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HomeMy WebLinkAboutTR-10052A Glenn Goldsmith,President ��OF SU(/ryo Town Hall Annex A. Nicholas Krupski,Vice President ,`O l0 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-TOW1Y TRUSTEES---- --------- - - - ------ -- -- TOWN OF SOUTHOLD Permit No.: 10052A Date of.Receipt of Application: January 14, 2022 Applicant: Joanna Chernushka Living Trust SCTM#: 1000-3148-13 Project Location: 600-Rabbit Lane,,East Marion Date of Resolution/Issuance: January 1'9,' 2022 Date of Expiration: January 19; 2024 Review ed by: Board of Trustees Project Description: Replace a failed sanitary system with an I/A OWTS 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, dated December 3, 2021, and stamped approved on January 19, 2022. 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. Glenn Goldsmith, President Board of Trustees Glenn Gc.—nith,President �QF s. - Town Hall Annex A. Nicholas Krupski,Vice President ,`O� ��� 54375 Route 25 P.O. Box 1179 John M.Bredemeyer III lxi[ 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 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-constr(i ctioii;-,hay-;bale,lino/"sift"'bbom/silt curtain 1St day of construction- % constructed X When project complete, call for compliance inspection; I I AS-BUILT SITE INFORMATION ' -SUFFOLK COUNTY TAX MAP ID 1000-31-18-13 OVV F N E V �� -EXISTING 2 BEDROOM HOME,NO PROPOSED CONSTRUCTION -LOT AREA O 17 ACRE, 6,758 SF �P� A, o, O�� -PROPERTY LOCATED AT GOO RABBIT LANE C 5 -VILLAGE OF EAST MARION,TOWN OF SOUTHOLD,SUFFOLK COUNTY,NEW YORK �� ✓� -SURVEY PROVIDED BY PECONIC SURVEYORS P C DATED 10-25-2013 -VERTICAL DATUM-NAVD'88 r f� ;n m Lill f� -SURFACE WATER SHOWN ON SITE PLAN FULLY BULLHEADED PROPERTY -HOME 15 CONNECTED TO PUBLIC WATER n �� -ALL HOMES WITHIN 150 LF OF PROPERTY ARE CONNECTED TO PUBLIC WATER var x GENERAL NOTES \ cS� Q 'I I EXISTING 2-BEDROOM HOME WITH SANITARY BLOCK CESSPOOL C{'Q 9 2 NO PROPOSED CONSTRUCTION "BEST FIT'DESIGN R OFESS, 3 EMERGENCY I/A OWTS SANITARY REPLACEMENT DESIGN-SUFFOLK COUNTY SIP GRANT PROS 4 SITE PLAN AND REFERENCE ELEVATIONS TO BE USED FOR I/A OWTS SANITARY 5YSTEM par- CONSTRUCTION ONLY EXACT PROPERTY BOUNDARIES, UTILITY LOCATIONS AND ELEVATIONS ARE { / NOT GUARANTEED REFERENCE ELEVATIONS BASED ON SUFFOLK GIS,ENGINEERS MEASUREMENTS 4,0 ..w .w..,. w AND LAND SURVEY 44A �. 5 ONSITE UTILITY MARK-OUTS TO BE PERFORMED BY CONTRACTOR PRIOR TO PERFORMING SITE „ XISTING OVERHEAD WORK ELECTRICAL SERVICE G SHALLOW SOIL TEST HOLE PROVIDED BY HOMEPORT ENGINEERING CLEAN SAND FOUND 2'BELOW I GRADE HISTORICAL TEST HOLE PREFORMED BY MCDONALD GEOSCIENCE 3-1-2013 IN SAME Y / LOCATION AS CURRENT TEST HOLE 7 EXISTING SANITARY BLOCK CESSPOOL TO BE PUMPED AND ABANDONED OR REMOVED A5 W sat .a NECESSARY PER SCDHS STANDARDS U 0-) • ,.` PROPOSED I/A OWTS SEPTIC SYSTEM FOR UP TO 4 BEDROOM RESIDENCE (1r) I ONE(I)FUJI CEN-5 I/A OWT5 WITH HELICALPILE5 FOR ANTI-BUOYANCY W d7 2 FUJI MAC BLOWER, CHARCOAL VENT AND CONTROL A55EMBLY SET ON ELEVATED PLATFORM W r ru ABOVE FEMA ELEVATION Q Z r EXISTING PUBLIC 3 ONE ORENCO SIMPLEX PUMP STATION W/ANTI-BOUYENCY,ORENCO CONTROL PANEL AND PF3005 Q �. WATER SERVICES Lu Z PROPOSED INFILTRATOR 34"CHAMBER PSD PUMP J k y " ,LEACHING TRENCHES (2X)26'X 2.83'ROWS 4 TWO(2) 2G LF ROWS OF STANDARD INFILTRATOR 34-INCH CHAMBERS TOTAL OF TWELVE(I 2) t _ CHAMBERS AND FOUR(4)END CAPS Z EXISTING UNDERGROUND .X4� ^ 5 IMPORT 20 YARDS OF CLEAN SAND FILL TO BE USED BENEATH LEACHING TRENCHES q m O ELECTRICAL SERVICE p G IMPORT 20 YARDS OF CLEAN SAND FILL FOR GRADING AROUND SANTITARY STRUCTURES `� m ` L'M € 1 1 ° 5' MI GENERAL SANITARY SYSTEM AND INSTALLATION NOTES = Q UTILITY CROSSINGS PER SCDHS STA ARDS.' ^ f I 1/A OWT5 SEPTIC SYSTEM"BEST FIT"DE51GN FOR UP TO 4 BEDROOM HOME PER SUFFOLK USE C-900 WASTEWATER PIPE °y ,y�, PROPOSED ORENCO SIMPLEX COUNTY DEPARTMENT OF HEALTH STANDARDS(SCDHS) � a PUMP STATION WITH DEADMAN FOR 2 CONTRACTOR 15 RESPONSIBLE FOR DE-WATERNG AND ACQUIRING ANY NECESSARY EXISTING BLOCK CESSPOOL TO BE PUMPED '> AE 8' MIN ANTI-BUOYANCY AND PF-3005 PUMP DE-WATERING PERMITS IF PUMPING GREATER THAN 45 GPM GROUNDWATER IS ANTICIPATED TO U) AND ABANDONED PER SCDHS STANDARDS:"" )� C � - BE 3.5'-4 O'± BELOW NATIVE GRADE CONTRACTOR TO TAKE ALL NECESSARY STEPS TO W EL 4.0� 10' MIN PROPOSED FUJI CEN-5 I/A OWTS PROPERLY INSTALL TANKS AND ANTI-BUOYANCY IN HIGH GROUNDWATER CONDITIONS IMPORT Q " o ^ OF CLEAN SAND AROUND TANKS AND LEACHING STRUCTURES IS REQUIRED AS NECESSARY = W EXISTING GAS STORAGE TANK 4.3'± W/HELICAL PILES FOR ANTI-BUOYANCY 3 SANITARY GRAVITY DRAIN PIPE INVERT TO BE 4-INCH CAST IRON AT FOUNDATION PENETRATION U 5' MIN AND 4-INCH PVC SDR35 DOWNSTREAM OF FOUNDATION Z ;u ` 4 I/A OWT5 SHALL BE TESTED FOR WATER TIGHTNESS PRIOR TO ARRIVING ONSITE USING THE > CO © ` FUJI CONTROL PANEL,MAC BLOWER METHOD APPROVED BY MANUFACTURER O G C IE 4.5'± 'x ASSEMBLY,AND VENT LOCATED ON 5 THE DE51GN ENGINEER SHALL OVERSEE THE OWT5 DURING EMERGENCY INSTALLATION AND m O m 1;51 w 1' RAISED PLATFORM ABOVE FEMA FLOOD SYSTEM STARTUP Z 2 r ELEVATION AS NECESSARY IN VIEW OF G THE OWTS INSTALLER SHALL BE LICENSED,HOLD AN ENDORSEMENT FROM SCDHS AND BE A FUJI O " �) * 59' SANITARY SYSTEM AUTHORIZED INSTALLER * y 7 THE OWTS INSTALLER SHALL REGISTER THE ONSITE TREATMENT SYSTEM WITH SCDHS THE F- " G[NEER SHALL PROVIDE CERTIFICATION DOCUMENTS AS REQUIRED BY SCDH5 z ( xnai46' O Z 8 AN OPERA ION AND MAINTENANCE CONTRACT BETWEEN THE MAINTENANCE PROVIDER AND THE W 's D O O P� Vr" ' PROPERTY OWNER SHALL BE PROVIDED TO SCDHS FOR I/A OWTS AND PSD SYSTEM Z A GARBAG GRINDER SHALL NOT BE INSTALLED UPSTREAM OF THE OWT5 W ' e Z W�p ®� ATER S ENER BACKWASH SHALL NOT BE FLUSHED TO PROPOSED SEPTIC SYSTEM V Go m " Z C) O 0 B�,JF�M OF I RUSTE r ONTRAC OR IS RESPONSIBLE TO OBTAIN TOWN BUILDING PERMITS AS NECESSARY PRIOR TO Q rn M ' & - IN5TALLATI DN OF THE PROPOSED SEPTIC SYSTEM J C.3 O r_ _ 7lTOWN I TE THE E IS A HOUSE TRAP I/A OWTS TO BE VENTED THROUGH 2 INCH CARBON VENT i '$ vMTY { fcws#TW$pa.4 •` ,a,E,gk> � m O LtLLI LF-UNEAR FOOT C9 Z Z ,i"a ysw.r, yt ;° - C r _ - _ LP-LEACHING POOL Z V Z* ° CO-CLEANOUT MAX-MAXIMUM O Of m " I ��T� /1�®. �O '/� CP-EX15TING 5ANI YCE55POOL MIN-MINIMUM W J Y uAr L f.0 OWfS-ON51TE WA5TEWATER TREATMENT 5Y5TEM �/ � -'L� CS Y CTG-CUT TO GRAD ly„ Q U N G - Db-315TRIBUTION I OX FT-PERCOLATION TE5T Z > 5CDH5-5UFFOLK COUNTY DEPARTMENT OF HEALTH 5ERVICE5 Q Q Y 5T-5EPTIC TANK 1 <-" • „ r,r ,,,;y.o„,k+, "` �r. i /T♦ .+>� EX-EXPANSION P L Z D ` Da5-EXI5TING TH-TEST HOE z W LLI _ y >,"` m FIFE-FINISHED FLO R ELEVATION V-VENT Enz A 4"# yFn GE-GRADE ELEVATI N TYP-TYPICAL L Il WM-WATER METER Q LJ HEGE-HIGHEST EX DAY GROUNDWATER n_ r- F VAOwls=INNOVA E/ALTERNATIVE OWT5 GRADE EL 4.3'+/- U� w Q IE-INVERT t7EVATl N -NTS- >_ � L Q O WEyp M rlsj $et''�zT _ L M TEST HOLE INFORMATION C) � = N m by origid GR,psaEBiicC in (OL) EL PROVIDED BY HOMEPORT tDC 0 8'--L ENGINEERING W d D 4A PROPERTY LOCATED AT SANDY LOAM GOO RABBIT LANE !, O (5M) EL EAST MARION,NY 1 1939. [ eil'dD AKA ! m- cel 2 3"DATED 1 1-30-2021LLI SAND AND DEPTH OF TEST HOLE 4 O'+_ ` e HIGHE5T EXPECTED LLI j G(-9v,/) L GROUNDWA TER U � �y, EL TATEMENT DATE 12-3-2021o s'JAR � � OS GROUNDWATER =� ,r AND AND SCALE: 1:20 ENCOUNTERED AT El O 5'± s iy iN Apo GRAVEL EL A Sm0old Tow c sA + (5m 0 3'-. DESIGNER:TAO SANITARY SITE PLAN r s=ees WATER ENCOUNTEREDAT EL — SHEET` SCALE= I :20 co *No ' TEST HOLE INFORMATION 0 20` 40' ` � SCALE NT5 "THIS 15 NOT A PROPERTY SURVEY" SITE PLAN BASED ON EXISTING'SURVEY AND GIS TAX MAP INFORMATION. Glenn Goldsm� rresident OS�FFO(qd Town Hall Annex A Nicholas Krupski, vii�e-President 5437.5_Route 25 Eric Sepenoski o "` P.O. Box 1179 Liz Gillooly Southold, NY 11971 Elizabeth Peeples ��l A Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD rr Date/Time: 1119422 9;.3o Completed in field by: G. Thomas O'Dwyer on behalf of JOANNA CHERNUSHKA LIVING TRUST requests an Administrative Permit to replace a failed sanitary system with an I/A OWTS system. Located: 600 Rabbit Lane, East Marion. SCTM#: 1000-31-18-13 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 / GG ,/ 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 completeness/comments/standards: I have read & acknowledged the foregoing Trustees comments: Agent/Owner: / Present were: E. Peeples L. Gillooly ✓ G. Goldsmith N. Krupski E. Sepenoski Other D E C E V E COUNTY OF SUFFOLK JAI 14 202 ,.I 9*=d,3,t Sout;71d Tonn _jWrd of-TrusteeL STEVEN BELLONE SUFFOLK COUNTY EXECUTIVE DEPARTMENT OF HEALTH SERVICES GREGSON H.PIGOTT,M.D.,M.P.H. Commissioner SANITARY REPLACEMENT/RETROFIT OK TO PROCEED January 13, 2022 Property Owner: Joanna Chernushka Living Trust Property Address: 600 Rabbit Lane,East Marion,NY 11939 TMP#: 1000-31-18-13 SHIP ID#: 21-00215 The pre-existing sewage disposal system at the above referenced property is being replaced/retrofitted with an innovative and alternative onsite wastewater treatment system (UA OWTS) in accordance with Section X.A. of the Department's "Standards for Procedures for the Replacement and Retrofits of Existing Sewage Disposal Systems for Single-Family Residences and Other Than Single-Family Residences" ("Standards"), effective July 11, 2019. The installation of the I/A OWTS is being performed and reported in accordance with the Standard and Article 6 of the Suffolk County Sanitary Code, and the Department has issued an "Ok To Proceed"with the sanitary system replacement/retrofit. If you have any questions or comments regarding this I/A OWTS installation please call 631-852-5459. $CDNS'O,KTG PROCEED }FtEPCACEIVIEiVI'QF.FA1LED"SfiT,4RYSY5TEMW1T14AiV.. W-, ,',,a1IUtt '" - wwwrealirinicturtivaterinfa , �e., .�s DIVISION OF ENVIRONMENTAL QUALITY PabliaHeslth 360 Yaphank Avenue, Suite 2B,Yaphank NY 11980 (631)852-5811 Fax(631)852-5812 Preecat Promote,i`ratea M R , ��- �..- m �� ' NA OLS ..� ��lS 3 � E AEE BEC NO DJa - �� � \`^ �� y'Y.S^•P �. Mk ne--0 a 41 •.a19 a2 l..IG.6 ,�n. „t: l . .-;,qB . �5 #,. K..: • 5 WP—AAA.— MATCH awXIG nk*cN esT< BEE EC 0072 �� fa . .,W tio - , AzaAee -a M ? a ozwoo, a � oy),a '•? '�n.]I e t s �� w sRgr ' t• a s,..�+� � '� xe ..as .a epp 44 a 7 Fn ° k"�,._. w wage by, �,q ya Fq.' aa� OJ.M 01 pq' ti ,d a: Y it b « a ..• �t A-!S^.. "b `{ > a, w k •f]Sk S ; m s.e, Y1..`+ a.' •.r ,t y+" w' E A ,,mow' Ay. ozoru `3 ar >, } '•ei"`t.s k���a. ua �` ,� "....°. 'e `°'�W"' rcri m .A<'`. d' n i •prros •'.t "' sx as *�,g ty. '•.* y A+6,, e` �yca q,. 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W �:` •t^ SJ.� '"eY, R�^P ,O `A d./� ,\: �,e. •Q � �0��• ..<, 11.3 A ,'i �' '• °( / ,� 'fie ; TO'MJ OF EOUTNOLO s s]s aA .i "' 90. �`M1 l('1a\.` `},i a lY,,a. ��•21, r �\ , �7'./' (!4\.�° � -4. S 1 9 R b...✓•.4' �� .o de S,tT ° .. �P� \: MARION LAKE _ ` ,. �' �i \. vd � .*rte ;_ •< / S� `v.��yyF�an�3y--� ta.av<r ° P_ } ..,` 1 p•e' F __. a ,. ``3• P .�, L aB,e �...F z w'g s,� °;� � ( ( ,� ,e,� sBk �. ,\4 °"6 '" •9,da'��. �,sa e���r 9'&� X17 +» r, w• At( \, c� / >° \. -� P/e\ a e1 sil�,S':1C of .. Y p •, i _ ,• A w � 4 c\e .� + \ \,t R. � � `,; a.ak 4 A �, .I, n "t\',6'�y,! 7 . '+„ sY q saw a i MARION FONF.c Hc,s . aA o,Vl 'fl «'•' a> r •4 i a o d;( ti. �.e ew) 7 ; y °s c4' T— YdRNOl1S� dy clJ A s <S.. .,6: y es P ♦ K / ! ',. t vx s, .xgy 6 �� • � .3 PPM1)q'OA�44.�.` k ''1k'-:.:'-4' .!-.3 ! :r, 31Yje,''�e� 3 Y ���� S`3''��� aw sox:• �,� A . °��.sl'" :� �,�. ,�� 3.«a � e'',•d �'° ",v at�) a 'a+jG 4° d°` ,�� x � �" rp � fes•"`�`..�. r ta1' i A • '���+e� P`'ti'M1Y ie� �QO �: � ,p£d,. — a]A a�x� a < r ♦ a �vo�tla`w e, � `� ♦( � .y i y, _:'2 FS .-,:B t(. wP,4;e / / r � '. — e a ? b.> 5 B U *r A n�.icf`E1.'�e+�•(f^p" M1r4e' a M1 Wq,, ,`''T y�y ��i v £ &': } � �'`� `� "� � : as Y E k.;.,. ;:..;:•. ,.. —..— >,,,.-.. COUNTY OF SUFFOLK O N nonce ..N ----- "• , >n R.4 Property Iax S-A.,Agency swas.m.BE.aia noN—. v ]� 031 sE] _——.—— _ _ z...�..: M., w we+ry-v war¢r wemu q of �ouTFwtp D —_,—— • __..—— " —__� <..wq. (21) OFFICE LOCATIvir MAILING ADDRESS: Town Hall Annex ®f S P.O.Box 1179 54375 State Route 25 ®�i� ®� Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) Southold NYTelephone: 631 765-1938 ED www.southoldtownny.gov COUh19�9� PLANNING BOARD OFFICE TOWN OF SOUTHOLD MEMORANDUM To: Glenn Goldsmith, President Town of Southold Board of Trustees From: Mark Terry, AICP LWRP Coordinator Date: January 14, 2022 Re: LWRP Coastal Consistency Review for JOANNA CHERNUSHKA LIVING TRUST SCTM#1000-31-18-13 Thomas O'Dwyer, PE on behalf of JOANNA CHERNUSHKA LIVING TRUST requests an Administrative Permit to replace a failed sanitary system with an I/A OWTS system. Located: 600 Rabbit Lane, East Marion. SCTM#: 1000-31-18-13 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 Policy Standards and therefore is 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 ;w r Glenn Goldsmith,President *QF SD(/�y Town Hall Annex A.Nicholas Krupski,Vice President ,`O� Ol0 54375 Route 25 P.O. Box 1 John M.Bredemeyer III Southold, New York 11971 Michael J. Domino G Q Telephone(631) 765-1892 Greg Williams leo Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application ® 0 E 6 V E Wetland Permit.Application -- Administrative Permit JAN 14/2022— Amendment/Transfer/Extension K Received Application: L/�•2?i Y, Received Fee: $ 206,0 46 uthold Town Completed Application: Incomplete: - SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: �,�oordination:(date sent): i0 LWRP Consistency•Assessment Form Sent:, AC Referral Sent: Date,of Inspection: _ Receipt of CAC'Report: ; echriical'Review: td Public Hearing Held: Ig 1 •y?�- Resolution: Owner(s) Legal Name of Property (as shown on Deed) J d�-yn� ������s���{� �%�i !✓�1 T Mailing Address �ys ��tY ����� ��i �/KioN Phone Number Suffolk County Tax Map Number: 1000 - 3 Property Location: (000 \Q ftW 1`- I ,W E. EAST Mf IZAW A-A/ (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable): 8����5 � r PE Mailing Address: P,0 . G O'K 1118 S L I A-U h ET ljy 11-773 @ �O���P Phone Number: 1 223 —S7SZ Email Board of Trustees Applic ion GENERAL DATA Land Area(in square feet): (0 ; 5 Area Zoning: fl f S i 01r x/r 1/k L_ Previous use of property: �E S► 0 9►vr(�L- ��, �► ►y �, Intended use of property: 0 E S 9( ENT1 0 t,-1"-0 MG c Mo C�t A-N 6 F 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 / 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 No Does the structure (s) on property have a valid Certificate of Occupancy? 1Z Yes No Prior permits/approvals for site improvements: Agency Date (V Nle IV 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): E Uk h Of I_fk I L ED G L-O Uk CSS,SpboL 51S—IEP WITH I/R 0v,;15 w0Ttt- 9.EAtiiNc, SysT-tN SSv�'Fdun�rC:c���ty „��cv�►h (�U"R ����� S��c` a��p�.���� ' G��w�" ��+a����: Sc-01+s F o�g5pr(C_ XVrL&CGFh _ OC-516V To 0WCu4-A4G 0a V-cttVr-" sur• Board of Trustees Applin' -lion WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: C0 LA,�N e,,�BBV G Lp C K C c S S PVC L- w t T(t 1� C)W'- Area of wetlands on lot: �n square feet Percent coverage of lot: �� % GC35FOOL- q vq t FF�1*p Closest distance between nearest existing structure and upland edge of wetlands: LA 8 feet VA,-rkf✓h (Qc L"tiLrAo Closest distance between nearest proposed structure and upland edge of wetlands: �tp6 feet 1-12P-K G V IELD guy-,mvNo 5/ fee-- Does the project involve excavation or filling? No Yes If yes,how much material will be excavated? 20 cubic yards How mucli mater-ihf will be filled? 20 cubic yards Depth-ofwhich-.material will be removed or deposited: 3 feet Proposed slope throughout the area of-operations:_ l do Manner in which material will be removed or deposited: F"O s-"vb LO shy So o L- (390 (390;f fiW C{ OQOWFO L V/ac it /b F(IFLO -p VE if PLACJFP I-INT-n CLE.4V 5A-td j0 Flu- SR151v Foa- DAAN Act 0400 iri L-(L kr(oN P(F/L 5c)01+S 5--ff/vO0 5 W)t(Wert- ak a"k V&T90 SOIL FQq. (/J\-O'.r-rS T-A-mns '(O 130 IZf►'aWo irnv n SJ-rE . 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): IMPROVE' EV-1 - or- L�rjkl-F6L ()Urtt-ITT Dve To �/�E ��1-5 VS JF�1STING ��ar-'A CC5SPODL . ffOeft -�-y wikTrin raot✓T-/t�,C �'uLLy �VLyctkf✓1kQ r?.0 AMD 54 0 P aS -q p 6✓t,(L OS 61Z20 Appendix B Short Environmental Assessment Form Instructions for Completing Part 1 -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 1 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 1 -Project and Sponsor Information Name of Action or Project: 606 f.kV6JT- LkwF- cm'ff (OO Vcy 1/N Overs ftel-Ac-rmrV7 Project Location(describe,and attach a location map): Brief Description of Proposed Action: �Pelle�r�lT"V`l- vF C0 "-/}051A/6 6L-00" CESSP60L_ wITtt 1/4 bwt'5 . SUfr0t ", A40aL7P0066kr~t Name.o Applicant or ponsor: ,Telephone: -Mail: Address: / Address: 600 Ogglr 1,A-0✓E r City/PO: State: Zip Code: EA-3T- 'MM0hki I Ny I 1193q 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: ❑ ECLA-1 h ouk W')TFr1s 30M (-4*V°` - S rO IA-s SHI p /4p9aoVA L 3.a.Total acreage of the site of the proposed action? acres b.Total acreage to be physically disturbed? OZ acres c.Total acreage(project site and any contiguous properties)owned .l7- or controlled by the applicant or project sponsor? ® acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) [:]Industrial ❑Commercial residential(suburban) El Forest ❑Agriculture ❑Aquatic ❑Other(specify): ❑Parkland Page 1 of 4 V 5. is the proposed action, ED YES N/A ::: a.A permitted use under the zoning regulations? ❑ ❑ b.Consistent with the adopted comprehensive plan? 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? ❑ Pr 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: Z . ❑ 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO 1 YES 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: ❑ ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: 1 NS Thl L1 Vb NES. ,{ ❑ l/R owt-s. P 12. a.Does the site contain a structure that is listed on either'the State or National Register of Historic NO YES Places? b,is the proposed action located in an archeological sensitive area? �. Ij.a.Does any.pprtion of the site of the proposed action,or lands adjoining the proposed,action,contain NO I YES wetlands or other waterbodies regulated by•a federal,state or local agency? b.Would the proposed action.physically alter,or encroach into,any existing wetland or waterbody? If Yes,identif [2r EJ y-the wetland of waterbody and extent of alterations im square feet or acres: 14. aIntify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: Shoreline 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? E__'�/J ❑ 16.is the project site located in the 100 year flood plain? NN N�u� NO YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, j a.Will storm water discharges flow to adjacent properties? [1NO DYES L=J ❑ b.Will storm water discharges be directed to established conveyance systems(run ffand storm drains)? If Yes,briefly describe: [ANO [DYES 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 INF MATION PROVI ED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponso?;.namePt Dater /3/lri z L Signature: UG�dI�� e .zuS /C� Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the following /6 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 I. Will the proposed action create a material conflict with an adopted land use plan or zoning ❑ 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? ❑ 4. Will the proposed action have an impact on the environmental characteristics that caused the establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or ❑ 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? b.public/private wastewater treatment utilities? 8. Will the proposed action impair the character or quality of important historic,archaeological, U architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, ❑` waterbodies,groundwater,air quality,flora and fauna)? Page 3 of 4 No,or Moderate small to large 1 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. Will 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 f /� Z Name of Lead Agency ! Date Cle—\ % CcU-;m4\ President Print Qr Type N e Responsible Officer in Lead Agency Title of Responsible Officer 'VSsignatu of Responsib e Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 Board of Trustees Appli, ion I I i jAFFIDAVIT BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S)AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE 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. { ,nature of Property Owner Signature of Property Owner SWORN TO BEFORE ME THIS DAY OF , 20 4W Notary Public DIANE DISALVO NOTARY PUBLIC-STATE OF NEW YORK No, 01D1475593 Qualified in Suffolk County fly commisstan Expires April 30. 2012' i I Board of Trustees Appli, , ion AUTHORIZATION (Where the applicant is not the owner) I/We, �1 owners of the property identified as SCTM# 1000- in the town of New York, hereby authorizes la-121a S &yt4_ to act as my agent and handle all necessary work involved with the application process for permit(s) from the Southold Town Board of Trustees for this property. P operty Owner's Signature Property Owner's Signature SWORN TO BEFORE ME THIS DAY OF Th ' 20 Zy Notary Public DIANE DISALVO NOTARY PUBLIC-STATE OF NEW YORK No, DIDI476593 Qualified In Suffolk County My Commission Expires April 30, 2017— APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE,FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The purpose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same.I YOUR NAME: J/D(�✓�w � //l/t�//�C/{' (Last name,first name,-ipiddle initial,unless you are applying in the 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 Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other r (If"Other',name the activity.) f/ �e,Qf/ Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town ofSouthold? "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%,offthe shares. YES NO- 'I/ 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 applicgnt (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. DESCRIPTION OF RELATIONSHIP Submitted Signature Print Nam Form TS l s 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- supporting facts. 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 SCTM# -I o 00 _ -31 PROJECT NAME �(� ����� G��-�+✓� �J✓)�nG�NC� s/� ®wTS' �1�P����iti r�j The Application has been submitted to (check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees 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:, Kr_r �Ath Dui %via°rR P R°M T7 P Location of action: c D d KA 0010 L-'"J Iz FAIT- )-1A-&i1+&1- AJ V Site acreage: 0-1-7 Present land use: R c C 0 0►r WT-1 Present zoning classification: icwrl A L- 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: '1�- (b) Mailing address: ' y (c) Telephone number: Area Code( (d) Application number,if any: 1�1 Will the action be directly undertaken,require funding, or approval by a state or federal agency? Yes ❑ No 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 1. 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 ❑ Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LW Section III-Policies Pages 3 through 6 for evaluation criteria 7Yes ❑ No ❑ Not Applicable I Attach additional sheets if necessary i 4 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 dyes ❑ No ❑ Not Applicable d 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 5: Protect and improve water quality and supply in the Town of Southold. See LWRP Section III —Policies Pages 16 through 21 for evaluation'criteria ErYes ❑ No ❑Not Applicable 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. [Y ❑ ❑ (V-4 No No� )plicable 4 I i 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 F] No Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III—Policies;'Pages 34 through 38 for evaluation criteria., ',Ye's." "No; 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. � j El Ye� No u Not Applicable Attach additional sheets if necessary WORKING COAST POL.,,C;.ES - ' 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 ❑ 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: Edyes ❑ No ❑ Not Applicable ` Attach additional sheets if necessary Policy 12.., Protect agricultural lands in the Town of Southold.,See LWRP'Section.1117 Policies; Pages 62 Afih ough'65 for'.evaluatioii criteria. Yes , Not Applicable t 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 010ock TITLE DATE