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TR-10087A
Glenn Goldsmith, President DQE SOUj�, Town Hall Annex A. Nicholas Krupski,Vice President ,`O� ��� 54375 Route 25 P.O. Box 1179 ' Eric Sepenoski i a l�E Southold, New York 11971 Liz Gillooly G Telephone(631).765-1892 Elizabeth Peeples .• �� Fax(631) 765=6641 arri BOARWOF..TOWN TRUSTEES :'TQWN OF:SOUTHOLD SOUTHO'LD,TOWN BOARD:OF TRUSTEES YOU ARE REQUIRED TCO CONTACT THE OFFICE OF THE BOARD Of TRUSTEES'.: 72 HOURS PRIOR.TO COMMENCEMENT Of THE ACTIVITIES:CHECKED OFF,. BELOW INSPECTION SCHEDULE Pre constructJon, ha bale Iine'silt boom/silt curtain 1st day::of co:nstructian ' /Z constructed 4 ' 'When.probed ..comp 0p alci:for compliance inspection, Glenn Goldsmith,President �OF soot Town Hall Annex Vv A.Nicholas Krupski,Vice President �� l0 54375 Route 25P.O.Box 1179 Eric Sepenoski J�[ [ Southold,New York 11971 Liz Gillooly va G Q Elizabeth Peeples Telephone(631) 765-1892 • O � Fax(631) 765-6641 . BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD _ Permit No.: 10087A Date of Receipt of Application: February. 14, 2022 Applicant: Antigone Amengual & Randolph Amengual SCTM#: 1000-77-24 Project Location: 220-0ak Avenue;.Southold Date of Resolution/Issuance: March 16, 2022 . Date of Expiration March:16, 2024 Reviewed by: -Elizabeth Peeples, Trustee" Project Description: Rernove.three (3) cesspools; abandon one (1) cesspool.and replace with the installation of an I/A OWTS sanitary�system.and gravity fed shallow dispersal:field; establish and perpetually maintain a 10' wide-non-turf_ buffer along la ndward�edge`of the retaining wall: 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 Glynnis M..Berry, RA; dated March 11, 2022, and stamped approved on March 16, 2022. Special Conditions: The Permittee is required to provide evidence that a copy of this- Trustee hisTrustee permit has been recorded with the Suffolk County Clerk's-Office as a notice covenant and..deed restriction to the deed of the subject parcel:-Such evidence shall be provided within ninety (90) calendar days of issuance of this permit. 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 Gol' Ah, President o��S11FF('' G Town Hall Annex A.Nicholas Kruj,.- -. Vice-President tk 54375 Route 25 Eric Sepenoski o "G P.0.�Box 1179 Liz Gillooly o ® Southold, NY 11971 Elizabeth Peeples y o! Telephone (631) 765-1892 ��l Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: 12,2- 12i 3bp Completed in field by: 13.PeeaWl.eS Glynnis M, Berry, AIA on behalf of ANTIGONE AMENGUAL & RANDOLPH AMENGUAL requests an Administrative Permit to remove three (3) cesspools, abandon one (1) cesspool and replace with the installation of a I/A OWTS sanitary system and gravity fed shallow dispersal field. Located: 220 Oak Avenue, Southold. SCTM#: 1000-77-2-4 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=� 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: StMIJM;YWOA — add 10'bu uloy%4g,� 6Rtr I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: E. Peeples ✓ L. Gillooly V G. Goldsmith V N. Krupski E. Sepenoski Other SURVEY OF CERTIFIED T0: RANDOLPHAMENGUAL ANTIGONE AMENGUAL LOTS 179 TH O GH 182 MAP�GOOSEBY ESTATES JOB NO.:2021-243 SITUA TE A T MAP NO.: 1176 SOUTHOLD FILED:NOVEMBER 13, 1934 OF NEtV REVISIONS: �P�� y TOWN OF SOUTHOLD PLOT FLOOD ZONE BOUNDARIES 1/12/2 5 �� W SUFFOLK COUNTY, NEW YORK S.C.T.M. DIST.: 1000 SEC.:77 BLK.:02 LOT 4 L q 10 5 0 10 20 30 40 50 60 70 80 90 SCALE. 1"=20' DATE:DECEMBER 4, 2021 .050 LAND Sv���O p � C � IV � JEFFREY W. HADERER L.S. FLOPli G f l$ f4 20 NYS LIC. NO.:050538 fmoO0, Southold Town Board of Trustees 0 0 $� YWINFORKS LAND SURVL'YING SUCCESSOR TO HANDS ONSURVMNG,MART/ND.HAND LS. 188 W.MONTAUKHIGHWAY,UNITE3 IIAMPTONBAYS,NEW YORK 11946 (V)631-369-8312-(F)631-369-8313 / email.tWnforkslandsmvey@yahoo.com R� COPIES OF THIS SURVEYMAP,EITHER PAPER OR ELECTRONIC,NOT BEARING THE LAND SURVEYORS INKED SEAL OR EMBOSSED SEAL SHALL NOT BE / CONSIDERED TO BEA VALID COPYAND SHALL NOT BE USED FORANYPURPOSE. Os LOTAREA: 14,700 SQ.FT. +/-=0.337 ACRE 0 /;; _ _ ELEVATIONS HEREON REFER TO NA VD 1988 G ALL PROPERTIES WITHN 150'OF SUBJECT BOUNDARY ARE n MGHWAtERMARK�o�3� S IMPROVED AND SERVICED BY PUBLIC WATER �p E, GM N �aG/ _ SANEALo O 0s, .w`1 9 NO VISIBLE WELLS WITHIN 150'OF SUBJECT PROPERTY /�_— �1 v■ ` ANO RTEST HOLE DATA EL.:12.0' ypK - A,k a SANDY KPRPcK c REtA�N1N Mo,,. LOAM oN I �oN (SM) �•�P�E clloN c -2.5' �.opSPATE I MIXED SAND .11"0 of M OPLL 00' W/GRA VEL �N G 0 \ IN- i 150„ $�� \ �- (SP) ' �•___ E E coN r000 ,`; . -7.0 00 N, \ FLOOD ZONE l� SANDY F�ZONEX R�AREA) SILT �VCH CHA T FLOOD HA7A (0.2%ANNURL N N (ML) \ \� -8.0' a \ \ MEDIUM TO coN°MoN EL \\ \ cp o FINE SAND W/GRA VEL % \� �� ��� -9.5'H.E.G.W. EL.:2.5' WATTEE R IN MEDIUM TO --- �� FINE SAND S��QPPy W/GRAVEL /a 3. ' S�����' �( �M - / p PAVER PA?IO Seo �O TSE T HOLE BORING BY / � SHAWN M. BARRON, M.S. o pp, S EPS cp NOVEMBER 19, 2021 E• $ GROUND WATER ENCOUNTERED q5'0 9.5'BELOW SURFACE GRADE � LBARRB Y SYSTEM U RESOURCE S1%611990 - TRic L Slog 7 \c \ fMOE,G Ago pW E 125 \\• � � ���II F.F• L 7m ` (0.2%ANNU F OZON O� / 31 NCE FL OD ROAREA) 0 31. EREp FLOOD NE SLATE \ A NTRY E Gf�oTP JA x'41 E 7EWA AY .y ppR ��0®R SIA ap �� �z ` Z 7 O� 0 0 '0z>;z v PLL- \ N 86008'30"W 156 o .15' cp OIP®\\ 1Z0 �L�iP2 OVER_ WIRE' StoNEDR \• DROP No N \ GOO sm RESR"RECOR�w"� (EST t•� N BIL-00 UNRECORDEDARENOTGUARANTEED UNLESS PHYSICALLYEVIOENTAT THE BELGIAN 1 1 nMEOFSURVEY. ` THE OFFSET(OR�MENSlONS/SHGWN \ HEREONFROM 7HESTRUCTURES T07NE000, PROPERrYUNESAREFORA SPECIFIC AENDTINNDUSEANO UIDE E ORE ARENOTVN FE CES.REIDEnIE I , ERECnONOL FENCES.RETAIRNG U WAILS,FOOLS. OS UIMN NG PNBLOc� n Al ANDA ANYOTHER COSTRU DON, E SS avDANVDTHErtcoNsmucnoN. BELGA pD� 'SQ UNAUTHORIZED Al TIONORADDInON 70TH/SSURVEY/S NZVYMS A V To DII YSURV�TNENEWYON STATE EL�3G S 6a N O LANI)FIHISSURVEYAT SSAL EAR/NG THEIANDSUAVEYO.RSINOTBE LOR 0 ro TL COPY. CONSILTH7ED CERnACA17ONSINQ'C(ASTEDHERONSHAL.RUN EpGE SPPREPARTMFDE DONHI0)RISHRl�SURVEv OLE3 ��A��Y Y CY �L,�P FLOOD ZONE BOUNDARIES HEREON AREAS DEPICTED ON THE TO F.E.M.A. FLOOD INSURANCE RATE MAP. TUnON.CERIMCAnONSARENOTTRANSFERABLE TONNDAERS, AL/NSniUnONSORsu8SE0UFNr MAP NO.:36103CO166 H-EFFECTIVE DATE SEPTEMBER 25, 2009 OWNERS, N SANITARY SYSTEM DESIGN: EXCAVATION NEEDED: SITE PLAN BASED ON t � ELGEN LEACHING FIELD: SURVEY OF LOTS 179 THROUGH 18218'-0"M,qX• C. toC. RESIDENTIAL wp00 0 49'X 4'X 4.1'=803.6 CF X 2= 1607.2 CF/27=59 CY MAP OF GOOSE BAY ESTATES U_ #OF BEDROOMS: 6 HYDRO ACTION: SITUATE SOUTHOLD ADVANCED TREATMENT UNIT: HYDRO ACTION AN600 �g 14' 8.4'X 7.75' = 911.4 CF/27= 33.8 CY TOWN OF SOUTHOLD, �`CO I/AOWTS CAPACITY REQUIRED: 660 GAL PER DAY,AS PER TABLE 3, SCDHS REMOVAL OF EXIST. CESSPOOLS" SUFFOLK COUNTY, NEW YORK ADE O w RESIDENTIAL STANDARDS 3.14 X 4'X 4'X 4'=200.96 CF X 4 = 803.84CF/27 =29.77CY MAP NO.: 1176, FILED NOVEMBER 13, 1934 =w I/AOWTS CAPACITY DESIGNED: 660 GAL PER DAY F- TOTAL: 122.57 CY 1 w SCTM DIST. 1000 SEC.: 77; BLK: 02; LOT 4u- LEACHING SYSTEM : CLEAN SAND/GRAVEL FILL NEEDED: DATED DECEMBER 4,2021 ELGEN LEACHING FIELD: BY FOR AGRAVELLESS GEOTEXTILE SAND FILTER BASED ON 6 SF/FT OF TRENCH, 92 49'X 4'X 3.2' =627.2 CF/27 = 23.23 CY JEFFREY W. HADERER L.S. NYS LIC. NO.: LINEAR FEET IS REQUIRED FOR A PERCOLATION RATE OF 1-5 MIN/IN. CESSPOOL FILL= 050538 O� PROPOSED: (2)48'LONG RUNS OF ELJEN LEACHING SYSTEM (96'TOTAL 3.14 X 4'X 4'X 4'=64 CF X 3- 192 CF/27= 7.1 CY TWIN FORKS LAND SURVEYING F� (1)48' LONG RUN FOR FUTURE EXPANSION AREA ) TOTAL: 30.33 CY � 188 W. MONTAUK HIGHWAY, UNIT E3 F G C�Gp AS PER-SURVEY 12/4/2021 HAMPTON BAYS, NY 11946 OS\i 9d2/ T 631 369 8312 PERSPECTIVE VIEW GENERAL CONDITIONS: TWINFORKSLANDSURVEY@YAHOO.COM 1. INSTALLATION SHALL COMPLY WITH SUFFOLK COUNTY DEPARTMENT OF HEALTH MFF `1�� CERTIFIED TO RANDOLPH AMENGUAL+ SERVICES'REGULATIONS, STANDARDS,AND REQUIREMENTS,AND SHALL BE �o�c��p"E ����� wap �°` "� ANTIGONE AMENGUAL STRICTLY IN ACCORDANCE TO THE: MANUFACTURER'S INSTRUCTIONS. , % TES ' �Q S�� \ g 700 SF OR 0.337 ACRE FENCE MINIMUM 2 x 2 LOT AREA: 14, M � POST 2.THE INSTALLER MUST HOLD A CURRENT LIQUID WASTE LICENSE PURSUANT TO NP ELEVATIONS HEREON REFER TO NAVD 1988 CHAPTER 563 ARTICLE VII (SEPTIC INDUSTRY BUSINESSES)AND ENDORSEMENT J ` �`�'� @` TEST HOLE DATA (INNOVATIVE AND ALTERNATIVE TREATMENT SYSTEM INSTALLER)THROUGH THE SUFFOLK COUNTY DEPARTMENT OF LABOR, LICENSING AND CONSUMER AFFAIRS, ALL PROPERTIES WITHIN 150'OF SUBJECT EL,;12,0' WOVEN WIRE FENCE PURSUANT TO SUFFOLK COUNTY CODE§563-79(11)(J). THE DEPARTMENT OF LABOR, yP� A� GW \ BOUNDARY ARE IMPROVED AND SERVICED SANDY (6 x 6 - 10/ 10 WWF) LICENSING,AND CONSUMER AFFAIRS MAINTAINS A LIST OF LIQUID WASTE LICENSE ESTABLISH AND PERPETU LLY �c� oc. \ BY PUBLIC WATER LOAM HOLDERS. MAINTAIN A 10 WIDE, NON-TURF " NO VISIBLE WELLS WITHIN 150'OF SUBJECT ($M) z BUFFER ALONG LANDWARD EDGE �y6a PROPERTY FILTER CLOTH g 3.ALL INSTALLED I/A OWTS ARE REQUIRED TO HAVE AN INITIAL 3-YEAR WARRANTY. OF THE RETAINING WALL MIXEDSAND N cn WI GRAVEL 4.ALL INSTALLED I/A OWTS ARE REQUIRED TO HAVE ACTIVE O&M(OPERATION ANDG� w W0 ' \� (SP) SCOPE MAINTENANCE)AGREEMENTS BETWEEN THE PROPERTY OWNER AND SERVICE �sA�� �o -'S fG00otEAE�E1'1 (2)ROWS, EACH 48'LONG I -7.0' PROVIDER. o. Q� iOt�X \ 96'TOTAL OF ELGEN SANDY 5. SERVICE PROVIDERS MUST REPORT ALL O&M ACTIVITIES TO SCDHS(SUFFOLK FENCE s/ 19�p CHA%CEfI�DHP7A SHALLOW LEACHING j SILT GRgo COUNTY DEPARTMENT OF HEALTH SERVICES). z s�� (ML) EMBED FILTER CLOTH F �g ,MP XISTING C S OOLS/ \ RAISE GRADE SLIGHTLY I -80 MIN. 6" INTO GROUND �E. TANKS TO BE R MOVED -. TO MIN EL. 8.1 IN 6. COVENANTS MAY BE REQUIRED ON PROPERTIES WHERE UA OWTS ARE INSTALLED ��6Sl,,s' ,,, \ \ LEACHING AREA MEDIUM TO Z REQUIRING; SYSTEM REPLACEMENT IN EVENT OF FAILURE;O&M REQUIREMENT; � p s FINE SAND ACCESS TO DHS INSPECTION/SAMPLING ON QUARTERLY BASIS IF NEEDED; OTHER �, �$ ss%''� � \ �� INSTALL ROOT GUARD WIGRAVEL 4 z zo REQUIREMENTS THAT SCDHS DEEMS NECESSARY. \ „' ,%'' �( ( ) "` � ''�� "� � TREE TO BE KEPT ONLY REMOVED IF 50% NEEDED � $W ' 7. PERFORMANCE STANDARDS FOR I/A OWTS TECHNOLOGIES: s=` ,'f g�, % / ?,, 6 -9,5 H'E'G'W'EL'2.5 \ Is G� +� ��; "" '� REPLUMB TO NEW WATER IN SECTION DETAIL UA OWTS MUST MEET TREATED EFFLUENT CONCENTRATIONS FOR TOTAL NITROGEN O T MEDIUM OF NINETEEN(19)MG/L OR LESS. \ - o,\�t F� ,;`'�' �, 12� �\ �� SANITARY OUTLET MEDIUM T FINE SAND AREA FOR FUTURE 50% EXPANSION StOrmwater Sllt Fence DetaIIIS, Southold WI GRAVEL SEPTIC/TREATMENT CONSTRUCTION CRITERIA: '� �, m 0P (SW) -16.0' 1. SEPTIC/TREATMENT I ALL NON-CONCRETE TANK WALLS, FLOORS, ROOF AND ACCESS COVERS SHALL TEST HOLE BORING BY RESIST AN APPLIED FORCE OF 300 POUNDS PER SQUARE FOOT(PSF). SHAWN M.BARRON M.S. 11. NON-CONCRETE PREFABRICATED SEPTIC TANK&UA OWTS SHALL CONFORM TO •� o CCNgTpIgPRR.ER N o THE INTERNATIONAL ASSOCIATION OF PLUMBING AND MECHANICAL OFFICIALS pPVE&5F46 �' �SWRwS5V5 MI -&2 NOVEMBEP,19,X021 o„IVN ,���° m GROUNDWATER ENCOUNTERED "AMERICAN NATIONAL STANDARD FOR PREFABRICATED SEPTIC TANKS"ANSI O09.5 BELOWSURFACE GRADE Z1000-2007 AND ANY UPDATES THERETO. MALE THREADED SLATE OR OTHER MALE THREADED MALE THREADED 111. EACH SEPTIC TANK& I/A OWTS SHALL BE IDENTIFIED BY THE MANUFACTURER FRPM rm HIGHEST EXPECTED GROUNDWATER LEVEL; EL.2.5 AND DISPLAY THE FOLLOWING INFORMATION PERMANENTLY MARKED AT THE INLET 2 SORE L� D - CONTROL PANEL+ BLOWER IN COVER ON PAD ADAPTER AND CAP SUITABLE COVER ADAPTER AND CAP ADAPTER AND CAP END OF THE TANK: i QW 1. MANUFACTURER NAME OR LOGO c G - �t 62 4"(2"MIN.) DIA. HDPE VENT W/CARBON 2. CAPACITY AND NUMBER OF OPENINGSFILTER 18 N a \ 9 125 " MIN.ABOVE GRADE, W 3. MAXIMUM DESIGN LOAD ° ��,;. _ _ - / 4. THE DATE MANUFACTURED. \ F F, - 103 d ��EL 1°. 36"MIN. FROM ANY WINDOW OR DOOR w IF IV ALL CAST-IRON AND HDPE COVERS SHALL BESET AT FINISHED GRADE, BE o _--'-FLo0Di0NEX W 6 v o , � , HYDRO ACTION AN600 LOCKING,TAMPER-RESISTANT,WATERTIGHT, INSECT-PROOF, FLAT, SKID-PROOF,AND 4- ` f%ANNUAL ) x Q BE APPROVED FOR SEWAGE USE. COVERS AND RISERS SHALL BE CAPABLE OF v° '� �. WANTI-BUOYANCY+2 ENTRIES Q -, � � FLocDioNE \ SEWER PIPE WITHSTANDING A TRUCK WHEEL LOAD(36 S IN. OF 2500 LB FOR 60 MIN WITH A MAX. SQA CO ,o EXIST. CESSPOOL TO BE REMOVED DOUBLE SIDED VERTICAL DEFLECTION OF 1.5 IN. J P� Eta _ ''�• 45 DEG. ELBOWS WYE V. HDPE COVERS AND RISERS ARE REQUIRED TO BE USED ON NON-CONCRETE \ `� w E� �Ea� s '� � LASCO D448-040 SEPTIC TANKS. THEY SHALL BE SE'T AT FINISHED GRADE, BE LOCKING,WATERTIGHT, CUT AND PLUG THREE OF THE Rw1 30 DEG ELBOW 60 DEG WYE OR EQ. INSECT-PROOF,AND BE APPROVED FOR SEWERAGE USE. SEWER PIPE EXITS. VI. IF A RISER COVER WEIGHS LESS THAN 60LBS A SECONDARY SAFETY LID OR REPLUMB PIPING TO OTHER EXIT ` DEVICE SHALL BE PROVIDED. 5, m� �'� S�A� 12 \ C� POWER SUPPLY CONNECTED TO < O CP r y N 8610813011 2. SEPTIC TANK&I/A OWTS SHALL BE WATERTIGHT AND CONSTRUCTED OF SOUND DEDICATED 115 VOLT AC, 'm W� LANTINGS 156.15' SINGLE-PHASE,20 AMP CIRCUIT AND DURABLE MATERIALS THAT ARE NOT SUBJECT TO EXCESSIVE CORROSION OR �\ N `9 98 ALTERNATE A: FOR BENDS ALTERNATE B1: FOR USE WITH ALTERNATE B2: FOR USE WITH o_ PLANTINGS '�R. A. ALL SEPTIC TANK&I/A OWTS MUST BE CERTIFIED AS WATERTIGHT BY BREAKER ON HOUSE MAIN-- \ 15� BLDG. EXTENSION/CONNECTION BLDG. EXTENSION/CONNECTION MANUFACTURER USING EITHER VACUUM TESTING OR WATER TESTING METHODS. �- 61 Sa� R.e�cK �� OVERNENDWIRES W/DOUBLE SIDED SWEEP I. VACUUM TESTING MUST PULL 4"OF MERCURY(HG), F6R 2 MINUTES WITH A SZONEC�WF �o CLEAN OUT DETAIL FOR AREAS NOT SUBJECT TO VEHICULAR TRAFFIC LOSS OF 10%OR LESS. TEST HOLE 11. WATER TESTING: SEAL TANK; FILL TANK WITH WATER TO OUTLET INVERT c ELEVATION FOR 24 HOURS. REFILL THE TANK TO OUTLET INVERT AFTER 24-HOUR \ 96�C�N�Cf CLEANOUT DETAILS PERIOD AND LET STAND FOR 10 HOURS.APPROVED IF WATER LEVEL IS HELD FOR 10 HOURS. EXIST. CESSPOOLo� B. ALL PENETRATIONS PIPES SHALL BE CONNECTED TO TANKS WITH A TO BE ABANDONED TWATERTIGHT, SEALED FLEXIBLE JOINT AND THE PIPE GASKET SHALL BE FASTENED O THE PIPE WITH A STAINLESS STEEL RETRACTABLE ��wNe ' o3�5Qpw 3.THERE SHALL BE A MINIMUM ONE-FOOT AIR SPACE MEASURED FROM THE OUTLET INVERT TO THE BOTTOM OF THE TANK COVER. ABBREVIATIONS: RO APP �EI� BY i � PP 4.ACCESS TO EACH TANK OR COMPARTMENT OF THE TANK SHALL BE PROVIDED BY BOARD OF f TRUSTEES AN ACCESS COVER WITH AN INSIDE DIMENSION OF AT LEAST 20 INCHES IN DIAMETER, Q3 0 10 20 30 50 & AND LP LEACHING POOL AND IN COMPLIANCE WITH 5-111 AND 5-114B-7 OF CDHS RESIDENTIAL STANDARD 2016. @ AT MAX. MAXIMUM TOWN OF SOUTHOLD ALL OPENINGS SHALL MEET THE FOLLOWING REQUIREMENTS: B.C. BOTTOM OF CURB MIN. MINIMUM A. OPENINGS SHALL BE PROVIDED OVERALL INLET AND OUTLET PIPES BW BOTTOM OF WALL N.T.S. NOT TO SCALE B. WHERE EXTENSIONS ARE REQUIRED, THEY SHALL BE WATERTIGHT CONC. CONCRETE PROP. PROPOSED DATE IYlf4jQr�} �(< < C. SEPTIC TANK&I/A OWTS MANUFACTURERS SHALL PROVIDE A LABEL OF /,�� NONCORROSIVE C.O. CLEAN OUT REQ. REQUIRED MATERIAL IN PROMINENT LOCATION AT EACH ACCESS OPENING TO WARN DB DISTRIBUTION BOX SCDHS SUFFOLK COUNTY DEPARTMENT OF "ENTRANCE INTO TANK MAY BE FATAL" n I/A OWTS LAYOUT E or ELEC. ELECTRIC HEALTH SERVICES i ELEV. or EL. ELEVATION ST SEPTIC TANK I 1" - 20'-O" G GAS T.O. TOP OF HDPE HIGH-DENSITY POLYETHYLENE T.C. TOP OF CURB I/A OWTS INNOVATIVE AND ALTERNATIVE ONSITE TW TOP OF WALL SEPTIC TANK&I/A OWTS INSTALLATION STANDARDS: WASTEWATER TREATMENT SYSTEM W WATER INV. INVERT W/ WITH , E C E 8 V E 1.ALL APPLICABLE RECOMMENDATIONS PROVIDED BY THE MANUFACTURER SHALL BE POWER SUPPLY LG LEACHING GALLEY IMPLEMENTED. CONNECTED TO 2.THE SEPTIC TANK&I/A OWTS SHALL BE INSTALLED AT LEVEL IN ALL DIRECTIONS(WITH DEDICATED 115 VOLT AC, A MAXIMUM TOLERANCE IN ANY DIRECTION OF+/-ONE QUARTER INCH)ON A MINIMUM 3 SINGLE-PHASE,20 AMP CIRCUIT INCH THICK(OR MANUFACTURER'S RECOMMENDATION)BED OF PROPERLY LEVELED AND BREAKER ON HOUSE PANEL MAR 1 1 2022 COMPACTED SAND(FREE FROM ROCKS)OR PEA GRAVEL.BACKFILL SHALL BE PLACED AROUND THE SEPTIC TANK&I/A OWTS IN SUCH A MANNER AS TO AVOID DAMAGE AND COMPACTED IN 6-INCH LIFTS. BACKFILL SHALL BE FREE OF LARGE STONES,STUMPS, CONTROL PANEL AND BLOWER IN COVER ON PAD SoutlioldTown AND CONSTRUCTION DEBRIS. Board of Trustees 3.THE TOP OF THE SEPTIC TANK&I/A OWTS SHALL NOT BE LOCATED GREATER THAN TWO AND HALF FEET OR LESS THAN ONE FOOT BELOW FINAL GRADE.FOR SEPTIC TANK 4"(2" MIN.) DIA. HDPE VENT &I/A OWTS WITH DOMES,THE TOP OF THE DOME SHALL NOT BE LOCATED GREATER W/CARBON FILTER THAN TWO AND HALF FEET OR LESS THAN ONE FOOT BELOW FINAL GRADE. 18" MIN.ABOVE GRADE, 36" MIN. FROM ANY WINDOW OR DOOR GENERAL NOTE 1. BEFORE ANY EXECUTION,VERIFY ON SITE,IF APPLICABLE: 4"WASTE CAST IRON WITHIN 2'FROM Innovative No. Description Date GRADE ELEVATIONS AT THE HOUSE WHERE THE WASTE MAIN PENETRATES. HOUSE FOUNDATION WALL, CONTINUED TO 4WASTE nnovative and Alternative Onsite GRADE ELEVATIONS WHERE EACH UNIT WILL BE INSTALLED. CLASS 2400 OR SDR 35, (OR SDR40) CLASS 2400 OR SDR 35, Wastewater Treatment System -HOUSE WASTE LINE MAIN LOCATIONS AND INVERT ELEVATIONS. ANY UNDERGROUND UTILITIES, INFRASTRUCTURES,AND/OR STRUCTURES 1/4"PER 12"SLOPE MIN. 1i8"PER 12"SLOPE MIN. (I/A OWTS) 220 Oak St. ANY TREES WHICH MAY AFFECT TO THE I/A OWTS INSTALLATION HYDRO ACTION AN600 DISTRIBUTION BOX 2. GARBAGE DISPOSAL UNITS SHALL NOT BE USED WITH A I/A OWTS. EL. 12.5'+/- W/ANTI-BUOYANCY, 12" POLYLOK 20"W/24"RISER studio a/b architects 3. TANKS SHOULD NOT BE PUMPED WHEN GROUNDWATER IS HIGH OR FLOOD CONDITIONS EXIST. RISER, INSTALL W/SECONDARY SAFETY DEVICE 651 West Main Street, _ SECONDARY Riverhead NY 11901 SAFETY DEVICE TYP. 3.0' MIN. CELLAR o I EL 10.1'+/- EL. � 631 591 2402 C.O. 631 3231426 � � I nls studioabarchitects.com � �;;�,,�;'� .�c ' 9 Y @ EL.7EL.8 .1 +/- .0 FLOOD - - -_-- t t _ ---- UJ w ___ w mailing address: ¢ PO Box 444 0L. 0 o z Orient NY 11957 HIGHEST EXPECTED 4 3 D p 12" 12" GROUNDWATER EL.2.5' M - -L - - - - c0 - - -L� - - - X op � ui � HIGHEST EXPECTED Owner: EL. 0'+/- w M M GROUNDWATER EL 2.5' I/A OWTS S L a o u t - - - - w - - - - - - _W__ - - - W - - - - - - - - Randolph Amengual y co M i REPLACE SOILS BELOW ELGEN Antigone Amengual Project number 21236 NEW EXIT NEEDS TO BE EL 8.66' _ c`Oo ,"'� u- M w LL TO EL.4'W/CLEAN SAND/GRAVEL 3/11/2022 Q OR HIGHER Y _ r r r Z Date O c`i O - w O roe Tax Ma #: W W w Q w w w t- property rtY p Drawn by G B M 0 5 10 FT z m z ~O L` -I z z O z z C 1000-077.00-02.00-004.000 Checked by HA M mow _ _ m _ M o site street address: 220 Oak Avenue C. 01 0 SECTION DIAGRAM Southold, NY 11971 3/16" 1_ �_0 " scale As indicated M k i a •/ � �r11f. t • F � �r x ktt'.e dg 3 Area for I/A OWTS 4. Side yard, looking north S p a t. E. 5 Backyard 6. Side yard, looking south Giza T-• tgc�° 7. Backyard, leaching area, looking north 8. Backyard, leaching area looking south 9. Looking toward driveway 10.South side of house (sewer line exit) et tzu - aszan N LtMk t _ ) " DO �- Q', -_ 22P �i`- •� .y, ,ar. ---'-� � _____-- its y 0 ----- ,. zs .m� E �_� _�_ Rtl �� --'0M__ wy --:-- m NOTICE '* COUNTY OF SUFFOLK © E a1e o° SOUTNOLD SEC 10 NO E ______ . y —4 �� y Real Prop=Tax Service Agency r / I'' N "a r �._ M„„.a...a.NYttmt u 077 p . u» u. Ott M.I•ta�• ,r —__— w.•... —_._— w.,r,,,__...__ nr rmcr.o )M PROPERTY AV,P 24190 Main Road w ® PO.BOX 444 glynis@studioabarchitects.com Orient,NY 11957 http://ariizumibeny.com T&F 631 323 1426 1 March 11, 2022 Board of Town Trustees Town of SoutholdD E C E I E Town Hall Annex 54375 Route 25 PO Box 1179 . LIAR 1 12M Southold, NY 11971 Re: 220 Oak Avenue,Southold, NY Southold Town TX Map# 1000-077.00-02.00-004.00 Board of Trustees Dear Reviewer, Please find enclosed three stamped plans that incorporate the 10' non-turf buffer zone. If you need any further information, my cell is 631680 9656 and email is above.We appreciate your review of this. Sincerely, Glynis M. Berry,AIA, LEED AP OFFICE LOCATION: it soyo MAILING ADDRESS: Town Hall Annex P.O.Box 1179 54375 State Route 25 Southold,NY 11971 (cor.Main Rd. &Youngs Ave.) Southold,NY 11971 G • Q Telephone: 631765-1938 �cO�ycoU 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: March 14, 2022 Re: LWRP Coastal Consistency Review for ANTIGONE AMENGUAL & RANDOLPH AMENGUAL SCTM# 1000-77-2-4 Glynnis M. Berry,AIA-on behalf of ANTIGONE AMENGUAL & RANDOLPH AMENGUAL requests an Administrative Permit to remove three.(3) cesspools, abandon one (1) cesspool and replace with the installation of a I/A OWTS sanitary system and gravity fed shallow dispersal field. Located: 220 Oak Avenue, Southold. SCTM#: 1000-77-2-4 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 Michael J.Domino,President ,�}� 3' Q��� - �fi`(�� Town Hall Annex John M.Bredemeyer III,Vice-President �`^_ 54375 Route 25 Glenn Goldsmith P.O.Box 1179 Southold,New York 11971 A.Nicholas Krupski Telephone(631) 765-1892 Greg Williams Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application Wetland Permit Application Administrative Permit ,,,Amendment/Transfer/Extension /Received Application: � 2.1�'•ZZ Received Fee: $ 1 00,BQ /Completed Application: 2•�(p•Z�i Incomplete: SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: ,-.. oordination: date sent): LWRP Consistency Assessment Form Sent: �rf,AC Referral Sent: li ✓ Date of Inspection: •ZY Re Receipt of CAC Report: �Fechnical Review: �--=---- i ,/Public Hearing Held: •ZZ ai°'�""Yn, Resolution Antigone Amengual+Randolph Amengual Owner(s) Legal Name of Property (as shown on Deed): Mailing Address: 220 Oak Avenue, Southold,NY 11971 Phone Number: 516 528 1615 Suffolk County Tax Map Number: 1000- 077.00-02.00-004.000 Property Location: 220 Oak Avenue,Southold,NY 11971 171.13'west of Pine Avenue (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT (If applicable): Glynis M. Berry,AIA, LEED AP (designer of I/A OWTS) Mailing Address: PO Box 444,Orient,NY 11957 Phone Number: 631 680 9656 i' Board of Trustees Application GENERAL DATA Land Area(in square feet): 14,700 Area Zoning: R-40 Previous use of property: Residence Intended use of property: Residence Covenants and Restrictions on property? Yes x No If"Yes",.please.provide a copy. Just'a filing w/Town Clerks office for I/A , x 0 VTS-only Will this project require a Building Permit as per Town Code? es 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 x 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 X No Removal and/or abandonment of existing cesspools. x Does the'structure.(s) on property have a valid Certificate of Occupancy? Yes No Prior permits/approvals for site improvements: Agency Date No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? x No Yes If yes,provide explanation: Project Description(use attachments if necessary): Replace numerous cesspools with,a new I/A OWTS sanitary system and gravity fed,shallow dispersal field. ' l Gd G a w Board of Trustees Appli,. .cion WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Improve treatment and disposal of sanitary waste from existing home. Area of wetlands on lot: 0- square feet Percent coverage of lot: 0 % Closest distance between nearest existing structure and upland edge of wetlands: 55.9 feet Closest distance between nearest proposed structure and upland edge of wetlands: 60 feet Does the project involve excavation or filling? _ No x Yes 122.57 CY If yes,how much material will be excavated? cubic yards How much material will be filled? 30.33 CY cubic yards Depth of which material will be removed or deposited: 7.75 feet Proposed slope throughout the area of operations: no change, Manner in which material will be removed or deposited: -_ excavators and dump truck 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): system removes nitrogen from effluent,as well as particulates,coliform. Quality of effluent entering groundwater/creek will be much better (from—40-60 mg/L to 11 mg/ L of N compounds Short Environmental Assessment Form Part I -Project Information 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 Randolph and Antigone Amengual Name of Action or Project: UPGRADE SANITARY TO I/A OWTS Project Location(describe,and attach a location map): 220 OAK AVENUE,SOUTHOLD,NY 11971 Brief Description of Proposed Action: Project will remove multiple cesspools from three sides of the structure and install a new I/A OWTS(HydroAction AN600 with a passive,shallow leaching system(Elgen) Name of Applicant or Sponsor: Telephone: 516 5281615 Randolph Amengual E-Mail: randyamengual@gmail.com Address: 220 Oak Avenue City/PO: State: Zip Code: Southold NY 11971 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 government Agency? NO YES If Yes,list agency(s)name and permit or approval:SC Department of Health Services;Southold Town Trustees ❑ 3. a.Total acreage of the site of the proposed action? 01337 acres b.Total acreage to be physically disturbed? 0.030 acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? 0.337 acres 4. Check all land uses that occur on,are adjoining or near the proposed action: 5. ❑Urban ❑ Rural(non-agriculture) ❑ Industrial ❑ Commercial 21 Residential(suburban) ❑Forest ❑ Agriculture ❑✓ Aquatic ❑ Other(Specify): ❑Parkland Page 1 of 3 5. Is the proposed action, NO YES N/A a. A permitted use under the zoning regulations? ❑ Fv] ❑ b. Consistent with the adopted comprehensive plan? ❑ Fv-1 ❑ NO YES 6. Is the proposed action consistent with the predominant character of the existing built or natural landscape? 7. Is the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO YES Name:Goose Creek,Name:Peconic Bay and Environs,Reason:Significant coastal fish&wildlife habitat, If Yes,identify: Reason:ProD...tect public health,water,vegetation,&scenic beauty,Agency:Southold,Town of,Agency:Suffolk ounty, F-1 ✓❑ NO YES 8. a. Will the proposed action result in a substantial increase in traffic above present levels? ❑ ❑ b. Are public transportation services available at or near the site of the proposed action? a ❑ c. Are any pedestrian accommodations or bicycle routes available on or near the 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: N/A ❑ 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: new I/A OWTS with shallow dispersal proposed RI ❑ 12. a.Does the project site contain,or is it substantially contiguous to,a building,archaeological site,or district NO YES which is listed on the National or State Register of Historic Places,or that has been determined by the ❑ Commissioner of the NYS Office of Parks,Recreation and Historic Preservation to be eligible for listing on the State Register of Historic Places? b.Is the project site,or any portion of it,located in or adjacent to an area designated as sensitive for ❑ RI archaeological sites on the NY State Historic Preservation Office(SHPO)archaeological site inventory? 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? ❑ ❑I 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: Page 2 of 3 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: ❑✓Shoreline ❑ Forest ❑Agricultural/grasslands ❑Early mid-successional ❑Wetland ❑ Urban ❑ Suburban I5. Does the site of the proposed action contain any species of animal,or associated habitats,Iisted by the State or NO YES Federal government as threatened or endangered? Piping Plover ❑ ✓❑ 16. Is the project site located in the 100-year flood plan? NO YES ❑ ✓❑ 17. Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, V ❑ a. Will storm water discharges flow to adjacent properties? ❑ ❑ b. Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? ❑ ❑ If Yes,briefly describe: 18. Does the proposed action include construction or other activities that would result in the impoundment of water NO YES or other liquids(e.g.,retention pond,waste lagoon,dam)? If Yes,explain the purpose and size of the impoundment: ❑ ❑ 19. Has the site of the proposed action or an adjoining property been the location of an active or closed solid waste NO YES management facility? If Yes,describe: Fv] FT 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 CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURAT+ THE BEST OF MY KNOWLEDGE /f Applicant/sponsor/name: r- Date: Signature:. _ Title: Al ►� Ylv Z PRINT FORM Page 3 of 3 EAF Mapper Summary Report Friday, February 4, 2022 4:43 PM Disclaimer: The EAF Mapper is a screening tool intended to assist - project sponsors and reviewing agencies in preparing an environmental assessment form(EAF).Not all questions asked in the EAF are answered by the EAF Mapper.Additional information on any EAF question can be obtained by consulting the EAF Workbooks. Although --~ '777,` the EAF Mapper provides the most up-to-date digital data available to DEC,you may also need to contact local or other data sources in order lr to obtain data not provided by the Mapper.Digital data is not a substitute for agency determinations. r7,-2 t 7'tT7 f3 ,lorftrcal 1 t -2-5 77•.2 -(• t K ;7 r Tgrtlnt 7Y2 3Rfir(�r f2 +i ce fiiltl d 0 r � tt 7t 3 I if r ry xJiz trrJ 77 22 i7 2 �aDctrolf+ G B ton j, 71-2-(} ee' - � , f� '°irfsfd tlt9 a 4 y ryi'*r'(44+)daf1eF t+a " r a« Ott r,6�aticl utm I } e41� .,- t ..�. .._� x ,y.plJtfFdigl(),hl_4.i IIA-1 uta lHn))<I l�onci fsn r �t:�tE(ITP� �R �n Esn lal��n.t 1E11 Esti t�In i fH�nrl:ki n Esn' 7 4 +Esii I fI� llane(IE<6� j :t�laai5'b' t 1 �trintuL}��to s �nsl_tli GIs 4Js17etp�1t_t�inYt ( nC717ct15tittitla 0ti7C�11li .'�ifil r�ot��i�-c'IS'Usel;Crnrn�amit,; :Part 1 /Question 7 [Critical Environmental ?Yes t Area] a Part 1 /Question 7[Critical Environmental Name:Goose Creek, Name:Peconic Bay and Environs, Reason:Significant Area- Identify] 4coastal fish&wildlife habitat, Reason:Protect public health,water,vegetation, f&scenic beauty,Agency:Southold,Town of,Agency:Suffolk County, Date:3-9- 190 Date:7-12-88 Part 1 /Question 12a [National or State No z ;Register of Historic Places or State Eligible Sites] 1 art 1 /Question 12b [Archeological Sites] iYes Part 1 /Question 13a[Wetlands or Other :Yes-Digital mapping information on local and federal wetlands and Regulated Waterbodies] �waterbodies is known to be incomplete. Refer to EAF Workbook. Part 1 /Question 15 [Threatened or Yes ,Endangered Animal] E Part 1 /Question 15[Threatened or Piping Plover jEndangered Animal - Name] _ 4 ;Part l /Question 16 [100 Year Flood Plain] {Yes :Part 1 /Question 20[Remediation Site] INo - -- -- -._ - -- -- -- - -- - ---- - - ---- - - - - - _ ..-- -- .----.... - - -' Short Environmental Assessment Form - EAF Mapper Summary Report 1 APPLICANT/AGENUREPRESETATIVE TRANSACTIONAL DISCLOSURF,FORM The Town of Soiitholii'S Cade oF`Etliicsroliibits conflicts of interest on the nart`of town officers and emnloyees The tiutoose of I anis form`is td rorovide inforination-Which can alert town ofaossible conflwts.of interest and allow it to tale whatever action is:. ecessatyta avoid same. Berry,Glynis M. YOURNAME: (Last name,first name,griddle initial,unless you are applying to the name of someone else or other entity,such as a company.If so,indicate thb other t 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 - i Other (If"Other",name the activity.),,-- - Do you personally,(or through your'Eompany,.spouse,sibling,panait,orchild) a relafionshlp 4VJ1Il ally(ffiCer OGClliployee of the Town ofSotitl iild? "RelaUnns_hip"incliidbs;by blood, nrieresL. iginess interi:sC'means a business; including a partnership,in which the town officer or'ctriPlcyee has even 5 partial'ownCh5 i� dt(or;;inplgyiii,.n by)s corporation in which the'town officer or employec;owns}mor4 th5n-5%,of th .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 applicantlagent/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%a of the shaics of tliesorporatc"stock of thg"applicant (when the applicant is a caijinradon);= B)thelegator beneficial o}yiter of any interest in a n_on-cgrporate entity(wlieri the app=s not, corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Owner Submitted this day of 200- _ Sigiiaturo _ Print Name.- ------ - Form TS l Board of Trustees Application AUTHORIZATION (Where the applicant is not the owner) Randolph Amengual and Antigone Amengual I/We, , owners of the property identified as SCTM# 1000- 077.00-02.00-004.000 in the town of Southold New York,hereby authorizes Glynis Berry,AIA of studio alb architects 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. Property Owner's Signature rope . Owner's Signator SWORN TO BEFORE ME THIS DAY OF ,20 a4k�c°. Notary Public REBECCA A LUCAK Notary Public-State of New York No.01 LU6386882 Qualified in Suffolk County My Commission 1=xpires Feb.04,2023 APPLICANT/AGENT/REPRESENTATIVE, TRANSACTIONAL.DISCLOSUU.F.ORM The Town of Southold's Cade of Ethics prohibits conflicts of interest on the partof town officers•and employes.The nt] Mseof this form is to provide informationwhich can alert the town of_possihle conflicts of huerestand allow it to lake whateveraction is necessary to avoid same. Amengual,Antigone YOUR NAME: (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 (If"O(her',name the activity.) Do you persotmlly(or through your company,spouse,sibling,parent,or child)have a relationship with any oi'licer or employee of the Town of Southold? "Relationship"includes by blood,ntacriage,or business intcresf means a business, including a partnership,in which the town otlicer or employee has even n partial ownership of(or i aiploytncnt by)a corporation in which the town officer or employee owns more than 5°fo 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 nota corporruion); C)an officer,director,partner;or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Owner Submitted thi day of�C-V1U CL Signature 0 0 Print Name C Form TS l REBECCA A LUCAK Notary Public-State of New York No.01 LU6386882 Qualified in Suffolk County My Commission Expires Feb.04,2023 APPLICANT/AGENT/REPRESENTATIVE- TRANSACTIONAL DISCLOSURE FORM The Town of Southold'-Code of Ethics prolubits conflicts of interest on the part of town nfTicers and cmnlovees.The nonose c, this form is to provide infortnation which can alertthe town ofpossihle conflicts nfinterestand allow it to lake wliatever action is necessary to avold same. Amengual, Randolph YOUR NAME:. (Last name,first name,.qtiddle 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 (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,ntanrtage,.Or business interest.."Business interest"tneans a business, including a partnership,in which the town officer or employee has even a partial ownership-of for bnploytnent by).a corpotqtion in which the town officer or employee ownsmore 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 orbenclicial owner of any interest in it non-corporate entity(when the applicant is not:-corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Owner Submitted thday of Signature a Print Name a&a Form TS 1 REBECCA A LUICAK Notary Public-State of New York No.OILU6386882 Qualified in Suffolk County IJIy Comrrissiro:, Feb.04,2023 - Board of Trustees:`Appli "xon. : AFFIDAVIT.: Randolph Amengual f Antigone Amen ua1 . BEING DULY SWORN DEPOSES AND'AFFIRMS THAT HE/SHEJS THE APPLICANT FOR THE ABOVE::- 'DESCRIBED BOVE DESCRIBED PERMIT(S)AND.THAT ALL STATEMENTS CONTAINED_HEREIN 'ARE TRUE TOTHE'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 ANDXREE FROM ANY AND-ALL.D'AMAGES AND-CLAIMS_-ARISING UNDER,OR BY VIRTUE OF SAID PERMIT(S),IV,- . GRANTED: IN COMPLETING THIS.APPLICATION;,I HEP.EBV-AUTHORIZE:THE - TRUSTEES;THEIR AGENT(S) OR.REPRESENTATIVE5,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 Property Owner 4ignatf Property O' ` er SWORN-TO BEFORE IVIS THIS DAY OF 20 ' : Notary.Public.:.:.. AEBECCA-A LUCAK. N0 No -:State of New,York - No 01 LU6386882 Qualified in'Suffolk County' : 'My Commission.Expires Feb 04;2023 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 signif'cant 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 shill 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# 077.00 02.00 004.000 PROJECT NAME I/A OWTS for 220 Oak Avenue, Southold 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: Removal and abandonment of existing cesspools.Installation of I/A OWTS -.(HydroAction AN600)plus gravity fed, shallow leaching field (Elgen) a Location of action: to east and north of house Site acreage: 0.337 Present land use: residential R-40 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: Randolf and Antigone Amengual (with Glynis Berry as an agent) (a) Name of applicant: (b) 'Mailing address: 220 Oak Avenue,Southold;NY 11957 (c) Telephone number: Area Code( ) 516 528 1615 (d) Application number,if any: Will the action be directly undertaken,/require funding, or approval by a state or federal agency? Yes F11 No❑ If yes,which state or federal.agency? NYSDEC 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. 0 Yes No Not Applicable Enhances wastewater infrastructure, greatly improving the quality of-effluent entering groundwater near a creek. Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III—Policies Pages 3 through 6 for evaluation criteria Yes ❑ No D 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 x] 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 x -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 E Yes ❑ No ❑Not Applicable Greatly improve quality of effluent entering groundwater. 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. 0 F ❑. Yes No Not Applicable Will reduce nitrogen loading.Excess nitrogen can cause algal blooms and contribute to hypoxia in surface waters. Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See.LVW Section III - Policies Pages 32 through 34 for evaluation criteria. 1-1 Yes ] No n 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 LVW Section III—Policies; Pages 34 through 38 for evaluation criteria. El Yes F] No 0 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. 0 YeO No Not Applicable Attach additional sheets if necessary 4 WORKING COAST POLICIES 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 0 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. ❑ Yes F] No 0 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. Yes ❑ 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 0 Not Applicable PREPARED BY Glynis Berry,AIA,LEED AP TITLE Designer of I/A OWTS DATE 2/5/2022 24190 Main Road studio a/b PO.Box 444 architects glynis@studioabarchitects.com Orient,NY 11957 http://adizumiberry.com T&F 631 323 1426 February 11, 2022 Board of Town Trustees Town of Southold Town Hall Annex 54375 Route 25 PO Box 1179 Southold, NY 11971 ��rE C E g V E Re: 220 Oak Avenue,Southold, NY �r i TX Map# 1000-077.00-02.00-004.00 FE® ' Southold Town Board of Trustees Dear Reviewer, 1 am the architect of the wastewater system and submitting on behalf of Antigone and Randolph Amengual.This packet is submitted for a permit from the Town Trustees for the installation of an I/A OWTS and shallow leaching field,to replace failing cesspools. - Wetland permit application fee—Check for$100 - Authorization form - Affidavit - Disclosures by Owners - Disclosure by Agent - Application plus copy - Short Environmental Form plus copy - LWRP consistency Assessment Form plus copy - Survey of existing property+3 copies Four sets of plans for I/A OWTS Photographs of site If you need any further information, my cell is 631680 9656 and email is above.We appreciate your review of this. Sincerely, Glynis M. Berry,AIA, LEED AP