HomeMy WebLinkAboutTR-111-9-1 & 2Board Of $outhold Town Trustees
SOUTHOLD, NEW YORK
PERMIT NO. i./.:.~:..~.~,~Z
DATE: ..1.: [H:C~. ......
ISSUED TO ......... ~.c.~%.ff=~ .......... k,,~.~..,f~ ................................................................
Pursuant fo fha provisions of Chapter 615 of the Laws of
the State of New York, 1893; and C.kapter 404 of fha Laws of the
State of New York 1952; and the Southold Town Ordinance en-
tiffed "REGULATING AND THE PLACING OF OBSTRUCTIONS
IN AND ON TOWN WATERS AND PUBLIC LANDS and the
REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS FROM
LANDS UNDER TOWN WATERS;" and in accordance with the
Resolution of The Board adopted afa meeting held on
19 ......... and in consideration of the sum of $....~,~,~p~: paid by
of ............................................................................... N.Y. and subiect to the
Terms and Conditions listed on the reverse side hereof,
of Soufhold Town Trustees authorizes and permits the following:
all in accordance with the detailed specifications as presented in
the originating application.
IN WITNESS WHEREOF, The said Board of Trustees h,ere-
by causes ifs Corporate Seal fo be affixed, and these presents to
be subscribed by a majority of the said Board as of this daf.e.
Trustees
TRUSTEES
John M. Bredemeyer, III, President
Henry P. Smith, Vice President
Albert I. Krupski, Jr.
John L Bednoski, Jr.
John B. Tuthill
Telephone (516) 765-1892
BOARD OF TOWN TRUS'I
TOWN OF SOUTHOLD
SCOTT L. HARRIS
Supervisor
53095 Main Road
~]1~.~. Box 1179
New York 11971
~'~ 16) 765-1823
~el}~e (516) 765-1800
o
Name of
Mai 1 ing
Address of Property:
Tax Map Number: 1000-
GRANDFATHER APPLICATION
Applicant: ~~ M ~ ~/~[ __
address: ~ 0~5 I~t~ ~C~C
Prior owner if known:
Diagram of existing structures,
included with this application:
Tel. No: -"/~)4--'-14
I [ t --q-7~ Approx.yr.of construct:
including all dimensions, must be
tD I'q C__.bC),5 t~ D
Indicate
pole number,
Signature of
Please note,
application.
on attached map: Location, ie; reference point, telephone
adjacent property owner.~ etc.
app 1 ic an t~~~/~///~~/~ Date:
there is a one time fee of $50.00 for filing this
Environment East, Inc.
R. R. No. 3 - 3075 Indian Neck Lane
Peconic, New York 11958
5! 6-734-7474
BEE BUSINESS FORMS. INC. 29313c
I DEC APPLICATION NUMBER ,
;TMENT GE ENV RONMENTAL CONSERVAT ON ': ';
JOINT:APPLICATIONFOR PERMIT U.S.ARMY CORPS OF ENGINEERS AePLJCA'[,ION NO,;",",'*
Please read ALL instructions on.back before completing this application. Please type or print clearly in ink. Attach additional-information a~ ngeded
~AETICLE 9/TITLE'1; A[TICLE 43 6NYCRR 646 (LAKE GEORGE RECREATION ZONE)
~ ~ ARTICL~ 15, TtTLE 3 (AQUATIC PESTICIDES CONTROL) ~6NYCRR 327 (AQUATIC VEGETATION) ~ 6NYCRR 328 (FISH)
~ARTIcLE 15, TITLE 5 6NyCR~ 608 (PROTECTION OF WATERS)
~For the construction, reconstruction, or repair of a DAM or other impoundment structure.
~ Fo~ the disturbance of a STREAM BED OR BANKS or excavation m or fill of NAVIGABLE WATERS ~401 WATER QUALITY CERTIFICATII
~ ARTICLE ,15, TITLE 15,;; ,(~6NYCRR 601 (WATER SUPPLY) ~6NYCRR 602 (LONG ISLAND WELL)
~ARTICLE.'~5; .TITLE 27 6NYCRR 666 (WILD, sCENIC AND RECREAT ONAL RIVERS)
~ARTIC,LE 24 6NYCRR 662, 663 (FRESHWATER WETLANDS)
~ARTICLE 25 6b ~TLANDS) ~ARTICLE 34 6NYCRR 505 (COASTAL EROSION)
AND HARBOR ACT OF 1899) for structures and work in nCvigable waters of the U.S. ~COASTA~ CONSISTENCY CERT~EICATION.
SECTION 404 (CLEAN WATER ACT OF 1977) for disposal of dredged or fill materia in waters of the U.S.
SECTION 103 (MARINE PROTECTION, RESEARCH AND SANCTUARIES ACT) for the transportation of dredged materials for dumping into ocean waters.
1. LIST PREVIOUS PERM T/APPL CATION NUMBERS AND DATES (If any)
2. APPLICA['
pality/Governmenta] Agency
TELEPHONE
TELEPHONE
POST OFF]CE
If YES, attach exp[anation'on, starting work without permit, include dates; 8. WILL PRO
.n map and/or drawings. ' [] Yes
STARTING DATE: tl. APPROXIMATE COMPLETION
.g,, quantity and type;of material to be excavated dredged or used for fi or r p rap, ocat on of
bt'of dam; size of impoundent; capacities of proposed water sources; extent of distribution system; etc.)
DITIONAL FEDERAL. :, .... ,, : STATE AND/OR LOCAL PERMITS? '~Yes~:~'*:;- ~ No
that information provided on this form and all attachments submitted herewith is true to th
Class A misdemeanor ~ursuant to Section 2~0.45 of th~ ~enal
lamage, direct or indirect, of whatever nature, and bg whomever suffered arisi~
~nd agrees to indemnifg and save harmless the State from su ts act OhS damages and costs of evew name and descr pt on resu tin~ from said
>n, F~deral law 18 U.S.C. Section 100~ crovides for a f n~ of 'not more than $30~000 or imprisonmeat ~or'not more than five gears, or both
knowingly and willfullg falsifies,~ls,~~~orcov~up~atg~al~¢; or, knowingly makes or uses a false-, fictitous or fraudulent statemenL
New York State Department of Environmental Conservation
Building 40--SUNY, Stony Brook, New York 11790-2356
Thomas C. Jorling
Commissioner
Applicant Name: (please print)
Application Number .'.
Project Location:
_~at.e l. tB · q
~ A:R-~ F,,..,o,.o L L.-,
/
8, ¢-.'2..s/:5 :~z:,.5' N~A L) PT:.
c_..L.)'"t'c.,v-,,"c)~--~o~ t',,3 .'7".
I hereby state~ as or on behalf of the applicant, that I understand
and agree that the lssuance of any permit pursuant to the above-
referenced app!ication does' not in any way mitigate an¢]/or resolve
any ontstanding violations of the New York State Environmental
Conservation Law ("ECL") and the rules and regulations enacted
/
pursuant thereto at the site of the proposed project2X
F~_trthermore, I HEREBY SWEAR THAT I (__ DO)~ ( ~/ DO NOT) HAVE
ANY CURRENT OR ON-GOING ( UN_RESOLVED ) NEW YORK STATE DEC
VIOLATIONS AT THIS PROJECT STTE[~,_..- ,,' -,. .,-
FOR ADJOINING AREA SEE MAP NO.28
PECONIC
4O
,41
;EE MAP NO.30