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HomeMy WebLinkAboutTR-10053A Gle�___ _,oldsm' President �1�(fT Town Hall Annex v A. Nicholas Krupski,Vice President ,`O lQ 54375 Route 25P.O. Box 1179 John M.Bredemeyer III l�[ [ Southold,New York 11971 Michael J. Domino G Q Telephone(631) 765-1892 Greg Williams �'0 �� Fax(631) 765-6641 �yenuff ' 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 PRIORIO COMMENCEMENT OF THE ACTIVITIES CHECKED OFF BELOW INSPECTION SCHEDULE Pre-construct qn; liay,"bale line/silt,-boom/silt curtain T �i St day of b6hstruction- Y2 constructed X When project complete, call for compliance inspection; Glenn Goldsmith,President o�*0 SO Town Town Hall Annex A. Nicholas Krupski,Vice President ,` lO 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 a0 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10053A Date of Receipt of Application: January 14, 2022 Applicant: Joseph Chernushka Living Trust SCTM#: 1000-31-18-20.1 Project Location: 640 Rabbit Lane, East Marion Date of Resolution/Issuance: January 19, 2022 Date of Expiration: January 19, 2024 Reviewed 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 Thoma&A. O'Dwyer, dated December 3, 2021; and stamped`approved on January-19, 2022. Special Conditions: None Inspections,: Final 'Inspection. Ifthe 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 AS-BUILT SITE INFORMATION. -SUFFOLK COUNTY TAX MAP ID 1 000-3 1-18-14*20 PER LAND SURVEY -EXISTING 3 BEDROOM HOME, NO PROPOSED CONSTRUCTION Q� N E dV -LOT AREA O 13 ACRE `�, Y0 -PROPERTY LOCATED AT G40 RABBIT LANE Q. P, -VILLAGE OF EAST MARION,TOWN OF SOUTHOLD,SUFFOLK COUNTY, NEW YORK S o O -SURVEY PROVIDED BY RODERICK VAN TUYL P C DATED 4-20-1993 ` -VERTICAL DATUM-NAVD'88 N -SURFACE WATER SHOWN ON SITE PLAN. FULLY BULLHEADED PROPERTY �" F;; fT1 y _ -HOME 15 CONNECTED TO PUBLIC WATER r y � -ALL HOMES WITHIN 150 LF OF PROPERTY ARE CONNECTED TO PUBLIC WATER L �' GENERAL NOTES � I EXISTING 3-BEDROOM HOME WITH SANITARY BLOCK CESSPOOL 0 q 2 NO PROPOSED CONSTRUCTION �� 9481 3 EMERGENCY"BEST FIT"I/A OWT5 SANITARY REPLACEMENT DESIGN-SUFFOLK COUNTY IF +['"�°' PROJECT - n g L Hues 4 SITE PLAN AND REFERENCE ELEVATIONS TO BE USED FOR I/A OWTS SANITARY SYSTEM CONSTRUCTION ONLY EXACT PROPERTY BOUNDARIES, UTILITY LOCATIONS AND ELEVATIONS ARE NOT GUARANTEED REFERENCE ELEVATIONS BASED ON SUFFOLK GIS, ENGINEERS MEASUREMENTS AND LAND SURVEY sz, �" �. d d N 5 ONSITE UTILITY MARK-OUTS TO BE PERFORMED BY CONTRACTOR PRIOR TO PERFORMING SITE WORK r G SHALLOW 501L TEST HOLE PROVIDED BY HOMEPORT ENGINEERING CLEAN SAND FOUND 2'BELOW 111' IN > ,� DE EXISTING PUBLIC 7 EXIST NG SANITARY BLOCK CESSPOOL TO BE PUMPED AND ABANDONED OR REMOVED AS W S WATER SERVICENECESSARY PER SCDHS STANDARDS EXISTING OVERHEAD \ r =� X ; PROPOSED I/A OWT5 SEPTIC SYSTEM FOR UP TO 4 BEDROOM RESIDENCE z C'7 ELECTRICAL SERVICE 4 n xPROPOSED RAILROAD I ONE(I)FUJI CEN-5 1/A OWTS WITH HELICALPILE5 FOR ANTI-BUOYANCY W TIE CURB FOR VEHICLE /� 2 FUJI MAC BLOWER,CHARCOAL VENT AND CONTROL ASSEMBLY SET ON ELEVATED PLATFORM Q W PROPOSED INFILTRATOR 34" "r 10 s it oPROTECTION "' ABOVE FEMA ELEVATION Z CHAMBER PSD LEACHING, G _ 3 ONE ORENCO SIMPLEX PUMP STATION W/ANTI-BOUYENGY,ORENCO CONTROL PANEL AND PF3005 co 1- TRENCHES:(2X)26'X 2 83'ROWS PROPOSED PUBLIC PUMP W Z 3� WWATER SERVICE 4 TWO(2)2G LF ROWS OF STANDARD INFILTRATOR 34-INCH CHAMBERS TOTAL OF TWELVE(I 2) ,��,��, P RELOCATION CHAMBERS AND FOUR(4)END CAPS m Z „�G y ""r 5 IMPORT 20 YARDS OF CLEAN SAND FILL TO BE USED BENEATH LEACHING TRENCHES g Q PROPOSED ORENCO SIMPLEX " �`5' p f 3 GENERAL SANITARY SYSTEM AND INSTALLATION NOTES y m PUMP STATION WITH DEADMAN FO, , ° I I/A OWTS SEPTIC SYSTEM DESIGNED FOR UP TO 4 BEDROOM HOME PER SUFFOLK COUNTY = Q ANTI-BUOYANCY AND PF-3005 PUM, { FUJI CONTROL PANEL,MAC BLOWER DEPARTMENT OF HEALTH STANDARDS(SCDHS) (n of Q 'ASSEMBLY,AND VENT LOCATED ON 2 CONTRACTOR IS RESPONSIBLE FOR DE-WATERNG AND ACQUIRING ANY NECESSARY PROPOSED FUJI CEN-5 I/A OWTS a I r RAISED PLATFORM ABOVE FEMA FLOOD DE-WATERING PERMITS IF PUMPING GREATER THAN 45 GPM GROUNDWATER 15 ANTICIPATED TO W/HELICAL PILES FOR 8 MI \ ' F-LEVATION AS NECESSARY IN VIEW OF BE 3 5'±BELOW NATIVE GRADE CONTRACTOR TO TAKE ALL NECESSARY STEPS TO PROPERLY W (,0 C~/) ANITARY SYSTEM INSTALL TANKS AND ANTI-BUOYANCY IN HIGH GROUNDWATER CONDITIONS IMPORT OF CLEAN W ANTI-BUOYANCY ��SQ y _ SAND AROUND TANKS AND LEACHING STRUCTURES 15 REQUIRED AS NECESSARY = EXISTING BLOCK CESSPOOL y A 7w: " q 3 SANITARY GRAVITY DRAIN PIPE INVERT TO BE 4-INCH CAST IRON AT FOUNDATION PENETRATION U W } + 4I TO BE PUMPED ANDAND 4-INCH PVC 5DR35 DOWNSTREAM OF FOUNDATION ABANDONED PER SCDHS r _, '` '► .Cl 4 I/A OWTS SHALL BE TESTED FOR WATER TIGHTNESS PRIOR TO ARRIVING ONSITE USING THE O STANDARDS ` O METHOD APPROVED BY MANUFACTURER ` ' - > O 5 THE DESIGN ENGINEER SHALL OVERSEE THE OWTS DURING EMERGENCY INSTALLATION AND SYSTEM STARTUP O Z Z1 w . -< x , G THE OWTS INSTALLER SHALL BE LICENSED,HOLD AN ENDORSEMENT FROM SCDHS AND BE A FUJI r Z 00 s ` 0 -n AUTHORIZED INSTALLER < Z 5 m „y= 57' {^¢ > O W 7 THE OWT5 INSTALLER SHALL REGISTER THE ONSITE TREATMENT SYSTEM WITH SCDHS THE DESIGN ENGINEER SHALL PROVIDE CERTIFICATION DOCUMENTS AS REQUIRED BY SCDHS ~ Z n ZJ ,� G` Z C7 8 AN OPERATION AND MAINTENANCE CONTRACT BETWEEN THE MAINTENANCE PROVIDER AND THE W O 2 -T7 _2 39' •`t ; m PROPERTY OWNER SHALL BE PROVIDED TO SCDHS FOR I/A OWTS AMC)PSD SYSTEM m O C fi i FFE Z7 9 A GARBAGE GRINDER SHALL NOT BE INSTALLED UPSTREAM OF THE OWTS W r D 10. WATER SOFTENER BACKWASH SHALL NOT BE FLUSHED TO PROPOSED SEPTIC SYSTEM W C Z r .. E 3 O'= j m I I CONTRACTOR IS RESPONSIBLE TO OBTAIN TOWN BUILDING PERMITS AS NECESSARY PRIOR TO V cl) C m ,, 1 ;7 INSTALLATION OF THE PROPOSED SEPTIC SYSTEM Q rn M :U r _ ,.�' �" 1 2 NOTE THERE I5 A HOUSE TRAP I/A OWTS TO BE VENTED THROUGH 2 INCH CARBON VENT a (n ci o _ D ^� r LEGEND a: O =l Y LF-LINEAR FOOT W Z�- �j - - CI-CAST IRON LP-LEACHING POOL N O Z m j{ CO-CLEANOUT MAX-MAXIMUM lL Z V } CP-EXI5TING 5ANITARY CE55POOL MIN-MINIMUM OJ CTG-CUT TO GRADE OWT5-ON51TE WASTEWATER TREATMENT 5Y5TEM ofLLi Lu d' !! DB-DISTRIBUTION BOX PT-PERCOLATION TE5T N Q W Y Y r i Y EL-ELEVATION 5CDH5-SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES < ` Z (3O „ EX-EXFAN51CN POOL 5T-5EPTIC TANK QQ FXI5-EXI5TING TH-TE5T HOLE I Z W; �✓✓^,,,,s.r^"' 4 ,{q{ a,`' E-GRADE ELEVATI NEIPVATION -VENT� TICAL 7 Z W N ?� APPROVEDHEGE HIGHEST PERP CTED GROUNDWATER WM-WATER METER ER Q `n J- I/A OWfS-INNOVATI /JV.TERNATIVE OWTS rr/^� �V O O�— i 4 IE-INVERT ELEVATI d 141 ""` BOARD OF !RUSTE E EL 4.0' D E � E � � � >- o o_ ¢o .t * - b9, ✓'^ -NTS- Z ¢O 1 OAM TEST HOLE INFORMATION , -TOWN OF S®IJTF�LD (OL) L PROVIDEDBY HOMEPORT \� W O rL 1 20�� y;,. - 5'±ENGINEERING JAN 4 f �n / PROPERTY LOCATED AT w•�,1 ,„r",s l ty ��,„ ,� s ®Af E _ p,�/•/Ate" ,A`ZC!/ SANDY LOAM 640 RABBIT LANE W 1 (SM) L EAST MARION,NY 1 1939 DATED 1 1-30-2021 outhotd Town DEPTH OF TEST HOLE 4 01± W v"3 d.�.' ,, SAND AND HIGHEST EXPECTED GRAVEL GROUNDWATER DATE 12-3-2021 �,•„ EL STATEMENT — {,.., m 0 5'±-TEST HOLE 5HOW5 SCALE: 1:20 GROUNDWATER ENCOUNTERED AT EL O 5'+t s r°`t •'",`>-' SAND AND DESIGNER'TAO GRAVEL SANITAKY SITE PLAN � �°' �* (5m oa± SHEET. SCALE 1 :20 to WATER ENCOUNTERED AT EL O 5'± 0 20' 40' TEST HOLE INFORMATION �� 7 "THIS 15 NOT A PROPERTY SURVEI^' SITE PLAN BASED ON EXISTING SURVEY AND GIS TAX MAP INFORMATION. SCALE:NT5 Glenn Gold,-;,� 1n, President o��S�FFQ(,I;� Town Hall Annex A Nicholas Krupski Vice-President 54375 Route 25 Eric Sepenoski o z P.O. Box 1179 Liz Gillooly o Southold, NY 11'971 Elizabeth Peeples �'�9p� �00�� Telep on -1892 Fax 765 6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD t P Date/Time: 1119122- S;40 Completed in field by: Thomas O'Dwyer on behalf of JOSEPH CHERNUSHKA LIVING TRUST requests an Administrative Permit to replace a failed sanitary system with an I/A OWTS system. Located: 640 Rabbit Lane, East Marion. SCTM#: 1000-31-18-20.1 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=q 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 completeness/comments/standards: J��o.�a�T 'TOT�✓C.�r/� I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: E. Peeples L. Gillooly A✓ G. Goldsmith N. Krupski E. Sepenoski Other rJ C E I �>f L� COUNTY OF SUFFOLK N 1 4,zozz, Southold Town 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: Joseph Chernushka Living Trust Property Address: 640 Rabbit Lane,East Marion,NY 11939 TMP#: 1000-31-18-20.1 SHIP ID#: 21-00214 The pre-existing sewage disposal system at the above referenced property is being replaced/retrofitted with an innovative and alternative onsite wastewater treatment system (I/A 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. 5CDHS OK TO:PROCEED 'REPLACE ENT.OF°FAILEDSANITARYSYSTEM WITH AN 1/AOWTS` a �* e��aim �WrW-ater www.reolaimaunva ter in ro . t DIVISION OF ENVIRONMENTAL QUALITY PublieHeslth 360 Yaphank Avenue, Suite 2B,Yaphank NY 11980(631)852-5811 Fax(631)852-5812 Prevent Promo..P.atM a `� _._--. a w eEEeFcwma M0• "R aEE Ec rya ota `v MA)OM LINE.•.,,.` 2�`. 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',� o..� �g i SEE EEC c X molalt.aFwea^ o / 6.�.- X 13 \` �, •#.1 ,�{I, ,R ,;p a ZxA =_y -< ,•, --- "".. _ COUNTY OF SUFFOLK u TCC _-_- E a.,,.o.. w•� ,MlutJ E ] M p ,,•••� _— "^ •�— •�.• `) �.,,.,.• tct.l<J heal Yrop<,t I S ce ARenLcy Me.rtev,�. wa^Is� r E tom—-- wa[.— —.— --- u"'••"• --`--'- W BEIM FMnory RIE e„ x°n 9 UTHOLp 31 ry wn�—� vvss_— — rb"• -- .awux, �., a•ay..,.i u e:Nl •ei Frrw,Po,x AnN,)'l!W I YuvEW UJJery Ax 1.4W 6 N�'Ie'i M e �. • L ——•—— —— —— ,� x. -w o cf pµ�Rrtualfr*a.(aeNxE rc3FN:r Eu "u"y OFFICE LOCATION: ��®� S® �® MAILING ADDRESS: Town Hall Annex P.O.Box 1179 54375 State Route 25 Southold, NY 11971 (cor.Main Rd. &Youngs Ave.) Southold,NY 11971 Telephone: 631 765-1936 9 LOCAL WATERFRONT REVITALIZATION PROGRAM 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#1000-31-18-20.1 Thomas O'Dwyer, PE on behalf of JOSEPH CHERNUSHKA LIVING TRUSTrequests an Administrative Permit to replace a failed sanitary system with an I/A OWTS system. Located: 640 Rabbit Lane, East Marion. SCTM#: 1000-31-18-20.1 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 Glenn Goldsmith,President x QF SD(/Ty Town Hall Annex A.Nicholas Krupski,Vice President ,`O� Ol0 54375 Route 25 P.O. Box 1179 John M. Bredemeyer III 1 [ Southold,New York 11971 Michael J. Domino G Q Telephone(631) 765-1892 Greg Williams a0 Fax(631) 765-6641 Owl BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application Wetland Permit Application X Administrative Permit Amendmeint/Transfer/Extension �Received-Application: TAN4Z022— eceived Fee: $ , ZOO.00 Q— Completed Application: j.I�• outhgld Town Incomplete: SEQRA Classification: Type I Type II Unlisted Negative_ Dec. ` Positive ec. Lead Agency Determination Date: oordination:(date sent): LWRP Consistency'Assessmeint Form Sent: OAC Referral Sent: ; ate�of Inspection: Receipt of CAC Report: chnical Review: Publio Hearing Held:_ •j •Z?� Resolution: Owner(s) Legal Name of Property (as shown on Deed):m J OS to b&1'44�s Y Mailing Address:? &Z piu & //mo i All 0' /i/ Phone Number: D 6 1127-jSk l Suffolk County Tax Map Number: 1000 - Property Location: �N 0 (? x`34 (`j' FAiT h A-ttrkN Ny i 19 3� (If necessary,provide LILCOOPole#, distance to cross streets, and location) AGENT(If applicable): / 4_ 0-5 D,®wyrA, PF Mailing Address: C, 0, QK 1111 S E TAU K E AIV 1 E 13 7� Phone Number: ��0-22 7 5� Email: OMP H 0 MFPO`t`F1rPVG 1 V rF �11eb . CO Board of Trustees Appli;' .ion GENERAL DATA Land Area(in square feet): S b (7 S ��— ©,1`3 Ac It E Area Zoning: PCNT-1 L_ Previoususe of property: iF s 1 or, ivr►A L 0 LIZ Intended use of property: S 8 014,ly P rk L- 0�—C L L. Ay 4 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 VINO 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 y 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? ✓Yes No Prior permits/approvals for site improvements: Agency Date 14A 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): t?1?PLhGf' iV7— 0 F Fftru gL.0LA SAW I T-AA I CFfSeoo L SOT-Eh t-MA 1 A I/A b VT5 LylTlt PYO LT-RcI+IN6 c.'�S fiEtL,) syF�oLh CO(J JET`/ y2OCL-A-I h r),,,a_ x,/Arc(l. 51FU(L I MP1LoVrhFk/T 16iLtw - eXIs- CT. 5colts gf?S 1" FtT" (FF'1mc vey SMl L REPLkCJ7MFJV,1T p1FS 10/v 4 No CffH-NvC-s To v��9`l�ity� nn o°rl+�r� S'T� T 1`AU LW KVrS . Board of Trustees Appli, ;ion WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: r? Cl P1-4Q2_,/4 JV — 01c Co LLAps ixi G I r3Loc� CVsS POOL Area of wetlands on lot: WA square feet Percent coverage of lot: '2-3 4-/_ (juin t+6,AO Closest distance between nearest existing structure and upland edge of wetlands: 3 feet Vii owTS Closest distance between nearest proposed structure and upland edge of wetlands: 3 9 feet �rCPcwnrV FIEt,O 5 7 I Does the project involve excavation or filling? No '/ Yes If yes,how much material will be excavated? Zn cubic yards How-much m46rial will be'filled? cubic yards ' Depth of which material will be removed or deposited:, feet Proposed slope throughout;the area of-operations: L I 01 e Manner in which material will be removed or deposited: 15A-is rwG Lo/t-n y S(? g L (3lflyrifkTh p(toposrp l.�/ �N6 FilzL-o To (3V (2r L,A-6fn C1,LrAu SA-r4 p FILL, 5p/Sy FON 01ZJkiWA be 4419 p r►tzahr i o)) PrR SCOR-5 ! TR+AIOA-ftrys, /AnP tri oNrt L (z>ccovv two SQ ol- tuft YA- Div-vf ThIvAf T-0 fC RtFn0vP)rP,011 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): 110010VEMEIVT OF 6,1A-T_JF[L CJUAU-rY ()UF To 1/p, 0 r-1 VS ( w(,IA CIFssPoo I- (POWIT-d fa0`7,-cr FvLL'Y 5UU11HEAQFn ANO fFs 704"A-AW CA00`r L,A Iwo r , 617.20 Appendix B Short Environmental Assessment Form Instructions for Completing Part l -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: Project Location(describe,and attach a location map): Brief Description of Proposed Action: (�FQp}= CC) LL-A-)%oN6 131_L,)c'� CI's51'bvl. LlIT(I ►//A- 57v1=F0L.w ,2CL f�rM Dur1`rtrl Srt'T1c- Ca0(,A'kr1, Name of Agplieant`-of`Sponsor: Teiephorie , /ff / v,_&3%y7�-4_.r / �Jd d,,,f -� 6L,1, 1/��C� ` �!cSf/� E-Mail:c,"C4ergt!5 eTa,��ivG, s�reT Address: 6'io tk-Bp4T 1,P,&JE City/PO: State: Zip Code: Ny 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: rc�-R 19 OU CL W�TKQ) S!-FT1e< GAA-nA Se0H-S 51,16, I �uashl El 3.a.Total acreage of the site of the proposed action? 0,81 acres b.Total acreage to be physically disturbed? ll). D Z acres c.Total acreage(project site and any contiguous properties)owned T- or controlled by the applicant or project sponsor? 30 acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial ❑Commercial L94(esidential(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? 1:1 IZ 0 6. is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? ❑ 1Z 1 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: r---X ❑ 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES ❑i' 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: InisrAc�iwI, 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? ❑ 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? ❑ b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: ffShoreline El Forest ❑Agricultural/grasslands ❑Early mid-successional ❑ Wetland ❑Urban [!Kuburban 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? 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-pointsources? NO YES If Yes, ❑ ❑ a.Will storm water discharges flow to adjacent properties? NO YES b.Will storm water discharges be directed to established conveyance systems(rug&ffand storm drains)? If Yes,briefly describe: NO YES Page 2 of 4 l 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: 0 ❑ 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/sname: a / 4,14 1 u- iolas//Aw Date /2/Z Signature: � C1 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?" -rot-k/ b 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 ❑ 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 r/j ❑ affect existing infrastructure for mass transit,biking or walkway? �J 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: El- a. 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, ❑ 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 impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage F]problems? 11. Will the proposed action create a hazard to environmental resources or human health? F 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. F] 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. 13 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 I tgZ9Z Name of Lead Agency Date 0,18:ns l I ASM;_Ty President Print o Type Nam of esponsible Officer in Lead Agency Title of Responsible Officer r ignature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 Board of Trustees Apple rtion AFFIDAVIT J4Cty��k. �i�e/'nasl�it'� 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. ature of Property Owner Signature of Property Owner SWORN TO BEFORE ME THIS DAY OF TA*(-4tV , 20 zY DIANE DISALVO fiu�t �(�f1 OFNOTARY PUBLIC-STATE OF NEW YORK No, OID147559.3 Notary Public Qualified in Suffolk County My Commission Expires April 30, 20 Z� � Board of Trustees Applin ;ion AUTHORIZATION (Where the applicant is not the owner) I/We, owners of the property identified as SCTM# 1000- in the town of New York hereby authorizes 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. r O erty Owner's Signature Property Owner's Signature SWORN TO BEFORE ME THIS AN DAY OF , 20 2� A I DIANE DISALVO NOTARY PUDLIC•STATE OF NEW YORK Notary Public Na. O1 D1476593 Qualified In Suffolk County My Commission fnxpires April 30, 20 2' u 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. YOUR NAME: ® �Ol�v»u— l�t7G/itGiS (Last name,first name,griddle 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.) S90TIL �YS T�✓9 ��d��a��vrrc/ 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 V/ 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. DESCRIPTION OF RELATIONSHIP Submitted this day of 200 Signature Print Name 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 asto its significant beneficial and adverse effects upon the coastal area(which includes all of Southold Towns . 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#' '�� _ Ind Zo PROJECT NAME VUO (ZMMIT , L-Nk C rZI(IFUM Mc y fA 0' T-S Mf' c.EMC 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: 6EpLk&E Fk(L,Ih/b 131-OCA, CESYNOL L--I-rH IA nwr, - S6FFowe f F-cL-t-,t -e 0V&- L-Aryl, V P , Location of action: G4 ® KA139tT- t_t}Nr JEIk.sI- I�ARs div �y Site acreage: D , 13 Present land use: 0 Es►0 r wT►it L� Present zoning classification: 9 tI 9/-"n/k L- 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: elevw,Slvlr4 (a) Name of applicant:v ��0���G- (b) Mailing address:,? Yf IIJIA¢ ' /�v 2��i z �i�5 i Alfl alv/U 11111 y (c) Telephone number: Area Code( ) ® (v� (d) Application number,if any: / 1 Will the action be directly undertaken,require funding, or approval by a state or federal agency? Yes ❑ NO- El, 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. dyes ❑ 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 F '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 ❑✓f 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 ❑ 1:1o' 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 R1 Yes ❑ No ❑Not Applicable 0 Phh T's-L-k-'r Do P✓ o F 'i✓e� 9.�i'S 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. LJ ❑ ❑ ` Ye No N-_ 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. F] 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., 1 f Yes 'E No 1-1 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. nn ffNot Yes--1 No Applicable Attach additional sheets if necessary WORKING COAST PO'i he__<_"'IES 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. F1 Yes ❑ No ENot 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. 1Yes ❑ No El 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. CYes., -No- Not 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 YNot Applicable PREPARED BY �t' '^-'ye 1L ��� TITLE DATE 2--13 �-