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HomeMy WebLinkAboutWALDRON, ROBERT JRHENRY P. SMITH, ~ - ~ JOHN M. BREDEMEYER, 'Iii ~ rPresident John Bednoski,-Jr. ALBERT KRUPSKI, JR., Vice-President BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall, 53095 Main Road P.O. Box 728 Southold, New York 11971 TELEPHONE (516) 765-1892 March 25, 1988 Mr. Robert E. Waldron, Jr. 2980 Ole Jule Lane Mattituck, New York 11952 Dear Mr. Waldron: Pursuant to your request for a Waiver of the Wetland Ordinance for the reconstruction of a deck on your property, please be advised that we have inspected the site on March 17, 1988 and have approved your request for same. This determination is not a determination for any other Agency or Department that may have jurisdiction in this matter. Very truly yours, John M. Bredemeyer, III President Board of Town Trustees JMB:ip cc: Bldg. Dept. file Please be advised that the $25.00 fee for the waiver is now due and payable. BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall, 53095 Main Road P.O. Box 728 Southold, New York 11971 TELEPHONE (516) 765-1892 APPLICATION iS HEREBY MADE TO THE TOWN TRUSTEES OF THE TOWN OF $OUTHOLD, SUFFOLK COUNTY, NEW YORK FOR THE ISSUANCE OF A PERMIT PURSUANT TO THE LAWS, ORDINANCES AND REGULATIONS GOVERNING THE COASTAL AND INTERIOR WETLANDS, FLOOD PLAINS AND DRAINAGE AREAS OF THE TOWN OF SOUTHOLD, AND THE ISSUANCE OF PERMITS PURSUANT TO CHAPTER 32 OF THE CODES OF THE TOWN OF $OUTHOLD, APPLICATION NO. DATE OF APPLI CATION PHONE NO AGENT PHONE NO. PERMIT REQUESTED TO ~<~¢~3N/~ LOCAT ION OF PROPERTY FOR WHICH PE~MI T WANTED HOME ADDRESS OF PERMIT APPLICANT IF DIFFERENT FROM AFORESAID LOCATION CREEK, BAY OR HARBOR FRONTING PROPERTY S,ZE OF PROPOSED WORK "/SRO Sq.. LENGTH PERMITS THAT MAY BE REQUIRED NO PERSON SHALL PLACE ANY SPILES, STAKES, BUOYS, PIERS, DOCKS, BULKHEADS OR OTHER OBJECTS IN OR ON ANY TOWN WATERS OR PUBLIC LANDS UNDER OR ADJACENT TO TOWN WATERS IN THE TOWN OF SOUTHOLD, NOR SHALL ANY PERSON REMOVE ANY SAND, GRAVEL OR OTHER MATERIALS FiROM LANDS UNDER TOWN WATERS IN THE TOWN OF SOUTHOLD, WITHOUT FIRST OBTAINING A PERMIT THEREFORE FROM THE BOARD OF TRUSTEES OF THE TOWN OF SOUTHOLD. Board of Town Trustees Main Road Southold, New York 11971 (516) 765-1892 ALL OTHER GOVERNMENTAL AGENCIES THAT MAY HAVE JURISDICTION AND MAY REQUIRE A PERMIT FOR ANY ACTIVITY MENTIONED ABOVE ARE LISTED BELOW AND MAY BE APPLIED TO S~MULTANEOUSLY WITH THE TOWN APPLICATION ARE AS FOLLOWS: Coastal Management Program 162 Washington Ave. Albany, New York 12231 (518) 474-3642 New York S ~'ate Department of Environmental Conservation S.U.N.Y. - Building 40, Room 219 Stony Brook, New York 11794 (516) 751-7900 U. S. Army Corps of Engineers New York District 26 Federal Plaza New York, New York 10278 (212) 264-9054 PLEASE RETURN TO THE BUILDING DEPARTMENT FOR A DETERMINATION OF JURISDICTION AS SOME PROJECTS REQUIRE ZONING BOARD OF APPEALS APPROVAT, IN ADDITION TO THE TRUSTEES AS DIRECTED BY THE BUILDING INSPECTOR. THANK YOU. SHOULD YOU HAVE ANY QUESTIONS OR CONCERNS, PLEASE DO NOT HESITATE TO CONTACT THIS OFFICE AT 765-1892 (516) DE PT H B EL OW L OW WATE R____~'_ff_~ YARDS TO BE E YARDS TO B~ ~ILL~D WIDTH OF CANAL, CR~K OR BAY FRONTING PROPERTY DE~TH AT LOW. TID~ AVERAGE RISE IN TIDE__~__~ DISTANCE TO THE NEAREST CHANNEL"'~ O FT. DISTANCE PROJECT EXTENDS BEYOND SIMILAR PROJECTS IN THE AREA iS THIS FOR PRIVATE OR BUSINESS USE? FT. AREA ZONING MANNER IN WHICH MATERIAL WILL BE REMOVED OR DEPOSITED ~!~. DESCRIBE ANY KNOWN PRIOR OPERATIONS CONDUCTED ON THE PREMISE ...... AND WHETHER ANY PRIOR LICENSE OR PERMITS HAVE BEEN ISSUED TO ERRECT STRUCTURES OR TO DREDGE OR DEPOSIT FILL ON SAID PREMISES AND WHETHER ANY PERMITS OR LICENSES WERE EVER SUSPENDED OR REVOKED BY A GOVERNMENTAL AGENCY DESCRIBE FULLY THE REHABILITATION AND PROPOSED CONDITION OF THE PREMISES AFTER THE WORK IS COMPLETED INCLUDE AN ADDITIONAL SURVEY OF THE PROJECT SITE IF NECESSARY ARE THERE ANY COVENANTS OR RESTRICTIONS IN YOUR DEED THAT WOULD PROHIBIT THIS PROJECT? ~/Q 14-~6-4 f2/87~--Text 12 [~R~OECT I.D. NUMBER 617.21 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART l--PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT/SPONSOR SEQR I 2. PROJECT NAME 3, PROJECT LOCATION: 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) 5. IS PROPOSED ACTION: [] New [] Expansion [] Modification/alteration 7. AMOUNT OF LAND AFFECTED: InitiallyH ~"~ ~R~'-7~', ~ Ultimately acres 8. WILL FROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? [] No If No, describe briefly 9. WHAT IS PRESENT LAND USE iN VICINITY OF PROJECT? ~[Residential [] !ndustrial [] Commercial Describe: [] Agriculture [] Park/Forest/Open space [] Other 10 DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? i~ Yes [] No If yes, list agency(s) and permit/approvals _ 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? [] Yes '~ No If yes, list agency name and permit/approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? [] Yes [] No I CERTIFY THAT THE NFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE - Applicant/sponsor name: I~l'~t~;~1~ .~-~Olb~l~,~ ~'~. ' Date: If the action is in the Coastal Area, and you are a state agency, complete the I Coastal Assessment Form before proceeding with this assessment OVER 1 PART II--ENVIRONMENTAL AS?'-~'~SMENT (To be completed by Agency) ~'~ A. DOES ACTION EXCEED ANY TYPE I , ,iRESHOLD iN 6 NYCRR, ~ART 617.127 If yes, coormnate the review process eno use the FULL L:~.F. [] Yes [] No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.67 If No, a negative declaration may be superseded by another involved agency. [] Yes [] No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLQWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change m use or intensity of use of land or other natural resources? Explain briefly C5. Growth subsequent-development, or related activities likely to be induced by the proposed action? Explain briefly. C6. Long term. short term, cumulative, or other effects not identified in C1-C57 Explain briefly. C7. Other imeac[s (incl~Jding changes in use of either quantity or type of energy)? Explain briefly. D. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? r~, Yes [] No If Yes, exDlain briefly PART Ill--DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whett~er it is substantial, large, important or otherwise significant. Each effect should be assessed tn connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. [] Check this box if you have identified one or more potentially large or significant adverse 'mpacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. [] 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 AND provide on attachments as necessary, the reasons supporting this determination: Name of Lead Agency Print or ['ype r,,ame et ResponsJg~e Officer n Lead Agency S~gnarure o~ Respons~bJe Officer in Lead Agency Tide of Responsible Officer Signature of Preparer (If different from responsible othcer) Date 6,17.2 1 SEC) R ' Appendix B State, Environmental Quality Review V sua! EAF Addendum This form may be used to provide additional information relaUng to Question 1 1 of Fart 2 of the Full EAF. (To be completed by Lead Agency) Distance Between Project and Resource (in Miles) 0-~A 1/4-V2 ':1/2-3 3-5 5 + Visibility 1. Would the project be visible from: · A parcel of land which is dedicated to and available to the public for the use, enjoyment and appreciation of natural or man-made scenic qualities? · An overlook or parcel of land dedicated to public [] [] .... [] [] [] observation, enjoyment and appreciation of natural or man-made scenic qualities? · A site or structure listed on the National or State [] [] [] [] [] Registers of Historic Places? · State Parks? [] [] [] [] [] · The State Forest Preserve? [] [] [] [] [] · National Wildlife Refuges and state game refuges? [] [] r-' [] [] · National Natural Landmarks and other outstanding [] [] [] [] [] natural features? · National Park Service lands? [] [] [] [] [] · Rivers designated as National or State. Wild, Scenic [] [] [] [] [] or Recreational? · Any transportation corridor of high exposure, such [] [] [] [] [] as part of the Interstate System, or Amtrak? · A governmentally established or designated interstate [] [] [] [] [] or inter-county foot trail, or one formally proposed for establishment or designation? · A site, area, lake, reservoir or highway designated as [] [] [] [] [] scenic? · Municipal park, or designated open space? · County road? · State? · Local road? 2. Is the visibility of the project seasonal? (i.e., screened by summer foliage, but visible during other seasons) [] Yes [] No 3. Are any of the resources checked in question 1 used by the public during the time of year during which the project will be visible? [] Yes [] No DESCRIPTION OF EXISTING VISUAL ENVIRONMENT 4. From each item checked in question 1, check those which generally describe the surrounding environment. Within · 1/,~ mile * ! mile Essentially undeveloped [] [] Forested [] [] Agricultural [] [] Suburban residential [] ~ Industrial [] [] Commercial [] [] Urban [] []' River, Lake, Pond [] [] Cliffs, Overlooks [] [] Designated Open Space [] [] Flat [] [] Hilly [] [] Mountainous [] [] Other [] [] NOTE: add attachments as needed 5. Are there visually similar projects within: * 1/2 mile [] Yes [] No *1 miles []Yes []No *2 miles -[]Yes [~]No *3 miles []Yes []No * Distance from project site are provided for assistance. Substitute other distances as appropriate EXPOSURE 6. The annual number of viewers likely to observe the proposed project is NOTE: When user data is unavailable or unknown, use best estimate. CONTEXT 7. The situation or activity in which the viewers are engaged while viewing the proposed action is FREQUENCY Holidays] Activity Daily Weekly Weekends Seasonally Travel to and from work [] [] [] [] Involved in recreational activities [] [] [] :~ Routine travel by residents [] [] [] [] At a residence [] [] [] [] At worksite [] [] [] [] Other F- [] [] [] 14q 5~:2 (2187)-- 7c 617.21 Appendix A SEQR State Environmental Quality Review FULL ENVIRONMENTAL ASSESSMENT FORM Purpose: The full EAFis designed to help applicants and agencies determine, in an orderly manner, whether a project or action may be significant. The question of whether an action may be significant is not always easy to answer. Frequent- ly, there are aspects of a project that are subjective or unmeasureable. It is also understood that those who determine significance may have little or no formal knowledge of the environment or may be technically e.xpert in environmental analysis. In addition, many who have knowledge in one particular area may not be aware of the broader concerns affecting the question of significance. The full EAF is intended to provide a method whereby applicants and agencies can be assured that the determination process has been orderly, comprehensive in nature, yet flexible to allow intro'cluction of information to fit a project or action. Full EAF Components: The full EAF is comprised of three parts: Part 1: Provides objective data and information about a given project and its site. By identifying basic project data, it assists a reviewer in the analysis that takes place in Parts 2 and' 3. Part 2: Focuses on identifying the range of possible impacts that may occur from a project or action. It provides guidance as to whether an impact is likely to be considered small to moderate or whether it is a potentially- large Impact. The form also. identifies whether an impact can be mitigated or reduced. Part 3: If any impact in Part 2 is identified as potentially-large, then Part 3 is used to evaluate whether or not the impact is actually important. Identify the Upon review information, lead agency DETERMINATION OF SIGNIFICANCE--Type 1 and Unlisted Actions Portions-of EAF completed for this project: [] Part I [] Part 2 []Part 3 of the information, recorded on this EAF CParts 1 and 2 and 3 if appropriate), and any other supporting and considering both the magitude and importance of each impact, it is reasonably determined by the that: [] A. The project will not result in any large and important impact(s) and, therefore, is one which Will not have a significant impact on the environment, therefore a negative declaration will be prepared. [] B. Although the project could have a significant effect on the environment, there will not be a significant effect for this Unlisted Action because the mitigation measures described in PART 3 have been required, therefore a CONDITIONED negative declaration will' be prepared.* [] C The project may result in one or more large and important impacts that may have a significant impact on the environment, therefore a positive declaration will be prepared. * A Conditioned Negative Declaration is only valid for Unlisted Actions Name of Action Name of Lead Agency Print or Type Name of Responsible Officer in Lead Agencv Signature of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Preparer (If different from responsible officer) Date PART 1--PROJECT INFORMA~ ION Prepared by Project Sponsor NOTICE: This document is designed to assist in determining whether the action proposed may have a significant effect on the environment. Please complete the entire form, Parts A through E. Answers to these questions will be considered as part of the application for approval and may be subject to further verification and public review. Provide any additional information you believe will be needed to complete Parts 2 and 3. It is expected that completion of the full FAF will be dependent on information currently available and will not involve new studies, research or investigation. If information requiring such additional work is unavailable, so indicate and specify each instance. NAME OF ACTION LOCATION OF ACTION (Include Street Address, Municipality and County) NAME OF APPLICANT/SPONSOR BUSINESS TELEPHONE ( ) ADDRESS CiTY/PO STATE ZiP CODE NAME OF OWNER (If different) ADDRESS BUSINESS TELEPHONE ( CITY/PO STATE ZIP CODE DESCRIPTION OF ACTION Please Complete Each Question-Indicate N.A. if not applicable A. Site Description Physical setting of overall project, both developed and undeveloped areas. 1. Present land use: [-1Urban []Industrial l-ICommercial I-]Residential (suburban) I--]Rural (non-farm) []Forest I-IAgriculture [-iOther 2 Total acreage of project area: acres. APPROXIMATE ACREAGE 'PRESENTLY AFTER COMPLETION Meadow or Brushland (Non-agricultural) acres acres Forested acres acres Agricultural (Includes orchards, cropland, pasture, etc.) acres acres Wetland (Freshwater or tidal as per Articles 24, 25 of ECL) acres acres Water Surface Area acres acres Unvegetated (Rock, earth or fill) acres acres Roads, buildings and other paved surfaces acres acres Other (Indicate typel, acres acres 3. What is predominant soil type(s) on project site? a. Soil drain.age: [Well drained % of ~ite E~Moderatel¥ well drained % of site ~Poorly drained % of site b. If any agriculturaJ land is involved, how many acres of soil are classified within soil group 1 through 4 of the NYS Land Classification System? acres (See 1 NYCRR 370). 4. Are there bedrock outcroppings on project site? I~Yes il-]No a. What is depth-to bedrock? (in feet) _~ 2 5. 'A~prox~mate percentage of p,_ ,~osed project site with slopes: D0-10% % [10-15% % [15% or greater % 6. Is project substantially contiguous to, or contain a building, site, or district, listed on the State or the National Registers of Historic Places? D-lYes DNo 7. Is project substantially contiguous to a site listed on the Register of National Natural Landmarks? DYes DNo 8. What is the depth of the water table? (in feet) 9. [s site located over a primary, principal, or sole source aquifer? DYes F-]No 10. Do hunting, fishing or shell fishing opportunities presently exist in the project area? []Yes []No 11 Does project site contain any species of plant or animal life that is identified as threatened or endangered? []Yes []No According to ' Identify each species 12. Are there any unique or unusual land forms on the project site? (i.e., cliffs, dunes, other geological formations) I-lYes []No Describe 13 Is the project site presently used by the community or neighborhood as an open space or recreation areal [l-lYes E~No If yes, explain 14. Does the present site include scenic views known to be important to the community? I-lYes [No ' 15. Streams within or contiguous to project area: a. Name of Stream and name of River to which it is tributary 16. Lakes, ponds, wetland areas within or contiguous to pro;ect area: a. Name b. Size (In acres) 17. Is the site served by~xisting public utilities? []Yes DNo a) If Yes, does sufficient capacity exist to allow connection? [-[¥es DNo b) If Yes, will improvements be necessary to allow connection? []Yes []No 18. Is the site located in an agricultural district certified pursuant to Agriculture and Markets Law, A~ticle 2S-AA, Section 303 and 304? -]Yes F~No 19 Is the site located in or substantially contiguous to a Critical Environmental Area designated pursuant to Article 8 of the ECL, and 6 NYCRR 6177 I~Yes I-1No 20. Has the site ever been used for the disposal of solid or hazardous wastes? [l-lYes []No B. Project Description 1. Physical dimensions and scale of project {fill in dimensions as appropriate) a. Total contiguous acreage owned or controlled by project sponsor b. Pro. ect acreage to be developed: acres initial]y; c. Project acreage to remain undeve!oped acres. d. Length of project, in miles: {If appropriate) e. If the project is an expansion, indicate percent of expansion proposed %; f. Number of off-street parking spaces existing ; proposed g. Maximum vehicular trips generated per hour (upon completion of F)roject)? h If residential: Number and type of housing units: One Family Two Family Multiple Family Initially Ultimately i. Dimensions- (in feet) of largest proposed structure height; width; j. Linear feet of f~ontage along a public thoroughfare project will occupv ii? acres. acres ultimately. Condominium length. ft. 2. How much natural material (i..~.,~rock, earth, etc.) will be removed from the site? 3. Will disturbed areas be reclaimed? l-lYes [-1No'- I-IN/A a. If yes, for what intend~C purpose is the site being reclaimed? b. Will topsoil be stockpiled for reclamation? []Yes f-lNo c, Will upper subsoil be stockpiled for reclamation? F-lYes [No 4. How many acres of vegetation (trees, shrubs, ground covers) will be removed from site? acres. 5. Will any mature forest (over 100 years old) or other locally-important vegetation be removed by this project? l--lYes F-INo ' ' 6. If single phase project: Anticipated period of construction 7. If multi-phased: a. Total number of phases anticipated b. Anticipated date of commencement phase 1 c. Approximate completion date of final phase d. Is phase 1 functionally dependent on subsequent phases? 8. Will blasting occur during construction? I-lYes I-lNo 9. Number of jobs generated: during construction 10. Number of jobs eliminated by this project 11. Will project require relocation of any projects or facilities? (number). months, (including demolition). month month I-IYes E3No- tons/cu'bic ~vards ' after project is complete year, (including demolition). year.. I-lYes I-]No If yes, explain 12. Is surface liquid waste disposal involved? 13 t4 []Yes I-]No a. If yes, indicate type of waste (sewage, industrial, etc.) and amount b. Name of water body into which effluent will be discharged ls subsurface liquid waste disposal involved? l-lYes I-1No Type Will surface area of an existing water body increase or decrease by proposal? Explain []Yes F-]No 15. Is project or any portion of project located in a 100 year flood plain? [Yes 16. Will the project generate solid waste? [l-lYes []No a. If yes, what is the amou~,t per month tons b. [f yes, will an existing solid waste facility be used? E3Yes E3No c. If yes, give name ; location d. Will any wastes not go into a sewage disposal system or into a sanitary landfill? e. If Yes, explain E~No [Yes I-qNo 17. Will the project involve the disposal of solid waste? F-lYes a. If yes, what is the anticipated rate of disposal? b. If yes. what is the anticipated site ife? years. 18. Will project use herbicides or pesticides? [l-lYes []No tons,tmonth. 19 Will project routinely produce odors (more than one hour per day)? I-lYes 20. Will project produce operating noise exceeding the local ambient noise levels? 21. Will project result in an increase in energy use? [l-lYes []No If yes , indicate type(s) F-INo [l-lYes ESNo 22. If water supply is from wells, indicate pumping capacity 23. Total anticipated water usage per day gallons]day. 24. Does project-~nvolve Local, State or Federal funding? F-iYes If Yes, explain gallons/minute. I-1No 4 2t5.~ Approvals Required: City, Town, Village Board i-]Yes E3No City, Town, Village Planning Board i-[Yes F-1No City, Town Zoning Board I-lYes t-INo City, County Health Department r-lYes I-qNo Other Local Agencies I-lYes i--INo Other Regional Agencies I-lYes [-1No State Agencies I-lYes [--INo Federal Agencies [--]Yes F-iNo C. Zoning and Planning Information Submittal Type Date 1 Does proposed action involve a planning or zoning decision? r-[Yes I-]No If Yes, indicate decision required: I-Izoning amendment I-Izoning variance I-qspecial use permit t-]subdivision [site plan I-lnew/revision of master plan []resource management plan l--Iother 2. What is the zoning classification(s)of the site? 3. What is the maximum potential development of the site if developed as permitted by the present zoning? 4. What is the proposed zonidg of the site? · 5 What is the maximum potential development of the site if developed as permitted by the proposed zoning? 6. Is the proposed action consistent with the recommended uses in adopted local land use plans? F-lYes []No 7. What are the predominant land use(s) and zoning classifications within a ~¼ mile radius of proposed action? 8. Is the proposed action compatible with adjoining/surrounding land uses within a ~,~ mile? r-lYes I-'lNo 9. If the proposed action is the subdivision of land, how many lots are proposed? a. What is the minimum lot size proposed? 10 Will proposed action require any authorization(s) for the formation of sewer or water di'stricts? []-]Yes [-INo 11. Will the proposed action create a demand for any community provided services (recreation, education, police, fire protection)? I-lYes fiNo a. If yes, 's existing capacity sufficient to handle projected demand? [l-lYes [--INo 12 Will the proposed action result in the generation of traffic significantly above present levels? fi]Yes r-INo a. If yes, is the existing road network adequate to handle the additional traffic? I-lYes I-]No D. Informational Details Attach any additional information as may be:needed to clarify your project. If there are or may be any adverse impacts associated with your proposal, please discuss such impacts and the measures which you propose to mitigate or avoid them. .. E. Verification I certify that-the information provided above is true to the best of my knowledge. Applicant/Sponsor Name Date Signature Title If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment. 5 · Proposed Action may cause substantial erosion. · Proposed Action is incompatible with existing drainage patterns. · Proposed Action will allow development in a designated floodway. · Other impacts: IMPACT ON AIR 7. Will proposed action affect air quality? I-INO E:]YES Examples that would apply to column 2 · Proposed Action will induce 1,000 or more vehicle trips in any given hour. · Proposed-Action will result in the incineration of more than I ton of refuse per hour. · Emission rate of total contaminants will exceed 5 lbs. per hour or a heat source producing more than 10 million BTU's per hour. · Proposed action will allow an increase in the amount of land committed to industrial use. · Proposed action'will allow an increase in the density of industrial development within existing industrial areas. · Other impacts: IMPACT ON PLANTS AND ANIMALS 8 Will Proposed Action affect any threatened or endangered species? [NO [-]YES Examples that would apply to column 2 · Reduction of one or more species listed on the New York or Federal list. using the site, over or near site or found on the site. · Removal of any portion of a critical or significant wildlife habitat. · Application of pesticide or herbicide more than twice a year, other than for agricultural purposes. · Other impacts: 9 Will Proposed Action substantially affect non-threatened or non-endangered species? []NO [-]YES Examples that would apply to column 2 · Proposed Action would substantially interfere with any resident or migratory fish, shellfish or wildlife specJes. · Proposed Action requires the removal of more than 10 acres of mature forest (over 100 years of age) or other localiy important vegetation IMPACT ON AGRICULTURAL LAND RESOURCES 10 Will the Proposed Action affect agricultural land resources? [Z]NO [Z]YES Examples that would apply to column 2 · The proposed action would sever, cross or limit access to agricultural land (includes cropland, hayfields, pasture, wneyard, orchard, etc.) '1 2 3,, Small to Potential Can Impact Be Moderate Large Mitigated By Impact Impact Project Change [] [] []Yes [-1No [] [] I~Yes i'[No [] [] []-]Yes []No [] [] - []Yes I--]No [] [] []Yes []No [] [] []Yes E3No [] [] I-'lYes J-]No [] [] [--]Yes []No [] [] []Yes []No [] [] []Yes []No [] [] ~Yes E~No [] [] []Yes EE]No [] [] []Yes []No [] [] []Y~s []No [] [] []Yes []No [] [] ~Yes []No [] [] ~Yes ~lNo · Construction activity would excavate or compact the soil profile of agricultural land · The proposed action would irreversibly convert more than 10 acres of agricultural land or, if located in an Agricultutal District, more than 2.5, acres of agricultural land. · The proposed action would disrupt or prevent installation of agricultural land management systems (e.g., subsurface drain lines, outlet ditches, strip cropping); or create a need for such measures (e.g. cause a farm field to drain poorly due to increased runoff) · Other impacts: IMPACT ON AESTHETIC RESOURCES 11. Will proposed action affect aesthetic resources? []NO l--lYES (If necessary, use the Visual EAF Addendum in Section 617.21, Appendix B.) Examples that would apply to column 2 · Proposed land uses, or project components obviously different from or in sharp contrast to current surrounding land use patterns, whether man-made or natural. · Proposed land uses, or project components visible to users of aesthetic resources which will eliminate or significantly reduce their enjoyment of the aesthetic qualities of that resource. · Project components that will result in the elimination or significant screening of scemc views known to be important to the area. · Other impacts: IMPACT ON HISTORIC AND ARCHAEOLOGICAL RESOURCES 12 Will Proposed Action impact any site or structure of historic, pre- historic or paleontological importance? r-INO I-lYES Examples that would apply to column 2 · Proposed Action occurring wholly or partially within or substantially contiguous to any facility or site listed on the State or NatiOnal Register of historic places~ · Any impact to an archaeological site or fossil bed located within the project site. · Proposed Action will occur in an area designated as sensitive for archaeological sites on the NYS Site Inventory. · Other mpacts: IMPACT ON OPEN SPACE AND RECREATION 13 Will Proposed Action affect the quantity or quality of existing or future open spaces or recreauonal opportunities.~ Examples that would apply to column 2 I-1NO E-]YES · The permanent foreclosure of a future recreational opportunity. · A major reduction of an open space important to the communi~v. · Other impacts: 9 I 2 3 Small to Potential Can Impact Be Moderate Large Mitigated By Impact Impact Project Change [] [] I-lYes I--[No [] [] I-'lYes [~]No [] : [] I-lYes i--]No I [] E3. r-lyes I--INo [] [] []Yes E3No [] [] []Yes [-']No [] [] i-lYes l--lNo [] [] []Yes r-lNo [] [] I-lYes I--INo [] [] ?,Yes. ~No [] [] t--lYes ~No [] [] [--[Yes i-[No [] [] i~Yes it]No [] [] ['-]Yes r-]No [] [] l-lYes E3No IMPACT ON TRANSPORTATION - 14. Will there be an effect to existing transportation systems? E~NO E3YES Examples that would apply to column 2 · Alteration of present patterns of movement of people and/or goods. · Proposed Action will result in major traffic problems. · Other impacts: IMPACT ON ENERGY 15. Will proposed action affect the community's sources of fuel or energy supply? I-[NO l-lYES Examples that would apply to column 2 · Proposed Action will cause a greater than 5% increase in the use of any form of energy in the municipality. · Proposed Action will require the creation or extension of an energy transmission or supply system to serve more than 50 single or two family residences or to serve a major commercial or industrial use. · Other impacts: NOISE AND ODOR IMPACTS 16. Will there be objectionable odors, noise, or vibration as a result of the Proposed Action? I-INO r-]YES Examples that would apply to column 2 · Blasting within 1,500 feet of a hospital, school or other sensitive facility. · Odors will occur routine[,/(more than one hour per da,/). · Proposed Action will produce operating noise exceeding the local ambient noise levels for noise outside of structures. · Proposed Action will remove natural barriers that would act as a noise screen. · Other impacts: IMPACT ON PUBLIC HEALTH 17. Will Proposed Action affect public health and safetv? Z]NO FqYES Examples that would apply to column 2 · Proposed Action may cause a risk of explosion or release of hazardous substances (i.e. oil, pesticides, chemicals, radiation, etc.) in the event of accident or upset conditions, or there may be a chronic Iow level discharge or emission. · Proposed Action may result in the burial of "hazardous wastes" in any form (i.e. toxic, poisonous, highly reactive, .radioactive, irritating, infectious, etc.) · Storage facilities for one million or more gallons of liquified natural gas or other flammable liquids. · Proposed action ma,/ result in the excavation or other disturbance within 2,000 feet of a site used for the disposal of solid or hazardous waste. · Other impacts: 2 · Small to Potential Can Impact Be Moderate Large Mitigated By Impact Impact Project Change - [] [] []Yes I--I No [] [] []Yes I-]No [] 'E~ I-lYes ~lNo [] [] i-lYes I-'1 No [] [] I-IVes []No [] [] ['-]Yes J-]No [] [] [-]Yes [-]No [] [] I-'lYes [-']No [] [] E3Yes r-'lNo [] [] [--]Yes []No [] [] []Yes I-'lNo ~ [] [] []Yes-.. I~No [] _ [~' i--~Yes [--]No [] [] []Yes []No [] [] l--lYes [~]N0 -[] [] []Yes []No 10 IMPACT ON GROWTH AND CHARACTER OF COMMUNITY OR NEIGHBORHOOD 18 Will proposed action affect the character of the existing community? []NO []YES Examples that would apply to Column 2 · The permanent population of the city, town or village in which the project is located is likely to grow by more than 5%. · The municipal budget for capital expenditures or operating services will increase by more than 5% per year as a result of this pro. ect. · Proposed action will conf ict with officially adopted plans or goals. · Proposed action will cause a change in the density of land use. · Proposed Action will replace or eliminate existing facilities, structures or areas of historic importance to the community. · Development will create a demand for additional community services (e.g. schools, police and fire, etc.) · Proposed Action will set an important precedent for future projects. · Proposed Action will create or eliminate employment. · Other impacts: 19. 1 2 3 Small to Potential Can Impact Be Moderate Large Mitigated By Impact Impact Project Change [] [] []Yes I--]No [] [] ' I--lYes []No [] [] I-lYes F-iNo [] [] i-]Yes l--[No [] [] ~]Yes []No [] -~ []' I--lYes [-1No [] ~ ~V~s ~No ~ ~ ~Yes ~No ~ ~ ~Yes ~No Is there, or is there likely to be, public controversy related to potential adverse environmental impacts? [~NO I-lYES If Any Action in Part 2 Is Identified as a Potential Large Impact or If You Cannot Determine the Niagnitude of Impact, Proceed to Part 3 Part 3--EVALUATION OF THE i~iPORTANCE OF IMP:~,~JTS Responsibility of Lead Agency Part 3 must be prepared if one or more impact(s) is considered to be potentially large, even if the impact{s) may be mitigated. Instructions Discuss the following for each impact identified in Column 2 of Part 2: I Briefly describe the impact. 2. Describe Iif applicable) how the impact could be mitigated or reduced to a small to moderate impact by project change(s). 3. Based on the information available, decide if it is reasonable to conclude that this impact is important. To answer the question of importance, consider: · The probability of the impact occurring · The duration of the impact · Its irreversibility, including permanently lost resources of value · Whether the impact can or will be controlled · The regional consequence of the impact · Its potential divergence from local needs and goals · Whether known objections to the project relate to this impact. {Continue on attachments) 11 COUNTY OF SUFFOLK ) STATE OF NEW YORK )SS: BEING DULY SWORN DEPOSES AND SAYS THAT HE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMITS, 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 AND AS MAY BE APPROVED BY THE TOWN BOARD OF THE TOWN OF SOUTHOLD. 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, IF GRANTED. In completing this application I hereby authorize the Trustees~ agent-or representative to enter onto my property to inspect the premises in conjunction with review of this application. SIGNATURE OF APPLICANT SWORN TO BEFORE ME THIS EXJ%MINED APPROVED ~'WETLANDS" PERMIT (CHAPTER 97) APPROVED "BOAT,DOCKS, WHARVES" PERMIT (CHAPTER 32) DISAPPROVED "WETLANDS PERMIT" (CHAPTER 97) DISAPPROVED "BOATS,DOCKS, WHARVES" PERMIT (CHAPTER 32) CONDITIONS, IF ANY EXAMINING BODY SIGNATURE OF CHAIRMAN COMPUTATION OF FEES Approved 2/27/85