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PI~JECT I.D. NUMBER
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6',-,.21
Appendix C
State Environmental Quality Review .'-'
-SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only
PART I--PROJECT INFORMATION (To be completed by Applicant or Project sponsor)~'(.,
4. PRECISE LOCATION (Street address an~ road intersections, ~rominent landmarks, ~Ic., or prow~e
SEQF
5. IS PROPOSED ACTION:
.M]~ew [] Expansion [] Modificati'on/alteration ' ·
6. DESCRIBE PROJECT BRIEFLY: ·
7. AMOUNT OF LAND AFFECTED:
Initially · 4.¢'..C~ acres Ultimately ' V~ acres
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
[] No If No,. describe briefly
WHAT IS PRESENT LAND US;z iN VICINITY OF PROJECT?
Describe:
%
[] Agriculture [] ParktForestlODen space [] Other
10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL,
STATE OR LOCAL)? '
*~"Yes []I',o Il'yes, list agency(s)and permit/approvals
11. DO~¢ANy ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ~ Yes ~lo If yes, list agency name and permit/approval
'12. AS A RESULT OF.PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION?
DYes '~O
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
If the action is in the Coastal Area, and you are a state agency, complete the
Coastal Assessment Form before proceeding with this assessment
OVER
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County of Suffolk )
State of New York )
L~ ~'~-~' BEING DULY SWORN DEPOSES AND
AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED
PERMIT(S) AND THAT ALL STATEMENTS' CONTAINED HEREIN ARE TRUE TO
THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT 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 TOWN 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 REPRESENTATIVE(s), TO ENTER ONTO MY PROPERTy
TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS
APPLICATION.
SWORN TO BEFORE ME THIS
NOTARY PUBLIC
DAY OF .~~
SUSA~ L SMITH
Notam/Public, Stere ¢ New York
No. 4944835
/
Suggested space for location Map
THIS IS NOT A PERMIT
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