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Home My WebLink AboutTR-505 Amend . . James F. King, President Jill M. Doherty, Vice.President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD July 24, 2007 Mr. David B. Wells P.O. Box 1259 Mattituck, NY 11952 RE: HOWARD L. WELLS 1860 BAYVIEW AVENUE, MATTITUCK SCTM# 106-11-18 Dear Mr. Wells: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Tuesday, July 24, 2007: RESOLVED, that the Southold Town Board of Trustees APPROVE the Amendment to Permit #505 to remove a 4' x 24' portion of the float area and install three additional mooring piles, and as depicted on the plans prepared by David B. Wells, received on June 26, 2007. Any other activity within 100' of the wetland boundary requires a permit from this office. This is not a determination from any other agency. If you have any questions, please call our office at (631) 765-1892. Sincerely, ro<~ James F. King President, Board of Trustees JFK:eac r4-'~ .-', G . T- - T --- 0- ....~ JJ t+- G' ->j . . APPROVED BY BOARD OF TRUSTEES TOWN OF SOUTHOLD DATE . ~o~r7 :tZjJ . fXI.~TJNV DocK. f><..I~TIN& P, U::..5 o - - -- PR Of'oSc.D Doc(<- L/11 /,,j 0 H~oPosej) PII.(.l (3) t"'/'M DEl€:T(O AR.~A (::!4'X 1-') 0 \ /JJZt9w/~ 6- ~cT /0 S"C"Ck (fJ0 rfi)~lG" ~J 'IIJ,_, tir0 I[UI Ji:~' 0 r ""00 ' ~ i vi, c, L0U'I ~j L____ ___ ____J I S!J":,I:;~id 10 ,',I. f FC:'Cj,":T:'::,r,_,oS _~ . James F. King, President Jill M. Doherty, Vice-,President Peggy A Dickerson Dave Bergen Bob Ghosio, Jr. ,. Town HaIl 53095. Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Southold Town Board of Trustees Field Inspection/Work session Report Date/Time: "1---- /(~ 07 David B. Wells on behalf of HOWARD L. WELLS requests an Amendment to Permit #505 to remove a 4'X 24' portion of the float area and install three additional mooring piles. Located: 1860 Bayview Ave., Mattituck. SCTM#106- 11-18 T))'Ie of area to be impacted: LLSaltwater Wetland _Freshwater Wetland Sound _Bay Distance of proposed work to edge of above: PmfofTown Code proposed work falls under: tL"Chapt.275 _Chapt. 111 ~other / Type of Application: _ Wetland _Coastal Erosion _Amendment _Administrative _Emergency _Pre-Submission_ Violation Info needed: ~f' Modifications: Conditions: Prese~; Were: _J.King ~oherty _P.Dickerson_D. Bergen_ B. Ghosio, Jr _H. Cusack_ D. Dzenkowski _Mark Terry_other Form filled out in the field by Mailed/Faxed to: Date: Environmental Technician Review ~,. n-l'" "."., ".0'-. '-0'.0 "'''-01 0>-0'-01 10-20-01 + ;i'" '_".0 '0-''''' '2-"-' 02_"'0 '-"'0 05-"'0 .-0"0' "'''-0' ,..0"0' '-O,-os Ol-O'-O \",J'0 '" I' ,., ~, .... ~. .. ,." lO.T .... ~. " ....,., .. I.",,, '., """" .. '.'Af" l' i..~. ~ "E"O on 31 '05-0''''' '!.t""...~,-", ~ ..,..0..,'" '., 1.,.,<, '-- ""... 12.'.,.'0.-1>.......... 12.'''<' _... 7< 1211 o ,. ..~ ~ " ,-,,,,, -+ I -N- ,I II " /, ~ " ~ ,_0"", II II' ,II' I '- tS 'Sll ' 'll.' , 'II , " '1"'1 " I , ~~ " , " ~!;( I , ; \J 'I I I . Il i\ \ , ,.....<) . ....", '" ".<M" @ , " U' '.' !l ,~ , (i) '_<$""""'-" ., ~ " .....'" " 1....., t.1 NOTICE (i) COUNTY OF SlfFOlK <D RecAPr<l\)ertyTox$ervlceAgericy Caot1ry~tIr !lIwrhocId,MIIl!lIl .. ,",,-E~"H, - . ~ ~ SECTlQ~ NO sruTHOLO '(;J;' -. , ,. f """ ......x~ . ,. ~ n. ,,, u' .""'"' ...."~,"-T.."O<....[OA ."-",,,"''''_,,"01''' ""'...,....""'...." '"""" "".""fIOf1ID<............"" ""-_,, ,.. """""".r'" 106 1000 PROPERTYWN' ,,,,,,,.,,,,,,,,,,,-".""' ~ ----."'~, "'"'.,...... --=f . . Office Use Only _Coastal Erosion Permit Application ~~lication , _AdministrativePennit endmen ferlExtenslon ~ecciv ": -;::~ ~ rc: (ii> rc: n \\/7 IT" .,,'\ ----l'"CeivedFee:$ ,::srr 0 IS li!J IS U 0 L~,I 1"',1, -,Sompleted Application ~--- __ . : J _Incomplete ~ :' _SEQRAClassification: JUN 2 6" 2n07 ,U' Type I_Type II_Unlisted_ U (..:.I _Coordination:(date sent) _. ----I ."..J:.AC Referral Sent5Jj()., Southold Town ~te of Inspection: I (t tOJ Board of Trustees _Receipt ofCAC Report: _Lead Agency Detennination:_ Technical Review: A'ablic Hearing Heid11 d-4Vt::i ) _Resolution: Name of Applicant J..I OW.!<4 Rn L. \J1t /.. W Address lJ'bO BA'rvIE..J AtE.; ?O, Box. ~55- -; f14TTITtlCK. /II If /I <} 6L Phone Number:( ) 2- C;u _ 40(, ? Suffolk County Tax Map Number: 1000 - /0 b - 1/ -; J::> Property Location: 1~6 0 !1,.,YVltl-V Av(., 114r7rrvCI( (Provide LILCO Pole #, distance to cross streets, and location) AGENT: f)"w /0 fl, V).( LL--J, (If applicable) Address: P. 0 fS O)G /25" r flp,T71 /(,1(: K. Phone: Ai'1 119.5 L 29J>- 2/77 . Board of Trustees ApPlicaton GENERAL DATA Land Area (in square feet): Area Zoning: Previous use of property: 12E.s IDE.IJ/T' 0.510~tIJf Intended use of property: Prior permits/approvals for site improvements: Agency 5)U:111 -# _5"0' AJ1'i{ I'VlhfA #S';!J 'i1/I~%:f G/zt/ / ?J _ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or susPE'l.!1ed by a governmental agency? --A.-No_ Yes If yes, provide explanation: Project Description (use attachments ifnecesSary):j!ltbM ~ i'<Dv<:t (WAr A<<" t-. Pl.-ArC( 3' PI L-C:.-S A'1fdClJKJ)) - . . '"' ~ . Board of Trustees Appliclon WETLANDITRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: -r; eeOcJC~ A1Rl"'~ !JND P<.ACf 7iI"i{ I1LCS Area of wetlands on lot: square feet Percent coverage oflot: % Closest distance between nearest existing structure and upland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling? / No Yes If yes, how much material will be excavated? cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: Statement of the effect, if any, on the wetlands and tidal waters of the town that mil)' result by reason of such proposed operations (use attachments if appropriate): Afi)N L . , . . . Board of Trustees ApPlicaton COASTAL EROSION APPLICATION DATA Purposes of proposed activity: ~ 'e[/.lCJC[ k..:!A7 o PL~ct AUA 3 t1L-f5 Are wetlands present within 100 feet of the proposed activity? No )( Yes Does the project involve excavation or filling? X No Yes If Yes, how much material will be excavated?~(cubiC yards) tJlA (cubic yards) How much material will be filled? Manner in which material will be removed or deposited: N/A Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) No E.~VItf..oNH61-7~ II-IPI!Jcr.... Dec/<.. -4U-4 150 &t,Ne- e'tOJc-fLJ,4w<ll 7NR.U PIL8 t1,(\C<LJ_ 4It Board of Trustees Applica4lton Comty of Suffolk State of New York UOIA/4P-'P L lU~' 10:::, BEING DULY SWORN DEPOSES AND AFFIRMS THAT HFlSHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HISIHER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORm 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 REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WIrn REVIEW OF THIS APPLICATION. 7~::t.,Wdk Signature SWORN TO BEFORE ME THIS J-2 DAYOF ~11~r;;:. ,20 iLl- ~41> ~ Notary blic MARK T. GAGEN NOTARY PUBLIC. State of Nl'w York No. 4695650 Qualified in S"ffolk County Commission Expires May 31. 2-D II ... Board of Trustees Applica~on AUmORIZATION (where the applicant is not the owner) I, #OW Afj} L ""-It LL-.) (print owner of property) residing at PO & )< "t.> i" (mailing address) f!At7/1cJCt: do hereby authorize (Agent) DAVID B ,^kLLj to apply for permit(s) from the SoutiIold Board of Town Trustees on my behalf 7/p.~~~1 t4udk (Owner's signature) TRUSTEES John M. Bredemeyer, III, President Albert J. Krupski, Jr., Vice President Henry P. Smith John B. Tuthill William G. Albertson Telephone (516) 765-1892 Fax (516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD SUPERVISOR SCOTT L. HARRIS Town Hall 53095 Main Road P.O. Box 1179 Southold, New York 11971 June 25, 1993 Howard L. Wells 1860 Bayview Ave. Mattituck, NY 11952 RE: SCTM 91000-106-11-18 Dear Mr. Wells: The following action was taken by the Southold Town Board of Trustees on June 24, 1993: RESOLVED that the Southold Town Board of Trustees grants an amendment to Permit 9505 to add (4) 4' X 16' floats in the new configuration as shown on attached drawing subject to the following fees: (4) floats 4' X 16' =256 sq.ft. X $2.00 = $512.00 If you have any questions, please do not hesitate to contact this office. truly yours, III President, Board of Trustees JMB:jmd TOWN OF SOUTHOLD BOARD OF TOWN TRUSTEES Pursuant to the provisions .of Chapter 615 of the Laws of 1893 of the State of New Y, ork; Chapter 404 of the Laws of 1952 of the State of New York;' the pro- visions of an ordinance entitled "South,old Town Ordinance Regulating the Placing of Obstructi,o.ns in and on T,own 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 ,of Trustees of the Town of South,old adopted at .a meet- ing of said Board on August 19, 1968 _ 27.00 ........................... , aha in consideration of the'sum of $ .......... , lawful money of the United States, paid ~ Howard L Wells residing at Shore Acres, Mattituck, L.r. oy ...... ~' ..... : ....... ................................................ , New Y. ork, the said Boa.rd of Trustees of the Town of Sou/ho/d, Suffolk County, New York, hereby authorized and permits said Howard L. Wells extend an existing dock with a ramp and float in Mattituck Creek, all in accordance with the application subraiited. The said Howard L. Wells .................................... , as part ,of the consideration for the issuance of this permit does hereby release the ,said Board of Trustees and the ~own of South,old from any and all d~mages claims for damages or suits that may arise ,or occur directly or indirectly as are, sult of any operation carried on un- der and pursuant to this permit, and wi I1 at his own expense, defend any and ali suits which may be brought by third parties, as a result ,of any' operation carried on pursuant to ,or in accord'ance with th e terms of this permit, and assume full Ii. ability with respect thereto to the complete exclusion of said Board of Trustees and the Town of South.old. THIS PERMIT is subject to the following terms and conditions: That there shall be no tmreas.onable interference with navigation as a result of the work herein authorized. That there shall be no interference w/th the right of the public to pass and re- pass along that portion of the beach between low and high water mark. That the work shall be subject to the supervision and approval of the said Board of Trustees or its agents. That if future operations of the Tow,n of Southold require the removal and/or alteration in the location of the work herein authorized, or fi, in the opinion of the Board .of Trustees of the Town of South~old, such work .shall cause reasonable 'obstruction to free navigation, the said Howard L. Wells will be required upon due notice from the said Board of Trustees, ~o. remove or alter the location .of the work here by authorized without expense to the Town of Southold, s.o as t.o render na vigation reas. onabiy free and unobstruct- ed. The authority conferred by this permit may be terminated by the Board of Trustees Howard L. Wells for a failure on the part of the said .................................................................................... to comply with the terms and conditions herein imposed. In the event of such termination, this permit shall be deemed revoked five (5) days after the date when the Board of Trustees shall mail to the said Howard L. Wells at the address given in his application, a certified copy of a resolution of the Board of Trustees directing such termination. IN WITNESS WHEREOF, the said Board of Trustees of the Town of Southold has caused its corporate seal to be hereunto affixed and these presents to be subscribed by a majority of the sai'd Board of Trustees, seal ST/Q'E OF NEW YORK ) SS: COUNTY OF SUFFOLK the day and year above written. · .~,,.o~ .~.¢-;~. ~..-~,,-%.. t L.-- S.) September ON THIS. .... 9th........... .... day of . ...... ............................................. , 19..6..8...., before me oersonolly appeared Alvah B. Goldsmith, Frank Dawson, John F. McNulty, George Simpson and Douglas t{obertson, ail .PersonaJJy known to me, who, being by me duly sworn, severally said that they each resided in the Town of Southold, County of Suffolk, State of New York, and were members of the Board of Trustees of said Town of Southold and constituted a majority of the same; that they knew the corporate seal of said Town of Southold; that the seal affixed to thc foregoing instrument was such corporate seal; that it was so affixed thereunto by order of the Board of Trustees of said Town of Southold and that each one signed his name thereto as a Trustee and by like order. Filed: Notary Public (/ MARION A. REGENT NOTARY PUBLIC, State of New York No_. 52-3233120 Suffolk Count~, term Expires March 30, / Notary public t.l,(~'~,~c*~-- ..... MARION A. REGEN1- N~TARY PUBLIC, State of New ~. 52-3233}20, Surf ok% ~ ~pJres ~arcn ou, ~/ OF SOUTHOLD BOARD OF TOWN TRUSTEES TOWN CLERK'S OFFICE SOUTHOLD, N. Y. f Examined ................................ 19 ..... Application hTo Disapproved a/c ?. ........... ~ _ ' ........ ........................................... airman, Board of Trustees APPLICATION FOR PERMIT INSTRUCTIONS A.iicate.This application to be completely filled in by typewri'ter or in ink and submitted to the Town Trustees in duD- B. Plot plan showing location of lot and buildings on premises, rela'tion to adjoining premises, public streets~ parks. etc., and giving detailed description of proposed layout of project must be drawn on diagram which is part of this application. C. The work covered by this application may not be commenced before the issuance of a permit. D. Upon approval of this application, Town Trustees will issue a permi't to applicant. Such permit shall be kept on the premises and available for inspection at ail times. E. Applicant shall notify the Board of Trustees upon completion of the work covered by permit APPLICATION IS HEREBY MADE to the Board of Trustees of the Town of Southold, Suffolk County, New York, for the issuance of a permit pursuan't to ~he laws, Ordinances and regulations governing construction of: docks, piers, bulkheads, jettys and dredging in, under, and over the waters of Town of Southold. The applicant agrees to comply with all applicable laws, ordinances, reg-ulations and conditions specified by said trustees, and to hold the Town of Southold. and all Town officials free from liability and damages of any kind. Name of Owner of Premises ........ ~IO.~a~.d.. ~. ,..'~.e.1..1.s. ....... Street Address of Property ......... Shor.e.. A.c.r.e..s.,..Mattitu~'~ ........................................... Home Address If Other Than Location Creek, Bay or Harbor Frontin~ Prooertv Mattitutk Inlet erm~ts Reques'ted To: t~Xt~.B~ e;C~.s'~zn~ dock wzth a ra.mp, and float Size of Proposed Work: Length .. j~2.6!..~..~0~Zidth ............ Pleighth Above High Water .............. Depth Below Low Water .............. Average Rise tn Tide ....6.~. ........ Yards to Be Excavated V~ridth of Canal, Creek or Bay Fronting Property ...... 1.~.0..~d~, ....... Depth at Low Tide .... 7..~. .......... Is This For Private or Business Use? ....... .l:~r..i..v.~.t..e. ....................... Area Zoning .... .~.9.S., .......... Complete plo't plan to be drawn on reverse side of this application. Existing dock has been in existance forat least 20 years, but t:o the best of my knowlege is not covered by any permit~ if a permit for it is necessary please advise. Although it is 55 ft. long, it is six feet from the water at low tide. A 24 ft. extension would give me roughly 3 ft. of w~ter at low tide, and would still in no way interfere with the channel. STATE OF NEW YORK ) )s.s. COUNTY OF ) ............................ being duly sworn deposes and says that he is the applicant for the above degcribed permit, and 'that all statements contained herein are true to the best of his knowledge' and'. belief ; that the work xvill be done in the manner se'r forth .in the application and as approved by the Board of Trustees of the Town of Southold, and the applicant agrees to hold 'the Town of Southold and said trustees harmless and free from an,~ and all damages and claims arising under or by virtue of said permit. (applicant) ¢xvorn to before me this ............... : day of...~...C~..c~zCj ............. 19..~.~ TARY PUBLIC, State of New g. 52-3233120 Suffolk Cou',.', ~em Bpires Ntarch 30, ' TRUSTEES Jot~n M. Bredemeyer, III, President Albert J. Krupski, Jr., Vice President Henry P. Smith John B. Tuthill William G. Albenson Telephone (516) 765-1892 Fax (516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD SUPERVISOR SCOTT L HARRIS Town Hall 53095 Main Road EO. Box 1179 Southold, New York 11971 Office Use Only: r~Coastal Erosion Permit Application ,~Coastal EroSion Variance Application ~etland Permit Application ~Waiver from Chapter 97(Application/permi ~Trustee Lands Permit Application ~randfather Permit Application ~-~0mpleted Apps. Date: ~i~% _~spection date: ~·~ C comments-Date: Sent Rec. fiance Required: (Y/N) ighbors notified-Date: t~oord.:~ Date se~% SEQRA Determin./date: __Public Hearing/date: Findings: Approved (Y/N) Special Conditions: (Y/N) (see file) ~. Permit(s) issued-date: DATE REC.: TOWel vF Application Number;SCTMgl000- logo Applicant: Date: Phone (~) Z?P-dO~ Interest: (owner, consultant, lessee,etc.) Owner of Property: ~d%q~ ~ l'~6q~ ~g~. Subject Property Location (Provide LILCO Pole'9, Distance to cross Streets if not on- loca5ion map) THIS IS NOT A PEPa~IT Page 1 Yds. to be excavated: ~ Yds. to be filled: Manner in which material will be removed or deposited: Width of canal, creek or bay fronting property: Depth at low tide: ~ ~ Aver. rise in tide: Distance to nearest channel: Distance project extends beyond similar projects in area: Area zoning: Land area in acres: Is project for private or business use: ~C~\Z~-rf~ Intended use of property: ' ~~ Describe known prior operations conducted on premises: Has any prior license or permit been issued to erect structures, dredge, or deposit filI on said premises: Has any license or permit ever been revoked or suspended by a Governmental Agency: ProjeCt Description The project description must also include plans for reclamation of land disturbed during construction of the principle and accessory structures and underground structures (i.e., pipeline and septic system; make additional attachments if necessary). THIS IS NOT A PERMIT · Pa~e 2 '~ ~ 1.'.-*,6-4 ~2/87~--Text 12 t ,', PR(~JECT I.D. NUMBER 617.~. Appendix C State Environmental Quality Review .? SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART l--PROJECT INFORMATION (To be completed by ADDlicant or Project sponsor) 1. APPLI~.~NT/SPONSOR . L_ --. PROJECT NAME SEQJ 3. PROJECT LOCATION: 4. PRECISE LOCATION (Street address and road intersectians, prominent landmarks, elc., or prov~ae map) 5. IS PROPOSED ACTION: [] New [] Expansion 6. DESCRIBE PROJECT BRIEFLY: ~Modification/alt oration AMOUNT OF LAND AFFECTED: 8. WILL PROPOSED ACTIDJ'~ COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? ~Yes [] No If No, describe briefly 9. WHAT IS PRESENT LAi'~D USE IN VICINITY OF PROJECT? ~'Res,clenfia~ [] !ndustrial [] Commerc,a, [] Agriculture Descrd~e: [-'~ Park/ForestlO~en space [] Other 10. DOES ACTION INVOLVE A PERMIT APPROVAL. OR FUNDfNG, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL A~ENCY (FEDERALLY, STAT E,.~..O?.~K;A L)? r.~es [] r~o If ye~, list agency(s) and permit/approvals 11. ~.F-~'ANy ASPECT OF THE ACTIOi'~ HAVE A CURRENTLY VALID PERMIT OR APPROVAL? [] ~fo If yes, Itst agency name and permit/approval 12. ASA OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? [] No I CERTIFy THAT THE. INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Dale: Slgnalure: '"~ 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 1 A. DOEs ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR. PARr 61T.127 ,,~'- coormna[o tee review proco~ and use tn',e EUL--~ [] Yes [] No B. WILL ACTION RECEIVE COOh,~INATED REVIEW AS ~ROVIDED FOR UiNLISTED ACTIONS IN 6 NYCRR, PARr 617.67 ~ may be Superseded Dy another involved agency, If Nc(, a negative declaration [] Yes [] ~o C. COULD ACTION RESULT tN ANy ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be I~andwntten. it leq~l~lel Cl.potentialEXiSling airfor qualitY,erosion. SurfaCedrainageOror. groundwaterflooding problems?eUalitY Exulain°r quantity,briefly:nOise levels, existing traffic patterns, solid waste Production~ or dispOSal, C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or COmmumty or neighborhood character?. ExolaJn briefly: C~. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or lr~reatened or endanger'ed spec]es? Explain briefly: C4. A corem unity's existing plans or goals as officially adopted, or a Change in u se or Intensity of use of land or other natural resources? ExBlaln briefly C5. Growth, suBseQuent develoDmeet, or related aclivities hkely to be Induced by the ProPosed action? ExDtatf~ Dr=ally. C6. Long term, short term. cumulative, or other effects not identified in C1~C57 Explain briefly. C7. Other impacts (inclUding changes..in use of rather quantity or type ct energy)? Explain briefly. D. ¢4 THERE. OR iS THERE LIKELY TO DE, CONTROVERSY RELA'~ED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? [] Yes [] No If Yes, explain briefly PART III--DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or Other~vise significant. Each effect should be assessed in Connection with its (a) setting (i.e. urban or rural); {bi probability of occurring; (c) duration; (d) irr6vers b fy; (e) geographic scope; and (fi magmtude. If necessary, add attaChmentS or reference suo;}orting materials. Eh.surD that explana?ons contain sufficient detail to show that all relevant adverse impacts have been identified and adequalely addressed. [] Check this box if you have identified one or more potentially large or significant adverse impacts which l',IAY occur. Then proceed directly to [he 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 propose(] action WILL ~OT result in any significant a~verse environmental impactS AND provide on attachments as necessary, the reasons supporting this detefminati'on: - . '...-~',:. County of Suffolk ) State of New York ) 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 AGENTIs) OR REPRESENTATIVEIs), TO ENTER ONTO MY PROPERTY 'TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW .OF THIS APPLICATION. SWORN TO BEFORE ME THIS S I GNATURE NOTARY PUBLIC CLAIRE !. GLL=W Notary Public, State ef New York No. 4879505 _ Qualified in Suffolk County ~/_~ ~oramission Expires December 8, Suggested space for location Map THIS IS NOT A PERMIT CONSTRUCTION JOB STAMP Sheet Checked by __ Coun-:¥ Job Title of __ P[ep. bV Z)ate Date Desi~cn !dent.: SH.No. L~:S? 22a ~,!2/73) hFLNo. Checked bv Data CONSTRUCTION JOB STAMP ~.Y.S. C RTMENT OF T~AI~SPORTAT~ON Sheet Checked by County of__ Prep. by__ Date Date Design ldent,: SH,No. __ P.I .N. Job Title }~..S,T 22a (12/73) No. Prep. by Date Checked bv D ate