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HomeMy WebLinkAboutTR-1558 ALL ~.,O0~I~.~GS AND STAKES MUST DISPLAY VISIBLE blOORiNG NUMBERS -~- ALL DOCF~ A~TD BULZCHEADS }lUST DISPLAY VISIBLE PERMIT NU~'4BERS Board Of 5outhold Town Trustees SOUTHOLD, NEW YORK ~OORZ~NG ~0. N/A Pursuanf fo +he provisions of ChaoS'er 6f5 of +he Laws of fhe Sf~fe of New York, 189~: and Chapfe'r 4,04 of fha Laws of fhe Slate of New York 1952: and fhe Sou'~hold Town Ordinance e~- fffled "REGULATING AND THE PLACING OF OBSTRUCTIONS IN AND ON TOWN WATERS AND PUBLIC LANDS and fhe REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS FROM. LANDS UNDER TOWN WATERS~" end in ~ccordance wifh fhe Resolufio~ of The Board edopfed afa meeting held on .H~.y.....~ ~ ....... 19. 8.~ .... and in consideration of fha sum of $_Z?..~..0...0. ....... paid by Eugene G. & Ellen ~o Steigerwa].d" of Ma'ct .......................................................................................... N. Y. ~nd sub[ecl fo fha Terms and Condffions I[sfed on ~'he reverse side hereof, of Soufhoid Town Trusfees aufhorizes and permffs fha 'co eonstr~et a 40 × 4 ft. cloak, ].2-× 3 ft ramp, a~cl 20 × 8 f:~ f:].oat±ng- dock -i~ Deep HoZe Creek, Hat'c±t~ all [n accordance wifh fha derailed s. '" ' pecmcaflons as preseM'ed in fha originating appllcafion. IN WITNESS WHEREOF, The said Board of Trusfees here- ~b¥ c~uses ifs Oorporafe Seat fo be affixed, and fhese pres'~n~rs fo be subscribed by a maiorffy of fhe smd Board as of ~his ............. ~ T~stee~ ' '-:~'::'~"?':'~"'==--"~' '~-'-~'-~-c~ c~ ~ Z~:~- ~.~_ f~ ..... ~'Z.~: Board Of $outhold Town SOUTHOLD, NEW YORK MOORZ~G ~0. N/A PERMIT NO ..........Z..5...5. 8 ............ DATE: ........ ISSUED TO Eugene G. & Ellen M. Steigerwald lrustees I, , certify that the work as authorized in this permit has been completed and"%s now ready for your inspec- tion. Also, the number required on this projec~ is clearly visible. I further understand this permit is not valid until this tear sheet is returned to the Trustees. Siqned - ~ner TERMS and CONDITIONS -The Pern~ Euqene G. & Ellen M. Steiqerwald ~{d'~§at_ 1275 Bunqalow Lane, P. O. Box 782.,. Mattituck N. lowing: 1. That the Southold Trustees Permit must be prominently displayed on the premises effected thereby during the period of 2. T~: ~e ~d B~dof T=~s ~d ~e Town of ~u~o[d ~ ~d ~rom ~7 ~d work ~ damages, or da~ for dmag~, of ~u ~ing ~y or ~y ~ z r~t of ~7 o~- under a~n ~ffo~ p~t to ~s ~ ~d ~e ~d Pe~ wfl~ at ~ ~h~ own ~% the defend any ~d MI su~ ~ ~t~ b7 ~d pa~, and ~e ~d wi~ respec= ~erero, to ~e mmplete ~ci~ion of ~e ~d of T~ of ~e Town of ~oldPerm~ 3. That ~ Permit is wild for a period of :ON~. V52AR which is considered to be sufficient time required to complete the work involved, But should circum~ances warrant, r~lU~St for an ex-tension may be made to the Board at a later date. Thit this Permit should be retaLued indefLaltely, or as long as the ~aid P~m~ to maintain the structure' or project involved, to provide evidence to anyone concerned that auth. orizafion was originally Obtained.' o' - 5. That the work involved will be subject to the inspection and approva/ of the Board or iu agents, and non-compliance with the provisions of the ori~rm~O, g application, may be cause for revocation of this Permit bZ resolution of the. said Board. - - : ...... - 6; -~'hit th~e'~*SHi 'be no unreasonable 'interference with navigation as a result of 'the work herein authorized. 7. That there shall be no interference with the right of the public to pass and repass along beach between high and Iow water mar~. 8.. That 'ff furore operations of the Town of Southold require the removal anil/or alterations in the location of the work her~4.n authorized, or if, in the opinion of the Board of Trustees, the work shall cause unreasonable obstrucnon to free navigation, the said Permirtee will be required, upon due notice, to remove or alter this work or projecr herein stated without expenses to the Town of SouthoId. 9. That the said Board will be notified By the Permirtee ot the completion of the work auth- orized. (See tear off sh~==t. ) 10. That the Permlttee wlH obtain all other permits and consents that may be resulted sup- plemental to this permit which may be subject ~o revoke upon failure to obrM- same.. BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall, 53095 Main Road P.O. Box 728 Southold, New York 11971 TELEPHONE (516) 765-1801 May 11, 1982 Mrs. Judith T. Terry, Town Clerk Town Hall Southold, New York Dear Mrs. Terry: The following action was taken by the Board of Southold Town Trustees at a regular meeting held May 4, 1982: RESOLVED to recommend to the Southold Town Board approval of the wetland application ~94 of Eugene and Ellen Steigerwald to construct a 39 ft x 4 ft catwalk, 12 ft x 3 ft ramp and 20 ft x 8 ft floating dock, with the provisions that the dock is parallel to and 15 ft from property line; that boats and float are 15 ft from property line and that neither will in- fringe on the channel. Yours truly, Paul Stoutenburgh, President Southold Town Trustees BOAI-{D OF TOWN TRUSTEES Town o~ Southold l~lain Road Southold, New York ] 1971 NOTICE OF ACTION - NOT A PERMIT To: Eugene & Ellen Steigerwald I. your application, doted .~.r...c.b....2..2..,.....1..9...8..2. ..................................... has been reviewed by this Board, at o meeting of the Trustees held on .......... .~M~..3.....4.,.....!..9...8..2. ........................................................ and resulting in the action, as indicated below: Application approved. Appllcotion denied. Application tabled. Comments and remarks: Approved with the provisions that the dock is parallel to and 15' from property line;that boats and float are 15~ from property line and that neither will infringe on the channel. ~ A PERMIT FEE ~_~ur c~D[ic ti n i ed_above. Rmf=~e'rmff-Fe~ is now duel and should be made payable t~e, order of the Board of Southold Town Trustees. This fee is ~omputed below accordino to }(e,~fh~¢_ ~f R~[esgs set fo~h in the ,instruction [heet _(Ecrm ]/1). ~his fe~ ~ust ~e pa~u ~n~n ~u ~ays or re-applying an~ a~L~ona! ~ee w~i~ De ne~essa~ [f the Permit Fee [s said in person to the Secretary of the Board, The germff will be obtainable the same time. If the 'fee [s paid by moil, the permit will be mailed [n reply. Computation of Permit Fee: 13'x 4' 'dock = 52 sq ft ~ $.~5 per sq ft = 12' x 3~ ramp = 36 sq ft ~ $.25 per sq ft = 20' x 8' float = 160 sq ft ~ .25 per sq ft = 3 piles ~ $5.00 per pile = $13.00 9.00 40.00 15.00 $77.00 Total Fee for this application , ~ $ 77,00 S~§ned ... Pres o Board of So~utho[d Town TrustYes. · .. ......... ? ..................................... BOARD OF TOWN TRUSTEES Town o£ Southold Main Road Southold, New York 11971 NOTICE OF ACTION - NOT A PERMIT To: Eugene & Ellen Steigerwald ] Your application', dated March 22, 1982 ' · ....................................................................... has been reviewed by this 8oord, at a meeting of the Trustees held on ....... Ap. ril 7, 1982 and resulting in the action, as indicated below: ( ............ ) Application approved. ( ............ ) Application denied. (-..~..) Application tabled. 2. Comments and remarks: Application to construct a float, ramp and dock in Deep Hole Creek, tabled until such time as a Wetlands Application is filed with the Southotd Town Board. Deadline for May meeting is April 22, 1982. A PERi, IT FEE 3. If yaur OoDliCation iS aDDroved above, ,~ ?urrnff ,-t~-~ tS now du% and should be made payable to th~ order of me Board of'Southo d Town Trustees Z '- ' · the S~hedule of Rates s~ ~ fn~fk :- :~ ..... . ~,h~ ~e ~s computed below accordmfl to pai~ wzthzn 90 ~' 6~"~'. ~99~[~r'q~nqe~ 5 r~ LAl. his Z ust be f the Perm,t Fee ~s oa~d m ner~ f~ ~h= ¢ ................ e necessary. ................ etary or rne ~oara, ;ne ~erm~t w~il be obtainable at the same time. If the fee is paid by mail, the permit will be mailed in reply. Computation of Permit Fee: Total Fee for this application By . ..~.o ~ O3~erk 7' ........................................... NAME OF CREEK BOARD OF TOWN TRUSTEES Town Of Southold Main Road Southold, New York 11971 A72 - Rev. APPLICATION FOR FIXED and/or FLOATING DOCKS 2. Contractor's name and address: .....~..9..7' .........C~..~...~.k~7 .............................................................. ...... . s.,a . . . . . . .'id .a ........ u .ra ...... :. :l: ................................... ,. . .q. . ?. .'4.. . .%q. 3. Briefly explain the purpose of this application: ...... C..Oi'~,,%...T~....?..c...T2....?.~.?.. .... .~.~),~. ....... ......... ............................................................................................................... 4. After issuance of a Permit, work must be completed within one year. LARGE 5. Secure the correct Area Map from the Clerk of this Board, and by using a/X WITHIN A CIRCLE indicate as closely as possible the location of this dock. On the reverse side of this map, provide a SCALE DRAWING which will show Ordinary High Water Mark, the shape and size of the dock and any supplemental pilings which are needed to hold a floating dock or tie-u;) a boat. Give all dimensions necessary to determine the area of the dock surface WHICH EXTENDS OFFSHORE fromtheO. H.W.M.]::~: adjacent proper owners have docks~ specify location and length to scale. 6. Will any portion of this construction extend offshore into Town Waters beyond on imagln~l::~, line o.r boundary formed by other similar structures along the area's shoreline? YES If it does extend beyond this sa-called dock line indicate by how far, approximately,. ....... 7. Provide the following documents: ~(a) A Licensed Engineer's Survey of the property involved. ~,(b) A copy of the Contractor's Plans and Specifications. ~(c) Short Environmental Assessment Form. 8. Will this construction require the Filling of any land offshore of the Ordinary_..High Water Mark or the Dredging of any material from Town Lands under water? YES or~...9) If it does, Form A/4 (Application for Dredging/Filling) must be completed and attached as part of this application. 10. In requesting approval of this application, I submit that: the information presented herein is true and correct to the best of my knowledge and belief; I am the person accountable for the performance of the work in accc~rdance with the plans and specifications attached; I have read or am familiar with the provisions of any Southotd Town Ordinance pertinent to the work involved; and further, I intend to adhere to and abide by the Terms and Conditions of the Permit, when and if issued to me. To expedite finding specific by using a temporary marker. Accepted b:~..~.~, ~ location for inspection, indicate ES Dated: Town Of $outhold Town Clerk's O~iee Southold, N. Y. APPLICATION FOR WETLANDS PERM~ Application No...f.~.... .................... Date of Application .............. .u(...~..~.~..~..~....~. ............... I de ntity of Appl icant ....~..~..~..~...~.......~. ,.. ~... ~ ~.~ ~.~ ..... ~ ........ .~.~.~.~. ~ ..................... Address of Applicant ................................................... ~ ....................... ~ ........................... .~.. INSTRUGTIONS FOR PERMIT A. This application is to be completely filled in by typewriter or ink and submitted to the Town Clerk in quadruplicate, accompanied by writter~ permission from the owner of the property Jf not the same as the applicant. B. Pilot Plan must be drown to scale on the reverse side of ~his application showing the location of property, the names and locations of owners of adjoining properties, and a detailed description of proposed project. (Note: Copies of the Pilot Plan may be made by a copy machine and attached to the Permit Application.() C. No operation shall be. initiated by the applicant until all permits that are required are issued. D. A detailed statement of the rehabilitation and proposed condition of the premises after the work is completed must be given, including a survey if required. E. If permit is being sought for a more sizeable excavation than the construction of a private single .dock or jetty, then this application must be accompanied by a survey and topographical, map certified by a registered land survey or Professional Engineer. 'Phe horizontal control of survey shall be based upon an approval local coordinate system. The vertical :control for elevation and sound- ings shaJl be based upon United States Coast and Geodetic Survey and/or United States Geological Survey .daCum. F. A statement must accompany the application describing any known prior operations conducted on the premises in question and whether any prior licenses or permits have been issued to erect structures or to dredge or deposit fill on said premises and vchether a~ny such permits or licenses were ever revoked or suspended by a governmental agency. G. A filing fee of $25.00 shall accompany the application. This filing fee includes one inspection, there ~s a $5.00 fee for each additional inspection. H. The Town Board upon requestq~f._~t~ applicant for a perm_~it, may waive in whole or in part, the provisions of Article II, Secti.on'=~l~'; subdivisions (~ and (~j~'where it finds that nature of the proposed operations are such that '~he requirements of such provisions are not necessary for a proper consideration of a permit application.. ]. Upon approval of this application ~h.e Town, Clerk will issue a permit to the applicant. Such permit shall be availaNe for inspection at any time, upon request. Examined .................................................. 19 ....... App roved ................................................................. Disapproved ........................................................... Conditions, if any ................................................................................................................................. Examining Body ..................................................................................................................................... Signature of Chairman ......................................................................................................................... APPLICATION IS HEREBY MA,DE to the Town Board of the Town of $outhold, Suffolk County, New York, for the issuance rOf a permit pursuant to the Laws, Ordinances and Regulations govern- ing the Coastal and Interior Wetlands, Flood Plains and Drainage. Areas of the Town of Southold: Permit requested to ...... ..~...¥..~..~...~.......(~..,.....~....~'...~..~.~,~....~. ...... ..~..: .... .~...T....~...G...~.~....ug..~?:..-~. ............................... Location of property for which permit wanted ............... ~ .... .~,.[:~E., ....................... ........... ~.~:.~..c~ ....... .~..'( ..... .~.~.~3. ......................................................................................... Home address of permit applicant if differen~t from aforesaid location .~,,,O.,..~,,.~,~,,.-l.,,~...~., ............. ........ ...~....~.m..~.c.~ ..... .~.~J.. ..... ~,.~.~..q.~..~.) ............................................................................................ Creek, Bay or Harbor fronting property .....~.[.~,.~l~......~.~...~.....C<....~.~,[ C~ ......................................... Size of proposed work: Length ......~..,.C..,~.?...~..~...~..~... ~..~........b~?.. ....... ..~...~. i..~.~...~...~..,)..C,~.....~.....eq~ .P....t.~.'.. ?..{~ ~. ~,.~...R:...~.....~...~.c...~.,...Z,{D' ~ Width .........~. ..................................... .) ............................. ~ ................................ ~. ..................... Height Above High W'ater ..................................................................................................................... Depth Below Low Water ......................................................................................................................... Yards to be ExcaYated ........... ..N...~....~ ................................................................................................... Yards to be Fillecl ............. I>l..~...~...~'.. ....................................................................................................... Width of canal, creek of bay fronting property ........ ~.0..0......~.~.~.: ..................................................... Depth at Low Tide ..... ).:[.~......~..o.......~_ ...................................................................................................... Average Rise in Tide Is this for private or business use? .......... ~.~.~..~... ................................................................................... Area Zoning ....... ~..~..S..~..~.. ~ .~....~...~. .................................................................................................. Manner in which material will be removed or deposited ..... .~.O..'C'.. ...... ...~..~.l~..~.~:l~y~....~.. .................. Written consent of owner o,f property, if not the same as the applicant ........ ~.¢4:~.....~.. ................. COUNTY OF SUFFOLK ) STATE OF NEW YORK ) SS: -,.~~..~...".....~......~..../__~ ...~....:...~. ~ being duly sworn deposes and says that he is the. applicant for the above described permit, and that all statements contained herein are true to the best of his knowledge and belief; that the work will be done in the. manner set forth in this application ond as may be approved by the Town Board of the Town of 'Southol& The applicant agrees to hold the Town of Southold and the Town Board harmless and free from any and all damages and cla'ims arising under or by virtue of said permit, if granted. Signatur{ of Applicant ~ "7 Sworn to before me this /~ .................... ............. ......... ~ ~ .~or~ Public JUDI~ T. TERRY ~a'P~ Pub)ic, S~:~tQ of New York ~- ~-03~3 SufF~ · SHORT ENVIRONMENTAL ASSESSMENT FORk{ ' ' INSTRUCTIONS: (a) In Order to answer the questions in this short EAF it is assumed thai the preparer wilt use currently available information concerning the project and the likely impacts of the action. [t is not expected that additional studies, research or other investigations will be undertaken. (b) [f any question has been answered Yes the project may be significant and a completed Environmental Assessment Form is necessary. (c.~ If ali questions have been answered No it is likely that this to the project site or physically a[te.r more than ZO acres of land? ............. Yes ~ No _ 2. Will there be a major change to any unique or" " -unusual land form found on the site? ........... Yes '~ No 3. Will project alter or hove a large effect on - existing body of water~ Yes ~ No 4. Will project have a potentially large impact --~- - on groundwater quality? ........................ Yes ~':No 5. Will project significantly effect drainage ~ '- :flow on adjacent sites?~- '- .............. Yes__~_No 6. Will project affect any threatened or endangered plani or animal species? ........... Yes ~ No 7. Will project result in a major adverse effect .... on air quali~y? Yes X NO 8. Will'project have a major effect on visual - -- character of the community or scenic views or vistas known to be important to the community? Yes ~ No ~. Will project adversely impact any site or ' structure of historic, prehistoric or paleontologi, cal importance or any site designated= ~s a critical environmental area by a local-agency? ..... -.~ ...... .'~..'~.v-..~..~--~...v Yes ~ No t0. Will project have a major effect on exis±ing ' - or future recreational opportunities? ......... Yes ~ No 11. Will project result in major traffic problems .... or cause a major effect to existing transportafion system's? ....................... Yes ~ No 12. Will project regularly cause objectionable ' odors, noise, glare, vibration, or electrical disfurbance as a result of the project's operation? ' - .... Yes ~ No 13. Will project have any impact on public health -- '' or.safety? ................................ '... Yes ~ No 14. Will project affect the existing community by ..... directly causing a growth in permanent popu!otion of more than 5 percent over a one year period or have a major negative effect on the charo~-~er of the community or neighborhood? Yes ~ No 15. Is there public controversy concerning the -- ' project? ...................................... Yes ~ No REPRESENTING ~ DATE project.is not significant. (d') En--~zronmentol Assessment ~ Will project resul't in o large physical change TOWN OF SOUTHOLD SHORT ENVIRONMENTAL ASSESSMENT FORM [NSTRUCTIONS: '' (a) I~ Order to answer %he questions in this short EAF it is assumed that the preparer will use currently available information concerning the project and the likely impacts of the action. It is not expected additional studies, research or other investlgotions will be undertaken. (b) If any question has been answered Yes the project may be significant and o completed Environmental Assessment Form is necessary. (c) If all questions have been answered No it is likely that this project is not significant. (d) E~-~i'ronmentot Assessment ~.' Will project result in a large physical change to %he project'site or physically al%e.r more than 10 acres of land? ........................ Yes ~ No 2. Will there be o major change to any unique or · unusual land form found on the si%e? .......... Yes ~ No 3. Will project al%er or have o large effect on ' existing body of wa%er? ....................... Yes ~ No 4. Will project have a paten%Jolly large impact on groundwo%6r quality? ....................... Yes ~:No 5. Wilt project significantly effect drainage - ~ - flow on adjacent si%es9 - Yes Y No 6. Will project affect any threatened or -- ' endangered plan% or animal species? ........... Yes ~ No 7. Will project result in a major adverse effect ---- on air quality? ............................... Yes ¥ No 8. Will project have a major effect on visual ' ' character of %he community or scenic views or vistas known to be.important %o %he community? Yes ~ No ~. Will project adversely impact any site or structure of historic, prehistoric or paleontological importance or any site designated os o critical environmental oreo by o local agency? ............ ~..'~-~.~'...-,..~.'~..v Yes ~ No la. Will project hove o ~ojor effect on existing ar future recreo%ionoi opportunities? ......... Yes ~ No 11. Will project result in major traffic problems -- or cause a major effect %0 existing transportation systems? ....................... Yes ~ No 12. Will project regularly cause objectionable ~ ' odors, noise, glare, vibration, or electrical J disturbance as a result of the project's opera%ion?. ................................... Yes g No ~3. Will project have any impact on public health · or.safety? ............................ ~ ....... Yes ~ No 14. Wilt project affect %he existing community by ..... directly causing a growth in permanent populo%'ion of more %hah 5 percent over o one year period or have o major negative effect on %he chora~Yer of %he community or neighborhood? ................................. _ Yes 15. Is %here public con%roversy concerning the .... project? ...................................... Yes % No PREPARER'S SIGNATURE REPRESENTING DATE 3-%~'~- NANO P -E APPLICATION NO. DEPARTMENT OF' THE ARMY NEW YORE DISTRICT. CORP~ OF ENGINEERS 82-345--L2 23 June 1982 PUBLIC NOTICE NO. 11200-82-345-L2 TO WHOM IT ~LAY CONCERN: This District has received an application for a Department of the Army permit pursuant to Section 10 of the River and Harbor Act of 1899 (30 Stat. 1151; 33 U.S.C. 403; /-~ Section 404 of the Federal Water Pollution Control Act Amendments of 1972 (PL 92-500, 86 Stat. 816, 33 U.S.C. 1344); Section 103 of the Marine Protection, Research and Sanctuaries Act of 1972, as amended (PL 92-532, 86 Stat. 1052, 33 U.S.C. 1413). APPLICANT: Eugene & Ellen Steigerwald Mattituck Lane P.O. Box 782 Mattituck, New York 11952 WORK: Catwalk, Ramp and Float WATERWAY: Deepho!e Creek, Great Peconic Bay LOCATION: Mattituck, Suffolk County, New York A detailed description and plans of the proposed work are inclosed to assist in your review of the proposal. The decision whether to issue a permit will be based on an evaluation of the probable impact of the proposed activity on the public interest. That decision will reflect the national concern for both protection and utilization of important resources. The benefit which reasonably may be expected to accrue from the proposed work must be balanced against its reasonably foreseeable detriments. Ail factors which may be relevant to the proposed work will be considered; among those are conservation, eco- nomics, aesthetics, general environmental concerns, historic values, fish and wildlife values, flood damage prevention, land use, navigation, recreation, water supply, water quality, energy needs, safety, food pro- duction and, in general, the needs and welfare of the people. NANY FL-129 Aug 78 NANO P-E PUBLIC NOTICE NO. 11200-82-345-L2 A preliminary review of the application indicates that an Environmental Impact Statement will not be prepared. A review of the latest publish- ed version of the National Register of Historic Places and of the pre- sence or absence of registered properties or properties listed in the latest published version of the Register as being eligible for inclu- sion, therein, has been made. Presently unknown archeological, scien- tific, prehistorical or historical data may be lost or destroyed by work to be accomplished under the required permit. The following government authorizations have been obtained or will be obtained prior to the issuance of a Department of the Army permit: A Permit from the New York State Department of Environmental Conservation Any criticisms or protests regarding the proposed work should be PREPARED IN WRITING AND MAILED TO REACH THIS OFFICE prior to 24 July 1982 otherwise it will be presumed that there are no ob- iections. It is requested that you communicate the foregoing information con- cerning the proposed work co any persons kno~m by you to be inter- ested and who did not receive a copy of this notice If you have any questions concerning this application, you ~a~y contact Mr. Dennis Santolo of this office, Telephone No. 212-264- 0183. 2 Incls: 1. Description of Work 2. Plans W. M. SMITH, JR. Colonel, Corps of Engineers District Engineer NANY FL-129-t Aug 78 NANOP-E APPLICATION NO. 82-345-L2 PUBLIC NOTICE NO. 11200-82-345-L2 DESCRIPTION OF WORK The applicants, Eugene and Ellen Steigerwald, propose to construct a catwalk, ramp and float for mooring a private boat in Deephole Creek, Great Peconic Bay, Mattituck, Suffolk County, New York. As shown on the attached drawing, the proposed timber catwalk would measure 39 feet by 4 feet and stand 3 feet above grade. It would connect to a ramp 12 feet by 3 feet and a float 20 feet x 8 feet. The catwalk, ramp, and float would extend a distance of 50~ feet from mean high water into Deephole Creek. APPLICATION FOR A DEPARTMENT OF THE ARMY PERMIT ?orm Approved - Office of For use of this form, see EP 1145-2-1 · Mgmt & Budget No. 49-R0420 The Department of the Army permit program is authorized by Section 10 of the River and Harbor Act of 1899, Sect on 404 of P, L, 92--500 and Section 103 of P. L, 92--532, These laws require permits authorizing structures and work in or affecting navigable waters of the United States, the discharge of dredged or fill material into waters of the United States, and the transportation of dredged material for the purpose of dumping it into ocean waters, Information provided in ENG Form 4345 will be used in evaluating the application for a permit,' Information in the application is made a matter of public record through issuance of a public notice, Disclosure of the information requested is voluntary; however, the data requested are necessary in order to Communicate with the applicant ~nd to evaluate the permit application, If necessary information is not provided, the permit application cannot be pro-- cessed nor can a permit be issued, One set of original drawings or good reproducible copies which show the location and character of the proposed activity must be attached to this application (see sample drawings and checklist) and be submitted to the District Engineer having jurisdiction over the location of the proposed activity, An application that is not completed in full will be returned, ~, Application number (To be assigned by Corps) 2, Date .... 3, 'For Corps use'only, Day Mo. Yr. 4, Name and address of applicant, 5, Name, address and title of authorized agent. Telephone no, during business hours Telephone no, during business hours A/C ($t(~) ~"~.. LmE3~O A/C ( ) - ~' A/C ( ) 6, Describe in detail the proposed activity, its purpose and intended use (private, publi~., commercial or other) including descrip- tion of the type of structures, if any to be erected on fills, or pile or float--supported platforms, the type, Composition a~d quantity of materials to be discharged or dumped and means of conveyance, and the source of discharge or flit material, If additional space is needed, use Block 14. 7, Names, addresses and telephone numbers of adjoining property owners, lessees, utc,, whose property also adjoins'the wate"r~ay', 8, Location where proposed activity exists or will occur. - Address: Tax Assessors Description: (if known) Street, road or other descriptive location Map No, Subdiv, No, Lot No, In or near city or town Sec. Twp. Rge, County State Zip Code 9, Name of waterway at location of the activity, ENG Form 4345, I OCT 77 Edition of I Apr 74 is obsolete, 10. Date activity is proposed to commence. Date activity is expected to be completed 11. Is any portion of the activity fOr which authorization is sought now complete? r--J YES ~ NO If answer is "Yes" give reasons in the remark section, Month and year the activity was colt~leted · Indicate the existing work on the drawings. 12. List all approvals or certifications required by other federal, interstate, state or local agencies for any structures, construc- tion, discharges, deposits or other activities described in this application. Issuing Agency Type Approval Identification No, Date of Application Date of Ap~rovat 13, Has any agency denied approval for the activity described herein or for any activity directly related to the activity described herein? Yes ~/'i No {If ''Yes" in explain remarks) 14. Remarks or additional information, 15. Application is hereby made for a permit or permits to authorize the activities described herein. I certify that I em familiar with the information contained in this application, and that to the best of my knowledge and belief such information is t~Ueo complete, and accurate. I further certify that I possess the authority to undertake the proposed activities. ~ign ture of Applicant\or Authorized Agent The application must be signed by the applicant; however, it may be signed by a duly authorized agent (named in Item 5) if this form is accompanied by a statement by the applicant designating the agent and agreeing to furnish upon request, supplemental information in support of the application· 18 U, S, C. Section 1001 provides that: Whoever. in any manner within the jurisdiction of any department or agency of The United States knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact or makes any false, fictitious or fraudulent statements or representations or makes or uses any false writing or document knowing same to contain any false fictitious or fraudulent statement or entry, shall be fined not more llman $10,000 or imprisioned not more than five years, or both. Do not send a permit processing fee with this application. The appropriate fee will be assessed when a permit is issued.