino G Q Telephone(631) 765-1892 Greg Williams Fax(631) 765-6641 (4UNT`1,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD SOUTHOLD TOWN BOARD OF TRUSTEES YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72•HOURS PRIOR TO COMMENCEMENT OF THE ACTIVITIES CHECKED OFF BELOW INSPECTION SCHEDULE Pre=construction';`>hay�bale lime/silt broom/silt curtain • t'day of„-don&ifion %.co'n.8 u0e - 'Wh6hi pr'ojeet complete,-call for compliance-inspection;. Glenn Goldsmith,President \\OF SUUTy� Town Hall Annex A. Nicholas Krupski,Vice President 54375 Route 25 P.O. Box 1179 John M. Bredemeyer III Southold,New York 11971 Michael J.Domino G • Q Telephone(631) 765-1892 Greg Williams Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10024A Date of Receipt of Application: November 5, 2021 Applicant: Michael Jensen & Donna La Manque SCTM#: 1000-91-1-9 Project Location: 4440 Sunset Way, Southold Date of Resolution/Issuance: November 17; 2021 "Date'of Expiration: November 17, 2023 Reviewed by: Greg Williams, Trustee Project Description: As-built installation of an I/A OWTS septic system.. Findings: The project meets all the requirements for issuance of•an Administrative Permit set forth in Chapter 275 of the Southold.Town Code. The issuance-of an Administrative Permit'allows for the operations as indicated on the site plan prepared by Thomas A. O'Dwyer PE., dated November 18, 2020, and stamped approved'on November 17,2021. Special'Conditions: None Inspections: Final Inspection. If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code, a Wetland Permit will be, required. This is not a determination from any other agency. ,�Z 4"_ - Glenn Goldsmith, President Board of Trustees A5-bUILT 517E INFORMWIlON l -5J`FOLY.COUNTY TAX MAP ID 1000-0 1-1-8 � -EX STING 4 5EDFOO F HOME qS S P,OPO5ED CON5TRUCTION c� a a :saw -LO, AREA O 33 ACRES 14 -PROPERTY LOCATED A- 440 SUNSET 144 -50UTHOLD,TOwf f OF 5OL'THOLD,SUFFOLK COUNTY,NEW YORE; (' �j Cee &i i= " -SURVEY PROVIDED B JOHiV C FREERS LAND SURVErOR (y��+0y�s, 4 yds SURVEYED 07-30-2004 UPDATED 04-27-2005 n ^' -VERTICAL DATUMS-NAV,. I S86 DATUM c �" EXIStIf 1 g �J� 5UPFACE WATER 5H01+.'N ON 5UeV=1%51,E PLAN. , -ALL HOIAE5 WITrIN 1 50LF ARE CONNECTED TO PUBLIC WATER GENERAL NOTES ��b�Sl � LAND N!F OaF FRANK,MANGANO` EXISTING 4-BEDROOM HOME WITH FAILING SANITARY BLOCY.CE55POOL(5) + _ - 2 EMERGENCY UA OWT5 5ANITARY REPLACEMiEN i DESIGN-SUFFOL:COUNTY SIP GRANT PROJECTC✓`F� y�, �E _- IMPROVED-PUBLIC WATER- _ ,� y 3 SITE PLAN AND P•EFERENCE ELEVATIONS TO BE U5ED FOP.EMERGENC` VA OWT5 SANITAR: SYSTEM CONS-[RUCTION ONLY EXACT PROPERTY STRUCTURE FOOTPRINT PROPERTY BOUNDARIES.TANK Lot- t OVERHEAD AND L1TILiTY"LOCATIONS AND ELEVATIONS ARE NOT GUARANTEED { } ELECTRICAL 4 ON51TE UTILITY MARK-OUTS TO BE PERFORMED BY CONTRACTOR.PRIOR TO PERFOPf/dNG SITE y SERVICE WORK ' 139- � �� 5 SOIL TE5T HOLE DATA PRODDED FOR NEIGHBORHOOD HOME LOCATED AT 2555 CEDAR BEACH � � '84� y Y _ ROAD.50UTHOLD N; R10-13-0025P SAND MATERIAL W45 FOUND 3 O'5ELOW'GRADE GROUNDWATER%WA5 FOUND AT EL O 5'+!- 1���C � � r SS S s 6 EXISTING 5ANITARY BLOCK CESSPOOL_TO BE PUMPED AND PPP114OVED OR ABANDONED A_. W V NECE55ARY PER 5CDr15 5TANDARD5 U X 7 THE HYDROACTiON TANK 15 ANTICIPATED TO 5E IN GROUNDWATER THE CONTRACTOR 15 RESPONSIBLE TO DEWATER AS NECE55ARY AND INSTALL 5CDH5 APPROVED ANTI-BUOYANCY � r _ DEADMAN FOR PRECA5T CONCRETE HYDROACTION TANK W el-5.9 PP.OP05E_I/A 01475 SEPTIC SYSTEM FOP,UP TO 4 BEDROOM RESIDENCE p Ff ptC1t3 i Q ONEC;PRECAST HYDROACTION MODEL AN-500C VA O%MT5 w;ANTI-BUOYANCY,TRAFFIC RATED Q _ iJi{{j t{� i 3; tv•+ POSERS AND CASTINGS TO GRADE W S3� i ( L44r 2. ONE HYDROACTION BLOWER VENT AND CONTROL ASSEMBLE 11 _ _(-t _ _ ' 3 ONE ORENCO SIMPLEX PUMP STATION AND PF3005 PUMP z t t HOT c4 'F 4.A/0(2)25 5 LF ROWS OF I-FOOT EFFECTIVE DEPTH TRAFFIC RAT,ED LEACHING GALE; P5D z W s^ A r LEACHING TRENCHES.TOTAL OF SIX(G) 1-FOOT LEACHING:GALLEYS uJ (n 5 APPPOYIMATELY 30 YARDS OF CLEAN SAND FILL FOR PSU LEACHING TRENCHES (j) Z J `t r, X e$=5,3 1 k: f'F'C3t: e Hou5c L' PUBLIC 0 GENERAL SASiTART 5Y,EM AND IN5TALLNTIONaJCTES a`\ a VA OW'I_ SEP,IC 5 STEM DESIGNED FOR U' ,O 4 BEDROOM NOME,ER 5U=FOU" COUN T V W (n O X @j �,I t t X Ej= � � t �j; � �i�, �LQQ°� EL'-8,2' - � � � WATER DEPARTMErJT OF rEALTH SiA1dD-PD (SCDIiS) I 4 EXISTING SEWER INVERT TO BE RELOCATE SERVICE 2 CONTRACTOR 15 RE5PON515LE FOR DEAVATERING A5 NECE55AR; GROUNDWATER ANTICIPATED _ r 1 0t Y G TO BE 4 +/-BELOW!NATIVL-GRADE DEPENDING OK TIDAL CONDITIONS CONTR4CTOR TO TAPE W d BY LICENSED PLUMBING CONTRACTOR. - j 1 e _ ALL NECESSARY 5TE?5 TO PROPERLY INSTALL TAN!S?ND DEADP•lAl:If:HIGH GROUNDWATER Q U) EXISTING BLOCK CESSPOOL TO BE PUMPE - EXIS FFE 82 _ CONDITIONS IMPORT OF 5r ND OR P`_A GRAVEL MAY BE REQUIRED = AND ABANDONED PER SCDHS STANDARDS PROP IE 5T± 3 5AN1rAcY GRAM I'DRAiN PIPE INVERT To 5E RELOCATED AND BE 4-INCH CAST IRON AT C) WOOD DECK EXIS GRADE62 t P OPA E ' FOUNDATION PENETRATION AND 4-INC7 PVC 5DR35 000/IV5TREAM OF FOUNDATION S iw v 'r Y } d f T 1 S / �+ T { _ 4 -^ ' _ -N 1=7.2 LA OWT5..HALL BE TESTED FOR WATER TIGHTNESS PRIOR TO ARRIV II.'G ONSITE U51NG HE 3 oV - METHOD APPROVED BY MANUFACTURER = _ EXISTING PROPANE TANK. L J ? 5 THE DE51GN ENGINEER SHALL OVERSEE THE O%AT5 DUPING EMERGENCY INSTALLATION AND _10' -L; MAINTAIN 10'SETBACK TO SYSTEM,STARTUP. t t SANITARY STRUCTURES. T �LkQ 1r - � 6 THE Ov:75 INSTALLER SHALL BE LICENSED, HOLD AN ENDORSEMENT FROM SCDHS AND BE A 60'fHYDROACTION AU T hORIZED I11J5TALLER LZ is - g �' y � 5'MIN ` 7 THT5 E 04. 1N-9TALLEP 5HALL PFG)STER THE ON5T 51TE TREAThAE1•4T 5YEPV.LVITH SCDH5 THE r_ X Ie 3= t-j4 OJ _ 8 DE51C-N EJGI"JEER SHALL PP.OVID�CERTIFICATION DOCUMENT5 Ass REQUIRED BY 5CDH5 EXISTING LEACHING SETBACK TO LG LG EL c B 8 AN OPERATION aldD MIAL'.TENAtJC ,CONTRACT BETNJEEIJ THE MAIIJTENANCE PROVIDER AND THE Z SURFACE WATER 60 LF g PROPERTY OWNER 5`IALL BE PROVIDED TO 5CDH5 FOR V4 014 5 ANtD PSD SYSTEM W i t& ,$ IX( j 9 A GARBAGE GRINDER 5HALL NOT BE IN5TALLED LIP5TREA,M OF THE OtYr5 X e j= X ej- .� 4` LG LG LG i 10 WATER SOFTENER BACs Vi FSH 5114LL NOT BE FLUSHED TO PPOP05ED 5EPTIC SYSTEM W n --- P n 115't 1 CONTPACTOR 15 RE5PON515LE TO OBTAIN TOWN 5UILDING PERMITS A5 NECE55ARY PRIOR TO Uco INSTALLATION OF THE PROPOSED SEPTIC SYSTEM Q ,t- M U? c-3 ;6 PROPOSED LEACHING SETBACK TO� ` ?^` _ ; W ~ o SURFACE WATER 115 LF { C r,FrJ c V;CF• P,f, 4`L^IfIN1 _ Z U z :�,,I: o "-m.i,n i;[ a: I,n•n�. H _ ...,r_„ w ~ e.t' - D K 6:53 o-: P.e.-n�ia,• :, ••It'-,tr 'r_,. Lu —I LFJ X el-7- =`` Z I�I W U)i ®POD &YROACTION - PROPOSED 2X 4.75'WIDTH BY 25 5'LENGTH 4EACHING GALLEY PSD W wPP� _- TRENCHES WITH 1-FOOT EFFECTIVE DEPTHIIAND H-20 TRAFFIC RATEDo ¢ONTROL PANEL, LAND N/F OF THOMAS SIMON COVERS. TOTAL OF SIX(6)LEACHING GALLED Z _ ¢p COMPRESSOR SSEMBLY AND VENT - IMPROVED-PUBLIC WATER W a 'BOAR®`OF IRUS ICAL' ACTION' _ -20 AMPS - TO\grOp I ®F,COI IT(�Q PUMP TATION: 20 AMPS ' p �P`i SOIL CONDITIONS.TEST HOLE FROM FOIL OF NEIGH80RIN PROPERTY:R10-13-0020NE W V V Y4 i V V V 1� ED PRECAST 0-6"LOAM,0 5'-3'BROWN CLAYEY SAND.3'-7'BROWN&PALE�3ROWN MEDIUM SAND{SP), { - ODEL AN-500C I!A _ I GROUNDWATER AT EL 0.5',7'-13'WATER IN PALE BROWN FINE TO MEDIUM SAND �d �. Ea J (' W ®ATE OWLS W/ANTI-B Y' C E h PSD LEACHING TRENCHES DESIGNED FOR 1-5 MIN/INCH PERCOLATION RATE AND 4 DATE:11-18-2020 26Z�PROPOSED OR NCOCO SIMPLEX PUMP (� MAN AND PF:3005f BEDROOM HOME.CONTRACTOR TO EXCAVATE DOWN TO SP SAND AND BACKFILL WITH I ;1 P171w " } CLEAN SAND FILL AS OF CLEAN SAND FILL.NECESSARY TO BASE OF PSD TRENCH APPROXIMATELY 30 YARDS SCALE: 1:20 DESIGNER:TAO �f ; NOV 5 2021 1'•. PSD LEACHING CALCULATION. SHEET: i FUJI CEN-5 CATEGORY 1 IIA OWTS otj;hola -l'OWPI 3 GPD/SF AT 1-5 MINUTE PERCOLATION RATE SANITARY SFE PLAN `_3,� C{ OF r.!Stees LEACHING GALLEYS 4 8 SF/LF,USE MAX 3 25 SF/LF Fri 440 GPD 13 0 GPD/SF/3 25 SF/LF=45 12 LF SCALE= 1 :20 USE 2X25.5 LF LEACHING GALLEY TRENCHES TOTAL OF 51 LF>45.12 LF i Glenn G(' `t ith, President �SUFF4i�.Co� Town Hall Annex A. Nic�iuias Krupski, Vice-President Akz�ki� y,,�Q 54375 Route 25 John M. Bredemeyer, III o =` P.O. Box 1179 Michael J. Domino oSouthold, NY 11971 *1 ©! Greg Williams Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: 2 Completed infield by: MICHAEL JENSEN & DONNA LA MANQUE request an Administrative Permit for an as-built - installation of an I/A OWTS septic,system. Located: 440 Sunset Way, Southold. SCTM#: 1000-91- 1-8 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=4 Setback Waiver Required 1. Residence: 100 feet 2. Driveway: 50 feet 3. Sanitary Leaching Pool (cesspool): 100 feet 4. Septic Tank: 75 feet ,5. Swimming Pool and related structures: 50 feet 6. Landscaping or gardening: 50 feet 7. Placement of C&D material: 100 feet TOP OF BLUFF: 1. Residence: 100 feet 2. Driveway: 100 feet 3. Sanitary leaching pool (cesspool) 100 feet: 4. Swimming pool and related structures: 100 feet Public Notice of Hearing Card Posted: Y / N Ch. 275 Ch. 111 SEQRA Type: 1 II Unlisted Action Type of Application: Pre-Submission Administrative Amendment Wetland Coastal Erosion Emergency Violation Non-Jurisdiction Survey <_ 5 years: Y/N Wetland Line by: C.E.H.A. Line Additional information/suggested modifications/conditions/need for outside review/consultant/application c pletene /comments/standards: I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: J. edemeyer M. Domino G. Goldsmith N. Krupski Williams Other COUNTY OF SUFFOLK STEVEN BELLONE SUFFOLK COUNTY EXECUTIVE DEPARTMENT OF HEALTH SERVICES GREGSON H. PIGOTT, MD,MPH Commissioner SANITARY REPLACEMENT/RETROFIT ACKNOWLEDGEMENT Letter in Lieu of Inspector Certification Prepared by: Emily Efstration Environmental Analyst Date: January 11, 2021 Subject: Donna LaManque and Michael Jensen (SIP Appl. ID 4242) Address: 440 Sunset Way, SOUTHOLD,NY 11971 The Suffolk County Department of Health Services Office of Wastewater Management has verified a catastrophic failure of the preexisting sewage disposal system on the above referenced property and has satisfactorily completed a sanitary system replacement/retrofit to an I/A OWTS. The replacement/ retrofit to an I/A OWTS was performed in accordance with the Department's Replacement and Retrofit Standards and reported electronically to the Department through the Septic Haulers Information Portal (SHIP) which launched on August 5, 2019. If you have any questions or comments regarding this I/A OWTS installation please call 631-852-5459. Sincerely, kkk(p � REPLACEMENTOF FAILED SANITARY SYSTEM W ITH AN I/AOWTS HAS BEEN COMPLETED Justin P Jobin Reclaim u r Water Environmental Projects Coordinator www mckirmumvatcr info 10 DIVISION OF ENVIRONMENTAL QUALITY PublicHeaIth 360 Yaphank Avenue, Suite 2B,Yaphank NY 11980(631) 852-5750 Fax(631) 852-5760 Prevent Promote P_-1 Suffolk County Department of Health Ser-,kes Office of Wastewater Management 360 Yaphank Avenue,Suite 2C Yaphank,New York 11980 (631)852-5700 OR HeaitliWWM(ddsuffolkcounryny.gov CERTIFICATION OF SEWAGE DISPOSAL SYSTEM BY INSTALLER Leave blank any items that are not applicable to the installation. **A sewage disposal system sketch along with location measurements from at least two building corners must be provided on the back,or on a separate sheet and attached to this form** I Health Department Reference Number: SHIP ID 20-01145 Suffolk Tax Map k: Dist: 1000 Sect(s) 91 Blk(s) I Lot(s) 8 Proiect Name or Address: :440Sunset Wav,Southold NY 11971 ApplicanUHomeowner Name: Nlichael Jensen and Donna Lamanauc Date of System Installation: , -V1 UA 06VTS TREATTrIrIENT UNIT SEPTIC TANK Make and Model: / d-t ,`per APS-00 C Volume(gallons): Rated Daily Treatmeht Capacity(gallons): 5'5`0 Material: [] Concrete, [ J Fiberglass/Plastic Material: [kC'oncrete [ ] Fiberglass/Plastic Shape: [ ] Rectangular, [ ] Cylindrical rr Top: [ ] Slab, [ ] Traffic Slab, [ ] Dome DISTRIBUTION LEACHING POOLS(f applicable) Name of Tank Manufacturer: Number of Pools ()r�C� 0L) �j I.-\ Diameter and Effective Depth GREASE TRAP Top: [ ] Slab [ ] Traffic Slab [ ] Dome Volume (gallons). Name of Precast Manufacturer: Material: [ ] Concrete, [] Fiberglass/Plastic Top: [ J Slab. []Traffic Slab, [J Dome LEACHING POOLS/GALLEYS Name of Tank ivlanufacturer: Total Number of Pools/Galleys Diameter/Dimensions and Effective Depth OTHER LEACHING STRUCTURES Top: [ ] Slab Traffic Slab [ ] Dome Make and Model (if applicable): [ ] N/A / n � Name of Precast Manufacturer: L4 Zl Total Linear Feet of Leaching Structure(s):CO VERS AND LIDS Installed covers comply with current standards (secondary safety device installed if cover weight less than 60lbs.) [ Yes [ ] N/A I hereby certify that the subsurface sewage disp sal system components described herein,have been installed by me in accordance with the approved plans and/or standards of t Suffolk, ounty Department of Health Services as well as any other municipal agency requirements;and any and all mechanical/electrical c p ficnts ave brceted and arc operational in accordance with manufactu7rer's recommendations installer's Name: John Craddell -Company Name: A&A Sewer and Drain Maintenance Inc Phone 631-849-1599 -Company Address: 12 Whitewood Drive Rocky Point NY 11775 Consumer Affairs Liquid Waste License Number and endorsement(s): 54440LW **IN ADDITION TO ABOVE, COMPLETE BELOW FOR SAIVI T AR Y REPLACEIbIE,VT/RETROFIT ONLY: In addition to the above information, I hereby ify that this OWTS replacement or retrofit meets the Department Replacement/Retrofit Standards, and that other alternativ s are i a ironmentaily feasible. I also certify that this M%7S replacement or retrofit installation represents an improvement to exla posal ys n ondittons ^staller s Si�anatlu e � jl Installer's Name. Johni�andell THIS DOCUMENT MUST CONTAIN ORIGIN kL SIGNATURES FROM THF.INSTM-LER WWII-078 (06/19) (qqo �ua► - S �ns�l�ec� -�a.r►, k l� aC�.l � - AI cL-o Ac & , ANScoc, f r CIO ,g j(or qdr ®• _ 3 3A-z3q' 4p �ss tr� nowt►ec,�— �Ow d Now doffs A A&A SEWER AND DRAIN �G g 59 MAIN°TENAlNCE,-SNC-. (516)491-8733 AASEWERANDDRAINMAINTENANCE.COM -, AASEWERDRAIN IL.C-0-m � t Suffolk County Department of Health Services Office of Wastewater Management 360 Vaphank Avenue, Suite 2C, Yaphank, New York 11980 (631) 852-5700 OR HeslthWWMna,suffolkcountyny.gov CERTIFICATION OF CONSTRUCTED WORKS BY DESIGN PROFESSIONAL Health Department Reference Number __ 0 �:-\___> -I;z C� —G k \L\5 Suffolk Tax Map# Dist 1000 Sect(s)_91 Blk(s)_I _ Lot(s)__- Project Name/Address y'4() SuNsET V*y SovTtiot_O Ny 1091 Appltcant/Propenv O%vner Name, M i c H NEI_ —1 NS FN ITEMS BEING CERTIFIED (Check all that apply) ( [ Community Sewer Lines and/or Community Sewer Collection System Components [ ) Retaining Walls(installed as part of the sewage disposal system) [ [,Sewage Pump Station/Valve Chamber ( Subsurface Sewage Disposal System and all Related Components(Septic tank,grease trap,kachtng Systerrn,l/A OWI S,Lk i If Appficabic- I/A OWTS Manufactwe r- HysAVA-41'10r✓ Model- Alvc—SOO [ j Sewage Treatment Plant and all Related Components [ )Water Supply Components ( ) Abandonment of Pre-existing Sewage Disposal System Components [ j Abandonment of Pre-existing Water Supply Components [VfOther 0,*QQ1ce Pumf rrkrroti/ *N# cNA147r 6*"Cy drP t."fttft s9l5rrp'1 As the Licensed Professional Engineer or Architect, I or qualified personnel under my direct supervision, have inspected the work specified above in accordance with the New York State Education La%N.and(check one) [ jV I hereby certify that all material and work conforms to approved plans and permit conditions, and/or standards issued pursuant to the Suffolk County Sanitary Code. (Attach any inspection or test reports required br the Department.) [ I 1 hereby certify that all material and work conforms to approved plans and permit conditions, and/or sLvidards issued pursuant to the Suffolk County Sanitary Code, except as described in my attached addendum(Also attach any inspection or test reports required by the Department.) INDICATE BELOW IF THIS PROJECT INVOLVED THE BEST-FIT REPLACEMENT/RETROFIT OF AN EXISTING SEWAGE DISPOSAL SYSTEM [ [ I hereby certify that this sewage disposal system installation has been perfornied as a Bcst-Fit Replaccinent/Retrofit.and conforms with the appropriate Standards to the greatest extent possible, and that other alternatives am not environmentally feasible. I also centfy that the protection of public health and the environment was given priority over all other considerations,and this OWTS installation represents an improvement to existing sewage disposal conditions Engineer's/Architect'signature, Print Name °H�� 0 �'� j?E N t—(z--2�Zt License Number: 1991f73 _ CO D O,p� m � v When inspections are required,this certification shall not b tt is by personnel of the Department. THIS DOCUMENT MUST CONT A TURE FES SO WWII-073 (05/19) A5-BUILT SITE INFORMATION -5UFFOLP,COUNTY TAX MAP ID 1000-SI-1-5 �t lSr4yt p. •, -EX;STING 4 5EDPOOM HCME NO PPOP05ED CON5TRUCN014 -LOT AREA.O 33 ACRE5, 14 !95 5F -PROPERTY LOCLTED AT 4A0 5UNSE T WAY v -5OUTI SOLD,TOWN OF 5OUTHOLD,5UFFOLK COUNTI',NEW YORY, l' p 5UP.VEY PROVIDED ByJOhN C.E11LtR5 LAND SURVEYOR —` 5LIRVEYED 07-30-2004 UPDATE 04-27 2005 V_ -VERTICAL DATUM-NAVQ 1988 DATUM - ! - Existing 5UPFACE WATER 511011`14 ON 5URVEY/51TE PLAID. �k 6_Q�` ��� -ALL HOIAF_5 WITHIN 1 SOLE ARE CONNECTED TO PUBLIC WATER ��.� �-4$T�^` ' J�' GENERALNOTEShaeSgV� LAND N/F OF NK MANGANO` EXI5TING 4-BEDROOM nOME WITH FAILING 5ANITARY BLOCK.CE55POOL(5) 4rbEM 2 EMERGF:NCY I/A ONT5 5ANIThRY REPLACEMENT DESIGN-5UFFOL:COUNTY 51P GRANT PROJECT - �'L C' 1 - F F ^Y r_ IMPR_ O_ VED-PUBLIC V1yATER ,_ � 3 SITE PLAN A{JD P.EFEPE�J„ ELE1 AI IONS TO BE USED OP.EA�ERGE,J�„ LA jJ1Mi5 SANITAR. 5f5TEM " ? '' CON5 T RUCTION ONLY.EXACT PROPERTY STRUCTURE FOOTPRINT.PROPERTY 5OUNDARIE5•TANK OVERHEAD AND UTILI l'LOCATIONS AND ELEVATiOi 15 ARE NOT GUARANTEED ^ m L'Jy §F { ELECTRICAL 4 ON51TE UTILITY MARK-OUTS TC BE PERPOPMED BY CONTRACTOR PRIOR TO PERF0 A NG SITE ' s SERVICE WORK 3 1 .c-i ;R � -` 5 SOIL TEST HOLE DATA PROVIDED FOR NEIGHBORHOOD HOME LOCATED AT 2855 CEDAR BEACH y - y ROAQ. OUTHOLD NY.RIO-13-002 Sr'SAND MATERIhL 4VA5 FOUINQ 3 O'5ELOW GRADE aT ; gg K GROUNDI WATER tA'A5 FOUND AT EL O 5' -� cls I 6 EXISTING 5AIJITAP.Y BLOCK CE55FOO 5 TO BE PUMPED AND REMOVED OR ABANDONED AS w -Z _ y i IJECE55ARY PER 5CDH5 STANDARDS t rvr �-E- 7"THE HYDROACTION TANK ;S �NTICIPATEQ TO BE IN GROUNDWATER THE CONTRACTOR 15 V I - X L' 6; ( RE5PON515LE TO DEWATER A5 NECE55AR,(AND INSTALL 5CDH5 APPROVED ANTI-BUOYANCY z { - X_ eI=6." t _ - ' r DEADMAN FOR PRECA5T CONCRETE HYDR&%,CTION TANK W f 15`�Ot> a". el-5-19 PROP05ED I/A OWT5 SEPTIC 5Y5TEM FOP UP TO 4 BEDROOM RE5IDENCE f� , a)'• a `� + I ONE(I)FRECA5T HYDROACTION I�AODEL AN-500C VA OWT5 N/I ANTI-5UOYANCY,TRAFFIC RATED (f� Q a .tc,.0 . ' PJ5ER5 AND CA5TING5 TO GRADE W ' 1 2" 014E HYDROACTION BLOWER VENT AND CONTROL A55EM5LY ? 4 'S y� 3 014E ORENCO 5IMPLEX PUMP STATION AND PF3OO5 PUTAP. z 4.TsNO(2)25.5 LF ROW5 OF I-FOOT EFFECTIVE DEPTH TRAFFIC RATED LEACHING GALLEY P5D uj Y, el-6, nis 'L " �`�-t ry " _ LEAChING TRENCHE5,TOTAL OF 51X(6) I-FOOT LEACHING GALLEY5 W U) Q € P - 5 APPROXIMATELY 30 YARD5 OF CLEAN SAND FILL FOR FSP LEAChING TFENCHE5 (f) Z J ILD e 3 _ D I GE14EPAL SANITARY S'5TEh/AND INSTALLATION NOTF5 W � 0 t'f Qr(�S HOVE F 5 PUBLIC S v -F =T PER e n�• J „q .0 s � (�(`�.� �� ' _ t X e i= WATER i UA WT_ SEPTIG 5,AI�M Dr_5 GI4ED FOR UFTO 4 BEDROOM HOME r�P St1`FOU:COUNTY (� _ / 6� OEPARTMIENT OF HEALTH 5TANDLPQS(5CDH5; - O F- 't zr SERVICE 2 CONTRACTOR 15 RE5P01451BLE FOR DEAVATERING A5 NECE55AR; GROUNDWATER ANTICIPATED -I d - EXISTING SEWER INVERT TO BE RELOCATE ( n" I ` TO BE 4 +;-BELOW NATIVE GRADE DEFENDING ON TIDAL CONDITIONS CONTRACTOR T.O TAYE W -�t BY LICENSED PLUMBING CONTRACTOR. 7 t ALL NECESSARY 5 T EP5 TO PROPERLY 11N5TALL TANi',5 AND DEADMAN IN HIGH GROUNDWATER Q EXISTING BLOCK CESSPOOL TO BE PUMPE - EXIS FFE.82 v CONDITIONS IMPORT OF 5AND OR PEA GRAVEL MAY BE REQUIRED = AND ABANDONED PER SCDHS STANDARDS. PROP IE 5.2't C DECK e� 3 5ANITAKY GR4VIT1'DRAIN PIPE INVERT TO BE RELOCATED AND BE A-INCH CA5T IROI I AT 0 WOOD EXIS GRADE62't a �sr 7} P OPA E �e FOUNDATION PENETRATION AND 4INCH PVC 5DR35 DOWN5TKEAM OF FOUNDATION X L.1=7.2 4 V4 OWT5 5HALL BE TESTED FOR WATER TIGHTNE55 PRIOR TO AP.RIVING ONSITE USING THE IS - - - - METHOD APPROVED BY MANUFACTURER i S - r { EXISTING PROPANE TANK. s L F F THE DE5IGIN ENGINEER 5hALL O ER51fP THE OWT5 DUPING EMERGENCY M5TALLATION AND �10 MAINTAIN 10'SETBACK TO SYSTEI`A 5TARTUP SANITARY STRUCTURES. G T;IE'OWT5 II45TALLER 5hALL BE UCEN5ED, HOLD AIJ ENDOR5EMENT FROM 5CDY5 AND BE A r 60'f _ _ HYDROACTIOPJ AUTrIOR!%ED IN5TALLEP. Q 0 5'IAN7 THE Ov�T5 IN5TALLEP 5h AL.PEGySTER T HE ON51 i E TREATMENT 5Y5TEM WITH 5CDH5 THE R-* 8' DE5IGIJ ENGINEER 5HALL PROVIDE CERTIFICATION DOCUMENTS Ate`•REQUIRED BY 5CDH5 ' EXISTING LEACHING SETBACK TOLc LG Lis= B 8 AN OPERATION AND IViAIPTENA!4G 1 CNTFACT B-FTWVEE14 THE IJ,A'NTENANCE PROVIDER AND THE z ! SURFACE WATER 60 LF z 3 PROPERTY OWNER 5hALL BE FROVI DED TO 5CDH5 POR ii P,OW'i 5 AND P5D SYSTEM W el-5.2 Q j= ,p x •c 9 A GARBAGE GRINDER 5HALL NOT BE IN5TALLED UP5TREAM OF THE OWT5 2 Q- i I C WATER 5OFTENER BACYWF.SH 5111-\U-NOT BE FLUSHED TO PROPOSED 5EPTIC SYSTEM W 4 115'± LG LG LG COt TRACTOR 15 RE5PON515LE TO OBTAIN TOWN 5UILDING FEP,MIT5 A5 NECE55ARY PRIOR TO U o0 INSTALLATION OF THE PROPO5ED 5EFTIC 5Y5TEIA Q PROPOSED LEACHING SETBACK TO r _ u• ��_; D -r ,;. ^V nr•r. - 'illNr U' Z ^� SURFACE WATER 115 LF >,FP=_ rr, W O z r _ ��F�y yG�j A P.�sQ �r � _-PL`. r:u! _ ..".t tF.":a•i,t_,i _r N � W W W Y jI x ����. g Jl ^:C^ tl P2�Lt',:Jrii LC•l*TI i��•"' C T- � � Lj ^t, -,.IS':i SCC{`;E:P A71=W "- • iTr,n q; x el-7- c:_c=.t:c:te,..-�..F, r; ,e.,-n:• I— z F- P a,LL-'N.Ft.�,,, ,•`.I� Z LLj �'W S-.CT,<:-'"•I�'+T`F ✓•-a A\- z W /D � 5` Cn - R - PROPOSED 2X 4 75'WIDTH'BY 25.5'LENGTH EACHING GALLEY PSD Wx ¢ LAND N/F OF THOMAS SIMON TRENCHES WITH 1-FOOT EFFECTIVE DEPTH I ND H-20 TRAFFIC RATED U D o ( HYDROACTION CONTROL PANEL, COVERS. TOTAL OF SIX(6)LEACHING GAL=,. z = ¢p COMPRESSOR ASSEMBLY AND VENT o ELECTRICAL- - IMPROVED-PUBLIC WATER W HYDROACTION: 20 AMPS - ORENCO PUMP STATION: 20 AMPS L� rG SOIL CONDITIONS.TEST HOLE FROM FOIL OF NEIGHBORING PROPERTY.R10-13-002ONE __ - W ? PROPOSED PRECAST 0-6"LOAM,0 5'-3'BROWN CLAYEY SAND 3•-7'BROWN 8 PALE\ROWN MEDIUM SAND{SP) {{ T ;i - HYDROACTION MODEL AN-500C I/A _ t GROUNDWATER AT EL 0.5',T-13'WATER IN PALE BROWN FINE TO MEDIUM SAND. i x 11 W OWTS W/ANTI-BUt9YANCY p� �1:_, - DATE 11-18-2020 Eiji PSD LEACHING TRENCHES DESIGNED FOR 1-5 MIN/INCH PERC t ATION RATE AND 4 PROPOSED ORENCO SIMPLEX PUMP i STATION W/DEADMAN AND PF:3005 f I BEDROOM HOME CONTRACTOR TO EXCAVATE DOWN TO SP SAND AND BACKFILL WITH ' = PUMP P'1 I E } I I CLEAN SAND FILL AS NECESSARY TO BASE OF PSD TRENCH.APPROXIMATELY 30 YARDS SCALE: 1:20 NOVC '/t OF CLEAN SAND FILL DESIGNER:TAO V V J 2021 Cr" SHEET: PSD LEACHING CALCULATION FUJI CEN-5 CATEGORY 1 I/A OWTS �O~ 3 GPD/SF AT 1-5 MINUTE PERCOLATION RATE hold, 'tOVJi1 SAN ITALY SITE PLAN )%!Iri O(if:,IStees LEACHINGGALLEYS4,8SF/LF,USEMAX325SF/LF 440 GPD 13.0 GPD/SF/3 25 SF/LF=45 12 LF SCALE== 1 :20 USE 2X25.5 LF LEACHING GALLEY TRENCHES,TOTAL OF 51 LF>45 12 LF I VTFdi 4 M X3 ��,_.A JN 1 y - ��1. �:. • r ti t , '•`� � u o ( � = -,� ''yam/• '' A N L t-a Jensen Sanitary System Upgrade 440 Sunset Way, Southold z 3 n 8 EACH RD. i 0')ITPAI,E f�CN s w_M r� ' L n As c _ Q� .......... ......................... 093 T, L t) ti w i! 09 t October 19, 2021 1:4,514 0 0.03 0.06 0.11 mi 0 0.04 0.09 0.18 km NYS ITS GIS Program Office,Westchester County GIS Real Property Tax Service Agency Copyright© The information contained in this webpage is the exclusive property of the County of Suffolk.The County of Suffolk grants the user a non-exclusive,non-transferable license to use the Tax Maps and/or Product as defined in your License Agreement. N CELLAR , K� COUNTY OF SUFFOLK 9� Rgonq s o o..nw.ray..M OFFICE LOCATION: MAILING ADDRESS: Town Hall Annex �" ' � h ,��, P.O. Box 1179 54375 State Route 25 �� �� 7 Southold,NY 11971 (cor.Main Rd. &Youngs Ave.) Southold, NYx Telephone: 631 765-1938 www.southoldtownny.gov ` COIL x x PLANNING BOARD OFFICE TOWN OF SOUTHOLD MEMORANDUM To: Glenn Goldsmith, President Town of Southold Board of Trustees From: Mark Terry, AICP LWRP Coordinator Date: November 16, 2021 Re: LWRP Coastal Consistency Review for MICHAEL JENSEN & DONNA LA MANQUE SCTM# 1000-91-1-8 MICHAEL JENSEN & DONNA LA MANQUE request an Administrative Permit for an as-built installation of an I/A OWTS septic system. Located: 440 Sunset Way, Southold. SCTM#: 1000- 91-1-8 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is CONSISTENT with the LWRP and therefore CONSISTENT with the LWRP. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Cc: Damon Hagan, Assistant Town Attorney Glenn Goldsmith,President 0� soar Town Hall Annex y� 54375 Route 25 A.Nicholas Krupski,Vice President -® sw P.O.Box 1179 John M.Bredemeyer III 13c' _ Southold,New York 11971 Michael J.Domino ci' G tt Telephone(631) 765-1892 Greg Williams Fax(631) 765-6641 QUO BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD T This Section For Office Use Only Coastal Erosion Permit Application E E � U E Wetland Permit Application _ S-_Administrative Permit Amendment/Transfer/Extension NOV 5 2021 - X Received Applicat'iown._:. 11.5,24.- - Received Fee: $ &7� aS-Sala- _ Completed Application:_ Southold ToWn Incomplete: . _ _ - Boar dr_of Trusteos'. SEQRA Classification: Type I Type 11 Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: Coordination:(date sent): —�LWRP Consistency Assessment Form Sent: CAC Referral Sent: Date of Inspection: Receipt of CAC Report: Technical Review: Public Hearing Held: _ I1;11Q Z1 Resolution: - Owner(s)Legal Name of Property(as shown on Deed): I'V&1146L ,T�,✓dEi� e ��o��a--��a/ylQ�v�'. Mailing Address: //Y sA& A/! sT faAr :yz'Fli�A.0a,6) 1,41Y 14--777 Phone Number: (-?/- yob- 0/6 s' Suffolk County Tax Map Number: 1000 - Property Location: fyy® saw-s i T W A X - S0v7110i,-A �Y /197 / (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT (If applicable): - Mailing Address: Phone Number:_ :-_ Email: Board of Trustees Appli ion GENERAL DATA Land Area(in square feet): Area Zoning: 6r_VAE„LT,� L Previous use of property: /1 s,o t;,-r,14 L Intended use of property: ,/P&S/pt,lr,/d 1. Covenants and Restrictions on property? Yes No If"Yes",please provide a copy. Will this project require a Building Permit as per Town Code? Yes _,Z'No If"Yes", be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes ,/ No If"Yes", please provide copy of decision. Will this project require any demolition as per Town Code or as determined by the Building Dept.? Yes __V- No Does the structure (s) on property have a valid Certificate of Occupancy? V/, Yes No Prior permits/approvals for site improvements: Agency Date V/ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? //No Yes If yes, provide explanation: Project Description(use attachments if necessary): le eer,4 onl Awj I Arw zdsrA1.i sarin.✓ OF 4N anlNvv,�r��� �rt/��r/�� d�s�?� w�s7��✓�Q �2r�r��f�.rSXSZP/1, '7�� /y�7✓ LaC1t770� /S AoN/rLLti i%&TNt72 4A,,4X r/4o/12 Sd,&)AW Wd fe/L '�lA� o/Z/ SYJ7FIn Board of Trustees Appli ,tion WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: . /t-Me" Area of wetlands on lot: 0 square feet CIA u t K NEMAn� q Al�7 wmlM E/34E Percent coverage of lot:. D Closest distance between nearest existing structure and upland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands: _ feet Does the project involve excavation or filling? _ _No Yes If yes, how much material will be excavated?. 26 cubic yards How much material will be filled? J a cubic yards Depth of which material will be removed or deposited:- S feet Proposed slope throughout the area of operations: _. o Manner in which material will be removed or deposited:= _ excAv r.a- Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason of such proposed operations (use attachments if appropriate): Nd '#E '. I -o � E2Tye pfrl� F)%er Wouth /sem AfIr/ve'._. dS Wis lAon-c-T R�PLs►erf ,�! CONVENT/e,.)/gC. S&-A77G S�/STt/► 4Z f �V1_;Ao4, iJ 'A :Ayele✓4 sE/'TIC S��r 61 Z20 Appendix B Short Environmental Assessment Form InstructionsTbr Completing Part I -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part I based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part I -Project and Sponsor Information Name of Action or Project: 7�s F,✓ SA,j 1TA1a_r s ys l-rh u164^ t' Project Location(describe,and attach a location map): yyY ,NY //77/ IhAP Arl C te^A o S dnr S t T wA So v x'7106A Brief Description of Proposed Action: �E""LoL/i?t' /'l/�� IZE/�LgGL" .�-ff 4'�Nv�ivT/oN/�L �fIN/Tf!/��° S?✓S?�/�'► �✓�/1 A'/ iNNov/tTidt'�cT�/U/.�J.—.�F c�/�f1�j sYtT�� ('.4�irU_F of /enoveav4 IV17Ao4el,,� Nom✓ GocAnnr of SAN/Ti4Ay Sysg-Y' /s F412we2 /¢rr�y loin su/Ltw GvfF nS er .m / r: T ow AL s Name of Applicant or Sponsor: -"telephone: 117., //,1 FLE-Mail:_ Address: City/PO: State: Zip Code' oQi VZ%-12.So1J 7 y /777 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that ❑ may be affected in the municipality and proceed to Part 2. If no,continue to question 2. 2. Does the proposed action require a permit,approval or funding from any other governmental Agency? NO YES If Yes,list agency(s)name and permit or approval: ,41)X0 L. 7/icom St)rFoul_ couNry tele of AALW SEA-IICC5 ❑ 3.a.Total acreage of the site of the proposed action? de 2? acres b.Total acreage to be physically disturbed? D 1/ acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? p,33 acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial ❑Commercial 9esidential(suburban) ❑Forest ❑Agriculture ❑Aquatic ❑Other(specify): ❑Parkland Page 1 of 4 5. Is the proposed action, NO '' YES N/A a. A permitted use under the zoning regulations? ;❑ b.Consistent with the adopted comprehensive plan? T] 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? 7. Is the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO YES If Yes,identify: © ❑ 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO _ YES El b.Are public transportation service(s)available at or near the site of the proposed action? © ❑ c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? ©' ❑ 9.Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements,describe design features and technologies: 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: [ j 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment:, XIFAJ S ylI-&l Qt/,dl 1,4Sj7ll �' ❑, 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic w NO YES Places? b.Is the proposed action located in an archeological sensitive area? ❑' ET 13 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO . YES wetlands or other waterbodies regulated by a federal,state or local agency? ❑ ET b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? I—,1� ❑-- !! If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: �I 14. IId�depptify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: Ushoreline El Forest ❑Agricultural/grasslands El Early mid-successional ❑ Wetland ❑Urban [Suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats,listed NO YES by the State or Federal government as threatened or endangered? a ❑ 16.Is the project site located in the 100 year flood plain? NO YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, Rr a.Will storm water discharges flow to adjacent properties? �NO YES El b.Will storib water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly`describe: 0 N ❑YES i Page 2 of 4 18.Does the proposed action include construction or other activities that result in the impoundment of NO YES water or other liquids(e.g.retention pond,waste lagoon,dam)? If Yes,explain purpose and size: 19.Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES solid waste management facility? If Yes,describe: ❑ 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES completed)for hazardous waste? If Yes,describe: I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: /C G Date: /a//JA I Signature: _ Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the,following questions in Part 2 using the information contained in Part 1 and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may occur occur 1. Will the proposed action create a material conflict with an adopted land use plan or zoning a regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? ❑ 3. Will the proposed action impair the character or quality of the existing community? Er 0 4. Will the proposed action have an impact on the environmental characteristics that caused the [-I/ establishment of a Critical Environmental Area(CEA)? �V 5. Will the proposed action result in an adverse change in the existing level of traffic or n/ ❑ affect existing infrastructure for mass transit,biking or walkway? 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate reasonably available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: ��/ ❑ a.public/private water supplies? 1�1 b.public/private wastewater treatment utilities? 8. Will the proposed action impair the character or quality of important historic,archaeological, [Iarchitectural or aesthetic resources? Ef 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, r�/ waterbodies,groundwater,air quality,flora and fauna)? LIQ El Page 3 of 4 No,or Moderate ' small to large impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage problems? 11. Wil I the proposed action create a hazard to environmental resources or human health? ❑ Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration, irreversibility,geographic scope and magnitude. Also consider the potential for short-term,long-term and cumulative impacts. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. 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. Town of Southold-Board of Trustees Name of Lead Agency ry Date Pre_siden_t 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) PRINT Page 4 of 4 Board of Trustees Appli `-.ion AFFIDAVIT 7orJN LA (nA/J QVC' ¢ /1J�c����`L �,✓sEr/ , BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMITS) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S),IF GRANTED. IN COMPLETING THIS APPLICATION,I HEREBY AUTHORIZE THE TRUSTEES,THEIR AGENT(S) OR REPRESENTATIVES,INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. Signature of Prop Owner Signature of Property Owner SWORN TO BEFORE ME THIS DAY OF JLYNNE K.BURNS NOTARY PUBLIC,STATE OF NEW YORK _ Registration No.4796041 Notary Public Qualified in Suffolk County My Commission Expires - j} APPLICANT/AGENUREPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold'-s'Code of Ethics proliibits•conflicts of interest on the part of town officers and efnployeos.The pdroose of this form is to nrovide information wAich can alert the town of possible coniliots:ofintee st and allow-iif•to take whatever action is• necessary,to avoid same. YOUR NAME:. %71;ylg�✓ . (Last name,first nathe,middle initial,unless you are applyinginthe name of someone else or other entity,such as a company.If so,indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance _ Trustee ,r Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other',name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town of Southold? "Relationship"includes by blood,Marriage,or business interest."Business interest"means a business, including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of the shares. YES NO ✓ If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIP'T'ION OF RELATIONSHIP Submitted this do da of d e n4 r-Y2- 200 a Signature11�ew_ _ Print Name -t .r Form TS l Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2: Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed-_action will. be -evaluated as to its significant beneficial and adverse effects upon the coastal area(which includes all of Southold Town 3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus. each answer must be-explained in detail, listing both supporting and non- suyho ingfacts. If an action cannot be certified as consistent with the LWRP policy standards and conditions;''it-shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold's website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION PROJECT NAME TF'NSEI-" SAN/7,4Ay s ysR _6(,A4M d e- The Application has been submitted to(check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees L`_7 1. Category of Town of Southold agency action(check appropriate response): (a) Action undertaken directly by Town agency(e.g. capital ❑ construction,planning activity, agency regulation,land transaction) (b) Financial assistance(e.g. grant, loan, subsidy) (c) Permit, approval,license,certification: Nature and extent of action: - P Location of action: y ya SvN 5,5-/� G✓i9 y S'o U IYo 64 4 N y//9 7/ Site acreage: -2 Present land use: /�tti3O�,J?�.� G Sia�2/3�,✓ Present zoning classification: 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: (a) Name of applicant: 1411 G&A L �.S CW (b) Mailing address: /It SARi-L✓� Sr /D/ZT f i�so,./L,�)' /1777 (c) Telephone number: Area Code( (d) Application number, if any: Will the action be directly undertaken,require funding, or approval by a state or federal agency? Yes El- No 1� If yes,which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy l.. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure,makes beneficial use of a coastal location, and minimizes adverse effects of development. See LWRP Section III—Policies; Page 2 for evaluation criteria. ❑Yes ❑ No Tot Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LNVRP Section III—Policies Pages 3 through 6 for evaluation criteria ❑ Yes ❑ No 2 Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III—Policies Pages 6 through 7 for evaluation criteria ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary NATURAL, COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages 8 through 16 for evaluation criteria Yes ❑ No Not Applicable Attach additional sheets if necessary Policy S. Protect and improve water quality and supply in the Town of,Southold. See LWRP Section III —Policies Pages 16 through 21 for evaluation criteria Yes ❑, No ❑Not Applicable ZHIS n/eG✓ lvlvo1/14T/vtlfz,7-eAv47-1/f' SLL.¢I-7Ar' Abfs 721ff CA16, ,41uYr ]o �r_'.OVCt N/T/�Ol,EjJ /�//tRL`'6v //dvT�G7i✓/�/YlEMRRY 5�,12FAGE /i//gTE,2J'� Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III—Policies; Pages 22 through 32 for evaluation criteria. ❑ ❑ Yes No 1� applicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and waastess.. See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes ❑ No [a Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III—Policies; Pages 38 through 46 for evaluation criteria. ' 1:1Ye� 1 "No Not Applicable Attach additional sheets if necessary WOREING COAST P01,._��'IE5 Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III Policies; Pages 47 through 56 for evaluation criteria. Yes 0 No Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. El Yes = No Not Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III—Policies; Pages 62 through 65 for evaluation criteria. D Yes F] No RNot Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. Yes ❑ No Not Applicable PREPARED BY . /l9ic%,ij ✓�iJ1�:� TITLE, (?o-oc-We L DATE /c a a a