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HomeMy WebLinkAboutTR-10161A Glenn Goldsmith,President ��,®g's® �® Town Hall Annex A. Nicholas Krupski,Vice President �® �� 54375 Route 25 P.O.Box 1179 Eric Sepenoski Southold,New York 11971 Liz Gillooly Q Telephone(631) 765-1892 Elizabeth Peeples ® a® Fax(631) 765-6641 cOUNT'1,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE 2077C Date: September 8, 2023 THIS CERTIFIES that the installation of an Innovative&Alternative on-site Wastewater Treatment System; At 360 Bayview Drive, East Marion Suffolk County Tax Map#1000-37-4-1 Conforms to the application for a Trustees Permit heretofore filed in this office Dated May 25, 2022 pursuant to which Trustees Administrative Permit#10161A Dated June 15,2022,was issued and conforms to all the requirements and conditions of the applicable provisions,of law. The project for which this certificate is being issued is for installation of an Innovative&Alternative on-site Wastewater Treatment System; The certificate is issued to Paul C. &Diane M. Goleb Revocable Trust owner of the aforesaid property. 0 a Authorized Signature l MAIL, V ; t Voss- `��lZt> 8,zz•Z3 .ccs Sat 801�.. Glenn Goldsmith, President � ��� S®U) � Town Hall Annex A. Nicholas Krupski,Vice President 54375 Route 25 P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillooly sea Telephone(631) 765-1892 Elizabeth Peeples ® a® Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: INSPECTED BY: Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, haybale line/silt boom/silt curtain 1St day of construction % constructed Project complete, compliance inspection COMMENTS: l6 (Ili 40 Air✓ CERTIFICATE OF COMPLIANCE: G �.� Glenn Goldsmith, President ri$ so, Town Hall Annex A. Nicholas Krupski,Vice President �® �� 54375 Route 25 Eric Sepenoski P.O. Box 1179 Liz Gillooly Southold, New York 11971 � `' ` � Elizabeth Peeples Telephone(631) 765-1892 Fax(631) 765-6641 Ph vu NTI,�� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD SOUTHOLD TOWN BOARD OF TRUSTEES YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE ACTIVITIES CHECKED OFF BELOW INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction '/z constructed When project complete, call for compliance inspection; t Glenn Goldsmith, President ®f so Town Hall Annex A. Nicholas Krupski,Vice President �� ®�® 54375 Route 25 P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillooly G Telephone (631) 765-1892 Elizabeth Peeples a® Fax(631) 765-6641 1®Uf��,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10161A Date of Receipt of Application: May 25, 2022 Applicant: Paul C. & Diane M. Goleb Revocable Trust SCTM#: 1000-37-4-1 Project Location: 360 Bayview Drive, East Marion Date of Resolution/Issuance: June 15, 2022 Date of Expiration: June 15, 2024 Reviewed by: Eric Sepenoski, Trustee Project Description: Installation of an Innovative &Alternative on-site Wastewater Treatment System. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the site plan prepared by Homeport Engineering, P.C., dated May 24, 2022, and stamped approved on June 15, 2022. Special Conditions: None Inspections: Final Inspection. If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code, a Wetland Permit will be required. This is not a determination from any other agency. Glenn Goldsmith, President Board of Trustees A5-BUILT SITE INFORMATION: 4E OF NEW), 'p ID:1000-37-04-01 Q4,r' w ao� '1 -GfISTING 3 BEDROOM HOME WITH I BEDROOM ADDITION.TOTAL OP 4 EEDROOM5. -LOT AREA:0.32 ACRES.13,773 5P. Y} �7 \ -PROPERTY LOCATED AT 360 BAYVIEW DRIVE \ -EAST MARION,TOWN OF SOUTHOLD,SUFFOLK COUNTY,NEW YORK - x y,r -SURVEY PROVIDED BY:5CAUCE L9.DATED 07.21.2021 -VERTICAL DATUM-NAVD'1988 DATUM -PUBUC WATER SERVICE p�TS \ -ALL HOMES WITHIN 15OLP OP PROPERTY CONNECTED TO PUBLIC WATER 9[RVICE. AR ►�' \ -5URPACE WATER SHOWN ON 517E PLAN. �E8s10N APPROVED B`� wo / 'k\ *--A w.w N 2,VAGENERAL NOTES HOM[. 2.SI ORIF SANITARY REPLACEMENT DESIGN-SUFFOLK COUNTY SIP GRANT PROJECT. BOARD O F I FZ U S T E E S / 3.917E PLAN AND REFERENCE ELEVATIONS TO Be USED FOR VAOWT5 SANITARY SYSTEM ' ,Px Q w,p ARE NOT ONLY.EXACT PROPERN BOUNDARIES.UTILITY LOCATIONS AND ELEVATIONS K 'i \ ARENOTBA5tDGUARANTEED, 4.fUEVATI BASED ON PROPERTY PURVEY PROVIDED BY ALTOVCAUCC L.9,DATED PERFORMING 5 TOWN /A' O[ (�O�T���E� / � ll� a� M � 5.ONSITE UTNTY MARK-0UTS TO BE PERFORMED BY CONTRACTOR PRIOR TO PERFORMING SITE �/N'V ( S 1 -'PV) WORK. Y / \ �Oi �',.J�J{ 6.SOIL TEST HOLE DATA PROVIDED BY MCDONALD GEO5ERVICE5 06-24-2021 oWa BUB(/ 7.EXISTING SANITARY CE55POOL5(5)TO BE PUMPED AND R[MOVED AS NECESSARY PER 5CDH5 P EdTTWWW/ \ 01 5TANDAR05. DATE J- 15- 4,,,�;AD eR RY Y r�o // / r \� x n. PROPOSED VA OWT5 SEPTIC SYSTEM FOR UP TO 4 BEDROOM RESIDENCE: W LU I 464*11t, L�/ \ T�wATQe W.CE 2.ONE(I)11YOROACTION HP80 BLOWER VENT AND CONTROL ASSEMBLY. Z '- / \ 3.THREE(3)8.5'X 4.75'X 4'EFFECTIVE DEPTH LEACHING GALLEYS WITH I'EXTENSION WITH f / •i TRAM IC SLAB AND H-20 TRAFFIC RATED CASTINGS TO GRADE. w O } �NE4. / _ e� ot£gHFiD E�cTRRA 4.TWO(2)8.5'X 4.75'FUTURE EXPANSION GALLL`Y5 _0 Z ♦ �1 - / G[NERAL SANITARY SYSTEM AND INSTALLATION NOTES: Cn w Z / F DPoSFD rNRBE(�I4POOT PRECAST LEA411w I. VA IC U EDROOM HOME PER SUFFOLK COUNTY w Lll _- / II T T^ RAL A WTN,'Ex1�N[IOC TRAFRC SAB K:p Q 4oT 7S / ♦ \ \ R y� RAIEDPoNpSAND1NA41CCA5TwGSTO CANOE DEPARTMENTSANITARY GR VI HEALTH STANDARDS(SCDHS). Q' > y 2. SANITARY GRAVITY DRAIN PIPE TO BE 4-INCH CAST IRON AT FOUNDATION PENETRATION AND m } R� \ oPos®SmL Emw+9a+IMOT INsrAUEDI 4-INCH PVC SDR35 DOWN5TREAM OF FOUNDATION. Q Q / \ wsmao aocN wS�00L AND LEA.7+mu Poa To 3. VA OWT5 BE TESTED FOR WATER TIGHTNC55 PRIOR TO ARRIVING ONSITE U51NG THE W m Y �/ 1 BE Ava�D Rao AeAAaD�eDRm s¢Hs srxluRo; METHOD APPROVED BY MANUFAmR[R J 4. THE DESIGN ENGINEER SHALL OVERSEE THE ORIF DURING INSTALLATION AND SYSTEM STARTUP. 0 C� h / Q R wA• 5. THE OWT5 INSTALLER SHALL BE LICENSED,HOLD AN ENDORSEMENT FROM 5CDH5 AND BE A (7 M U) / M h 6. THE OWT5 INSTALLER SHALLAUTHORIZED REGISTERTALLER'THE ON51TE TREATMENT SYSTEM WITH 5CDH5. THE w DESIGN ENGINEER SHALL PROVIDE CERTIFICATION DOCUMENTS AS REQUIRED BY 5CDH5. T+ F 2 ) 7. AN OPERATION AND MAINTENANCE CONTRACT BETWEEN THE MAINTENANCE PROVIDER AND THE ' PROPERTY OWNER SHALL BE PROVIDED TO 5CDH5 FOR VA OWT5 AND PSD SYSTEM. Y��rii k4p_ 61 8. A GARBAGE GRINDER SHALL NOT BE INSTALLED UPSTREAM OF THE OWT5. 77 4 Sg 1 ST x m� O 9, WATER SOFTENER BACKWASH SHALL NOT Be F_U5HED TO PROPOSED SEPTIC SYSTEM. r 1 O 10. CONTRACTOR 15 RESPONSIBLE TO OBTAIN TOWN BUILDING PERMITS AS NECESSARY PRIOR TO INSTALLATION OF THE I-ROP05ED SEPTIC SYSTEM. 0•$ ByU T 1 1.EXISTING 5EW[R LINE HAS A HOUSE TRAP. VA OWT5 TO BE VENTED THROUGH 2 INCH CARBON VENT. \ / - OP09H,NYOROACIION MOOFL AAGSOO VA M Z O'f) \ OMS W N21 TpnFslC RATED WSEASAID _ r w •S �1a a\T x n. ` CASE RONWO TOORALE �L (� O^ I SEPABL IMIN CONTROL PMIELIX]MRRESSOR avox w O`- �� S�BL AIDVBIT newn�w sov LLJ Z�- Z r / Alo E.10 V- / Q- o°»Aaw.awNow,Ta w w 'j 0 a� eN o ^ Y OO E E 1 E Z ao S �L 27 10 <a ft,,�,"f zo",F4� L -6o. �Ov L MAY 2 5 2022 � �'�Ef NErpom�E - Sg 00. DATE.05-24-22 SCALE:1:30 SANITARY SITE PLAY, Southold Town DESIGNER TAO SCALE= 1:30 Board of Trustees SHEET: 0 3a 60' S ' 520 LOAD RATED BOLTED CAST IRON COVER MAX WLIM OF T OF EXTENSION OF NIE&V Y COLLARS MAY BE USED TO Q'lE��g O� BRING CASTING TO GRADE. c" OW`A�gy'Cr. UTYL RUBBER GASKET ITlet UBEER PIPE CONNECTOR r Outlet ``b,D aa4e1' k`'6 Rp SSt�Py Inlet Outlet (EMOTE PNC COrmVOL PANE W NPAOCONPRE550R s HP80 COMPRESSOR SCALE:NTS 10' c) c) HYDROACTION AN-5000 ANN-BUOYANCY CALCULATIONS W HYDROACTION ANS06C NITROGEN REDUCTION SYSTEM PRECAST CONCRETE U �--' MONOLITHICTANK MATERIAL PROPERTIES: OE`=BxaAssnN_ Z WEIGHTS' HS-20 LOAD RATED WATER: 7.482 GAUCF 8.54 LB'GAL 62.4 LEVCP BASE UNIT:12,250 LBS, EARTH COVER:0.60-3.0 FT. CONCRETE:DRY:ISOLB/CP SUBMERGED/NET:87,6LB'CP "T'PA�' Q Z ROOF SLAB:4,100 I.S. SOIL: DRY:IOOLB(CP SATURATED:117UNCP NET:83LB'CP ®LI-mAAms-1mvAc au el N Z HYDP,OAGTION ANG 00 1500 GALLON T,TANK: DESIGN NOTES: TOTAL VOLUME:1,500 DRY WEIGHT,TANK:1.510 LB,COVER:4,100180 -H2O T FFIC RATED HYDROACTION MODEL PRECAST AN-500C UA OWT5 FOR TOTAL BUOYANCY:1,500 GPLX8.3a LB/GAL=12,510 LB M.meuwrtrn X�YDcmN IX RESIDENTIAL STRENGTH WASTEWATER UP TO 550 GPD.DESIGN FOR xwcrum, rum ED ANTI-BUOYANCY CALCULATIONS: WQ 4-BEDROOM 440 GPD. NET BUOYANCY OF TANK:12,51 O LB J M Mi -SECONDARY SAFETY COVERS TO BE INSTALLED UNDER ALL TREATMENT UNIT NET WEIGHT OF TANK SA -BUOYANCY),12,250+4,100=16,350 LB HYDROACTION AN-500 SINGLE LINE VVIRING DIAGRAM SCALE;NT5 (0 co COVERS. NET ANTI.BUOYANCYAT PULL SUBMERSION:[(;,350112.510-130% 010 F- (� -USE WITH HYDROACTION REMOTE HP80 COMPRESSOR BLOWER ASSEMBLY DESIGN FOR SO%SUBMER510N OF TANK IN GROUNDWATER PEP,SITE CONDITIONS: tu[J AND REMOTE PLC CONTROL PANEL, 12,51 O N8 X 5046-6,255 LB -PLC CONTROL AND HP80 COMPRESSOR TO BE REMOTELY INSTALLED ALONG 16,350 LE 16,255 LB-261%ANTI-BUOYANCY. FOUNDATION AS SHOWN ON SITE PIAN. 261%>150%5CDhS REQUIREMENT. -TANK TO BE INSTALLED ON LEVEL COMPACTED SAND OR GRAVEL BA5E AND -_- ---- - PROPERLYBACKFILLEDPERMANUFACTURERRECOMMENDATIONS. C HE^ R (a -INSTALLATION TO BE PERFORMED BY A HYDROACTION AUTHORIZED INSTALLER '„_� ONLY. -START-UP AND SERVICE TO BE PERFORMED BY A HYDROACTION AUTHORIZED L DI SERVICE PROVIDER ONLY. HYDROACTION MODEL PRECA5T AN-500C I/A OWT5 6 ANTI-BUOYANCY CALCULATIONS L MM AY 2 5 2022 Arnz SCALP-Kra Z co Z�L................................................_................................__........._T................................................_..........._.................................._P_......_................._................_._........._.............._....._....._.....__........_............._........._......._. �dd=»z i _ p E j i j $Qut l^�L:;TrL"ttl :r i .«:.. I i ! 1'EXTENSION V4TH TRAFF�SLAH +s.-...__^_,,,.;.,,:._ ;a i � d 1 l NID HEAVY DLfTY TRAF W j : - - -. , ........._..........................__.."......i............_........__.......__..._._.... ..._............_...... i BEM WO LOCWNO CAST BION, _ I ......,_...._......................_...__..._...... .. 15 T....._..._...._. i �..... CO ER7vG7MA T. ........................_...._....._.. _.__..... �o ••••"'El09 BRACc EL 1<L'i—• FFEL 12.904 TRAFFIC BFARWG V RISERS TO i } ^ Ex19 GRAGB EL+IB• GRADE N1TH CASTWOB 1 gam^" IXIS GD EL 12.6'2 IXIS INV 11.0! 10,_.....__....... ®®o0®co ocL:aO®oc o®aO�v Zoa Rim Q 4-NCH PVC SM35 MW SLOPE.O]'AF MIN LNDHPVC6SLOPE.S'AF1',`L , 51.............._....-. E ELSE OF CHAMBER EL S.1'z i i j _.................. _.. ............., . __........_................1.....__�4...®®a _.... ..............a�..s............._y..__.._._.._e._._... �.....;........_......._...................._......_I NIDTRAFFIC NATED i (3X14'LEACHWG GA1 YS SPACED IFOOT APART W LINE DATE 05.24-22 HYDROACTION MODEL VM 4NCH S6RS5 CROSSOVER PIPES 7 PRECAST AN-SSACVAOK S MWIMWM F00TSET. FROM BOTTOM OF SYSTEM TO E .�'Y E SCALE:NTS I j OROU ATFA.S YSETBACKSHOVM Ln HEGW 0.6ti t DESIGNER:TAO OI MIOXEST D(PECTEDGRd1NpWTEROB'; + j HIGHEST IXPECTEOiGRwNCNPTEROa ` ?HtGHE51 ER4CTEDORCUNDMTe1i0B': 10, 20' 30, 40' 50' 601 70, SHEET: HOU5E SANITARY ELEVATION PROFILE SCALE:NTS O gY�OF New yr,F A.Oz, "Pf 18.04 o 00+87% 861ON� GRADE eL 14.0 x 1 \ �y• RAVE4 SAN EL TMT HOLE INFORMATON iii � ��O _ Tq LOAM 5M �5'�GE09eRVR:E�9 A PROPERTYLOCATEDAT I Q 'f7 360 FAL! No&x DMI!EANOUT AT FACE OF BUILDING P CSaD lAlTMARO,N1199.(s?) Nw3 EXISTING PUBLIC WAT AE -4.2021 AA M UT DETAIL DEPTH OPTE5T HOLE IT.0s��� M EXISTING OVERHEAD E p`�f, " �' �" BK nNe �ATaa zSAJ SP) CIL a o \ SERVICE Wp Z [J p ep aye a OUNTCRPD N Z GRA EL \ 0 X 1s 83 PROPOSED THREE (3)4 j~ MAY c 5 2022 OLE INFORMATION DRIVE AY ` �S�` \ GALLEYS WITH 1' EXTE � °"`E`" w im RATED RINGS AND TRA ! soitigrd_ro�i ! 0 X 14.90 H_ HEAVY DUTY T , IC BEARING M N Qv _�.__•M_ D�TNSIBPS; LOCKING CAST RONCOVERATGRADE f �y PROPOSED 50% EXPAN -- - OOO 1 EM RAFIFIC SLAB 2' \ EXISTING BLOCK CESSF BE PUMPED AND ABANE ®®® 0 ®®® 1a� X 13.48 c9 01 GRv� {>.'� eC 12.67 I 3.p^ N O co 4.0' \ CP C 11 .81 r GROUNDWATER MIN.3' ~ ` EL:12.5't v 1 LEACHING GALLERY DETAIL�NOTES Q ' I OI (' SCALE:NTS 0 � ST O c� O LEACHING GALLEY NOTES \ X 11 .01 nO —11-0- PRECAST CONCRETE LEACHING GALLEYS MINIMUM 4-POOT EFFECTIVE LEACHING DEPTH OF GALLEY DATE:05.24.22 H-20 RATED TRAFFIC CASTINGS TO GRADE I'WVN51ON WITH 7RMF1C SLAB SCALE:1:10 X 12.71 v0 v TOTAL OP 300 SP EFFECTIVE LeACHING AREA FOR UP TO 4-BeOROOM HOME C .92 - MINIMUM SETBACK FROM BASE OP CHAMBER TO GROUNDWATER 3-FOOT. DESIGNER:TAO EXISTING-901L CONDITION STATEMENT SHEET: �111u AND GRAVEL ONLY Op.5W) - 501L CONDITONS MAY VARY AND NEED TO BE=MMKMED IN FIELD AT TIME OF INSTALLATION. I/A OWTS INSTALLATION PLAN O TO' 20' REMOVE MID REPLACE UNSUITABLE 501L91F NECESSARY WITH CLEAN SAND AND GRAVEL POR A S-FOOT COLLAR AROUND GALLEY,EXTENDING DOWN INTO THE EXISTING ACCEPTABLE MATERIAL(5P SAND). SCALE= I:10 Glenn Goldsmith,President Town Hall Annex �O Gy A.Nicholas Krupski,Vice President 54375 Route 25 Eric Sepenoski CO ? P.O.Box 1179 Liz Gillooly �y • o�� Southold,NY 11971 Elizabeth Peeples ��l �� Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: 2"-2-- Completed infield by: PAUL C. & DIANE M. GOLEB REVOCABLE TRUST requests an Administrative Permit for the installation of an Innovative &Alternative on-site Wastewater Treatment System. Located: 360 Bayview Drive, East Marion. SCTM#: 1000-37-4-1 Type of area to be impacted: Saltwater Wetland Freshwater Wetland Sound )e Bay Part of Town Code proposed work falls under: X Chapt.275 Chapt. 111 other Type of Application: Wetland Coastal Erosion Amendment _Administrative Emergency Pre-Submission Violation Notice of Hearing card posted on property: Yes No Not Applicable Info needed/Modifications/Conditions/Etc.: Present Were: G. Goldsmith N. Krupski X E. Sepenoski L. Gillooly E. Peeples p i.DER—75—Em SYMBOL LEGEND GRAPHIC SCALEa $s o u/-¢a ��\A oil a+QIQQp $¢ ( 93, 1N Rik S319 6, 311 �! o O 61 ET ct 5 ®Tr-wEr N e it C ■,ue.ac, e f -.i,v.�.,�c\.. `ems' v v Man �•C ERpea > 07 gil Px I.b v®elt 11flA5`MM N 16C NO SEPTIC VrSI CA eAr mao-a E W SUOI[Ct PADVDSIY NO AVA6ABLE RECORD DCGVMENT ! `A•jP Y*b"44 \ $I•ti-j. t\ :\\ aMgg rC. W J" Cf F Y�J. r\\ �� vrvaosaa r^ E g�8 \ u® 11.19 FRAESO MRESIDENCE \1 APUBLIC WATER) App y FM LOT 122 TAX LOT 2 'a b ", � "�y Q� J �O ya./ 'No aal TMF A BOUNDARY NOTES, WALL I. CWiUC1N0 1wHwO(W4V1 iWND d IxE VIwII1Y e faWS"°aaww.�na oht e �Q ro m oN�a°�E ucs or nns Ott. v - t>J ~ 'tL� `dR z uUC'ro TIR Ulx a C[GMCIRr w 11E aro N+D aN tV WALL 4 'tom' Q///��u �tL�� BawmRY u¢a cI>fttm uSwDuswo tcvuus w p *"d s\� i cY e s YJJ,J• ..,��. I j1. LLLL`��� V IT p N N tit. P6SS65pl{R¢DD LNF9 I1O D1D 9wWLY4 IIIE 5 `� ApwPTNO oR0 roR rAx IDr z usm II¢Yu,PAGE ' Q• I�'ti t � g a8 xaD rw ne xwwDrtr AHD vamar �'. ' r,s+ 6. \ Watt / �;DMAY 2 lie N Q 811 s• ¢1.'D•—=LL_ �_.,....ffitaR-I�bFty-- `�,.� oc., 20I I e t5.5' a D IIEg OTAVEL �" z FND Pxe RE `>• �•, "S °° '.o ' Southold Town o ffi 9 Board of Trustees �� " ��� Dns ,:� �,`�•�o ex• _ MDN � ��• O pe ~ 0 Y4 ...to.e• W aa} \ Y � µv�� � �o Q�¢1 (FOR HEALTH DEPARTMENT USE ONLY) I \ a-N q $ N Q�Q \ R o N o I r� 260.00 o.- , V_t B2 W Z ¢¢ L = 59.03' �a6gz^�z 9�$ e �n333 1 y TAX LOT 23 ` O- !n c „S 'o �� TCDD DOW �1 W to$ Z U3Q�p C NO AYAhAB��yL48LE NF2TT � p � �YJ IQppQ� ir V) 8 •ALL EL&ATIONS REFER TO NAVD88•DATUM \ ,0 A5-5UILT 51TE INFORMATION: 01 NEW k.-r1` • 1=77777W ID:I 00Q37#-0I Q4f A ppb -EXISTING 3 BEDROOM HOME WITH I BEDROOM ADDITION.TOTAL Or 4 WDKOOM5. -IAT AREA:0.32 ACRES.13,773 Sr. \ -PROPERTY LOCATED AT 360 BAYVIEW DRIVE \ -EAST MARION,TOWN OF SOUTHOLD,SUFFOLK COUNTY,NEW YORK X y,NNCO -SURVEY PROVIDED BY:5CAUCE L.S.DATED 07-21-2021 VERTICAL DATUM-NAVD'1988 DATUM rI r.a -PUBLIC WATER 5MVICE 15fir, R \ -ALL HOM[5ROLFa PROPERTY CONNECTED r0 PUBLIC WATER SERVICE. a pV \ -5URrACE WATER SHOWN ON SITE PLAN. EBsION tu GENERAL NOTES: 4-5EDROOM HOME. 2. 17E VA OWT5 SANITARY REPLACEMENT DESIGN-SUFFOLK COUNTY 51P GRANT PROJECT, 3.5PLAN AND REFERENCE ELEVATIONS TO BE USED POR VA OWT5 SANITARY SYSTEM �O - CONSTRUCTION ONLY.EXACT PROPERTY BOUNDARIES.UTILITY LOCATIONS AND ELEVATIONS ARE NOT GUARANTEED. 4.ELEVATIONS BASED ON PROPERTY SURVEY PROVIDED BY 5CALICE L.5.DATED 07-21-2021 P y 5.ONSITE UTILITY MARK-OUT5 TO Bt PERFORMED BY CONTRACTOR PRIOR TO PERFORMING SITE i a� WORK. 501L TEST HOLE DATA PROVIDED BY MCDONALD GE05ERVICE5 06-24-2021 ✓D SOA 6 RMR�q rER - \ r� \�� 7.EXISTING S SANITARY CESSPOOL9T^9)TO BE PUMPED AND REMOVED AS NECBSPRY PER SCDFSAID a) 4 � FRR y V / `�a1,` ♦ \\ X PROPOSED VA OWT5 5EPIIC SYSTEM FOR UP TO 4 BEDROOM RESIDENCE: U (jJ / (� rx•Is wsucwA*Fn 9�iH!F 2.ONE(1)HYDRDACTION HP80 BLOWER VENT AND CONTROL A55EMBLY. > 3.THREE(3)8.5'X 4.75'X W EFFECTIVE DEPTH LEACHING GALLEYS WITH I'EXTEN51ON WITH Z w } '!�Y ♦ TRAfflG SLAB AND H-20 TRAFFIC RATED CASTINGS TO GRADE. LL.) (�y� —� sTlw o�PolEAo aecTalcx o Z 4.TWO(2)8.5'X 4.75'FUTURE EXPANSION GALLEYS _ f Ip1J �4• GENERAL SANITARY SYSTEM AND IN5TMIATION NOTES: (n W Z V / �, iN Y \ r oPo�rNREprnacoorRaLCAsr�' I. 9Y5 M U EDROOMHOMEPR5UPPOLKCOUNTY W 0 RA11EY$YATI11'PxrENc+a+Y.nn rRAF'FlC SLAB KD RATEDPonos rNo mNs1[CASlnxls io cxnoE. SANITARYDEPARTMENTGR VI HEALTH Birt!TO 5S(SCDH C Q' SANITARY GRAVITY DRAIN PIPE TO BE 4F UN CAST IRON AT FOUNDATION PENETRATION AND I � \ oaos®saa DwrNsuN lnor lnsrAum: 4-INCH PVC SOR35 DOWNSTREAM OF FOUNDATION. m Q \ 3. VA OWT5 SHALL BE TESTED FOR WATER TIGHTNC55 PRIOR TO ARRIVING ON51TE USING THE I. srlNo aaa cessaoa ANO LEAom+a Aoaro m � BE Pud'EO MIG ABAfA:�01Ep RETE SCLk65TNIGND: METHOD APPROVED BY MANUFACTURER J 4. THEDE51GN ENGINEER SHALL OVERSEE THE OWI5 DURING INSTALLATION AND SYSTEM 5TARTUP. 0 C) / 5. THE OWT5 INSTALLER SHALL BE LICENSED,HOLD AN ENDORSEMENT PROM 5CDH5 AND BE A C7 (M W / N HVDROACTION AUTHORIZED IN5TALIER �i 6. THE OWTS INSTALLER SHALL REGISTER THE ON51TE TREATMENT SYSTEM WITH 5CDH5. THE OM ENGINEER 511 PROVIDE CERTIFICATION DOCUMENTS AS REQUIRED BY 5COH5. .a 7. AN OPERAERTYTION AND MAINTENANCE CONTRACT BETWEEN THE MAINTENANCE PROVIDER AND THE GR( �' I�.n N� 8. A GGAARBAGEGRIRIND R SHALL NOT BE INSTALLED UPSTREAM 5HALL BE PROVIDED TO 5CDH5 FOR I/A Or THE OWTWIS AND F5 5. SYSTEM. �I p� Gl�9 I ST j X n.a O 9. WATER SOFTENER/ BACKWASH SHALL NOT BE FLUTED TO PROPOSED SEPTIC SYSTEM .1 O 10.CONTRACTOR 15 R[5PONSIBL[TO OBTAIN TOWN BUILDING PERMITS AS NCCE55AKY PRIOR TO �X p•r INSTALLATION OF THE PROPOSED SEPTIC SYSTEM. O�A� '-"'- r\A I • I I.EXISTING SEWER UNE HAS A HOUSE TRAP. VA OWT5 TO BE VENTED THROUGH 2 INCH �1 CARBON VENT. / D 1334 � •» / \ � Xr.A / — OP09®1flIXMACIION AIDOFL ANC-loo UA ^ ,�� �M .c BM ` X n. 4'1 owrsw+o a ro aoaria�E agas wo - ( $^ s f S LRNI)LY anraot VAHaLUNRaEgsoa c;AsseRELv Nn vert eo.®R•o« _ ,w.+�ti.e,.� W 2?- M� \� � Alp ■� .» ��� � �\D4� (ttn Z)w ULI K p a< I E C E I V E < WON 0 O x 0 21110 `�� Q m (no a 4 zor R - zsoo �� I MAY 2 5 2022 59.0s. DATES 05.24-22 SCALE:1:30 5ANITAKY 51TE PLAYA Southold Town DESIGNER TAO SCALE= 1:30 Board of Trustees SHEET: o ao• Ba S� ' 5-20 LOAD RATED BOLTED CAST IRON COVER MAXIMUM OF T OF EXTENSION OF NIEW Y COLLARS MAYBE USED TO �Q'CE AdO BRING CASTING TO GRADE. y [� UM RUBBER GASKET ?O �F Inlet UBEER PIPE CONNECTOR NLHEOutlet A(y a 0868790 ROFESStONP`. F i Inlet a n Z D Outlet iSif OTE PLC CGNINOL PANEL W rW9CGMPF£99OR 3 HP80 COMPRESSOR SCALE:MS L 1a E�+O HYDROACTION AN-5006 ANR•BUOYANCY CALCUI.A710N9 W HYDROACT10N ANSOO-C NITROGEN REDUCTION SYSTEM PRECASTCONCRETE MATERIAL PROPERTIES: LOAD RATED WATER: 7.482 GAUCP 6.34 LE �corrmwATsno7rs Z WEIGHTS: MONOLITHIC TANK HS-20 GAL 62.4 LB/Cr UNTT:1Z250LES. EARTH COVER:0.60.3.0 FT. CONCRETE:D .150 LBCP 5UBMERGED/NET:87.6 LB/CP �crwuLPwflv. p Z ROOFSLAB:4 ,100 LB. SOIL: DRY:IW U3CP SATURATED:117 LBCP NET:83 LECP C8L1.]p OTOS-130YAC V Z HYDROACTION VoLuNi ANC-500 1500 GALLON VA TANK. DESIGN NOTES: TOTAL VOwh1E:1,900 DRY WEIGHT:TANK:12,250 LB,COVER:a.100 LB Lu 0 -H2OT TRAFFIC RATED HYDROACTION MODEL PRECAST AN-500C VA OWTS FOR TOTAL.BUOYANCY:1,500 GAL X 8.34 LBAWAL=12,510 LB NM.P.— CgtDPA®ppllH RESIDENTIAL STRENGTH WASTEWATER UP TO 550 GPD.DESIGN FOR xaavN+a Aem, ANTI-BUOYANCY CALCULATIONS: W t 4-BEDROOM 440 GPD. NET BUOYANCY OP TANr.12,51 O LB J m -SECONDARYEAFETYCOVERSTO BE INSTALLED UNDER ALL TREATMENT UNIT NET WEIGHT OF TANK(ANT-BUOYANOY):12,250+4,100-I6,85OLB HYDROACTION AN-50051NGLE LINE WIRING DIAGRAM NET ANTI-BUOYANCYAT PULL SUBMERSION:16,350/12,510=130% O F_ COVERS. SCALE:NTS M (n -USE WITH HYDROACTION REMOTE HP80 COMPRESSOR BLOWER ASSEMBLY DESIGN FOR 50%SUBMERSION OP TANK IN GROUNDWATER PER SITE CONDITIONS: LLQI AND REMOTE PLC CONTROL PANEL 12,510 LB X 50%=6,255 LB -PIC CONTROL AND HP&O COMPRESSOR TO BE REMOTELY INSTALLED ALONG I G,'35001r,25 5 LB-261%ANTI-BUOYANCY. FOUNDATION AS SHOWN ON SITE PLAN. 261%>1505 SCDHS REQUIREMENT. -TANK TO BE INSTALLED ON LEVEL COMPACTED SAND OR GRAVEL BASE AND --_-_---- PROPERLY BACKFILLED PER MANUFACTURER RECOMMENDATIONS. ((:t1 -INSTALLATION TO BE PERFORMED BY A HYDROACTION AUTHORIZED INSTALLER EL u-$ f. EONLY. _ U -START-UP AND SERVICE TO BE PERFORMED BY A HYDROACTION AUTHORIZED _ �!s .��� SERVICE PROVIDER ONLY. - HYDROACTION MODEL PRECAST AN-5000 I/A OWT5 4 ANTI-BUOYANCY CALCULATIONS m AY z SCALE_NMTS 5 2022 — 20..........._...............__....._........ ............._..........._....___...._...._................................................._............................................ ..._...._.........._._...__..........._._.__..,_,_..............._....._.....__...._.................................................. r . . . ._ a I I 1 �tT:ltlnli':f•L'. C3 3 I 1'EXfEt/SI0NW0HTRIFFIC ! i FR'�'.'Ul.�s'tii^', S: I1J ! ! /NDHEAvy ourr TRPPp I I LEMNG LLOCKINO CAST IRON! _..._........__....... ........:..........__..... ..._......._........_...._......_......_...'_._........................._....._.._.. _.. ..._....._............__._......_..-_.....j N o 15 Cd4f1i S'0 aGE7 MAX_7_..._._.............._.._._.._..., E D09OPAOEEL NII f FFEL 12.9171 F TRAFFIC aEARNo a'R1sERS To 3 ! ! ` �.,¢ p_ EJn90RApR R.1f.Pf GRADE WtTH CASTINGS i �X EXIS GD EL 12.54 I ; ¢ t EAS INV I I.D3 F- 10.......___._............._..... vvmOv®v vmmOvvv mva0®v IE rOIIf ._..... .. ._._.. .._................_. i. E:99f �E:9.9'1 R��00I�ppyRp� �ME Mw mmmi (n 4NCN PVC SDR% CH � G� ! �pgOG�lO ®��j £ MN SLOPE.OT'AF MINCLOPE.O�f YIFS 51 .......BALY OF CNPMBERE 8.f': i Hap TRAFFICf1ATE0 L9XI4'LEACH NOOA<t�YS BPACED:WOTAPART NLNE ! N DATE:05-24-22 HYMIDACTIONMODEL i ! VA481CH PSS CROSSOVER PmEB PRECAST A11d00C VAOWTS MNRAUM Sf00TSEft;aCK FROM BOTTOM OFSYBTEMTO ''^^ :f SCALE:NTS ! OROU ATEA.53'SETBACN SHOWN u J } HEGW O.St I DESIGNER:TAO 01 MOHESTEMPECTHIGRWNDfATERp4'! ! f NIpNE9TIXFECTED!ORP1NWwTERGk ?HIONESIE CTM­w,0A'! 0. 20' 30' 40' 50' 60' 0' SHEET: HOUSE SANITARY ELEVATION PROFILE SCALE:NT5 OF New Y.p� y4PawoQW OT 18.04 `2 oaasTfl ��v GRADE EL 14.0 S X 17. -NTa. / 4 RAVEL SAN GL TEST MOLE INFORMATION4 Tq LRAM SM 3 yi I Y GE05ERVICES 7J PROPERTY LOCATED AT Q CLEANOUT AT FACE OF BUILDING+a.® PING SAND 360 BAIVIEW DRIVE EXISTING PUBLIC WAT PALE(SP)) DATED OG24-2 2'1'AT9 AM / UTDEfAIL DEPTH oPTeSrnoLelT.ax CL eer M / \ `_A EL EXISTING OVERHEAD E �` ' =` - �m IRO !FINE tNwUM AAG�D PT 4o z a} \ SERVICE E a •3.ax w � Z \80 � e NTECED PROPOSED THREE 3 4 MAY 25 2022 OLE INFORMATION � �z W GRA EL DRIVE AY \ ,yp�0�` 16.03 GALLEYS WITH 1' EXTE NTw\ X 14.90 RATED RINGS AND TRA jALE, o�� �Q�rt..Gld•TOwqHTT IC BEARING 1 USf005: LOCKING CAST RON COVER AT GRADE y PROPOSED 50% EXPAN -- 9ii VEXTENSIONWITRAFFIC EXISTING BLOCK CESS BE PUMPED ANDABAN ®gX 13.48 ®®®® z(7 ��. ®® •6D / WDvE4 * ® O :'_ mI _ �JEvyP� (' BC 12.67 'I I �- e:�„ W� a Q co t .0, \ CP Q�� C 11.81 GROUNDWATER MIN.3' ~ EL:12.5'! �� C1 + O LF-ACHING GALLERY DETAIL NOTES g 0 5CALE:NTS ST Gj� I O LEACHING GALLEY NOTES X 11 .01 O PCT Ve DEPT PRECAST CONCRETE LeACHING GALLEYS O I Q O - MINIMUM 4-FOOT EFFECTIVE LEACHING DEPTH OF GALLEY DATE 05.24.72 H-20 RATED TRAFFIC CASTINGS TO GRADE \ "WENSIDN'MTH TRAFFIC 5LA8 SCALE:1:10 X 12.71 OO - TOTAL OP 800 SF EFFECTIVE LEACHING AREA FOR UP TO 4-BEDROOM HOME • �l - MINIMUM 5ET8ACKFROM BASE OF CHAMBER TO GROUNDWATER 3-FOOT. DESIGNER:TAO v C 92 EXISTING 501L CONDITION STATEMENT SHEET: - ft,kvALLtytX yAND GRAVEL ONLY(5P,5W) - 501L CONDITIONS MAY VARY AND NEED TO BE CONFIRMED IN FIELD AT TIME OP INSTALLATION. I/A OWTS INSTALLATION PLAN 0 Ta 2a REMOVE AND REPLACE UNSUITABLE SOILS IF NCCE55ARY WITH CLEAN SAND AND GRAVEL POR A 3-FOOT COLLAR AROUND GALLEY,EXTENDING DOWN INTO THE Da5TING ACCEPTABLE MATERIAL(5P 5AND). SCALE= I:10 t k� __ pN ,xasxs oanss oaxam aslom " a►nm owxm �Z osxxcs t r osasw osxxar t +' 01 17� oam.x a�' t t P � r r / b t r r F or uR /lee r, 'o r s 4 • t xa a t .t Q a,' t le d � .off ry P�• O .`� � t s 1 a""a° so•Yv Pu�o as u (1 N"eO0. 1p ,P" 1 Is x ; / P•� + ,r 0. P� I / l L •M�- _�_ —^^-- --^-- NoncE ,� COUNTY OF SUFFOLK © e of d aoumoLe SECTION NO (21 � -- -- — -- it., £ Real Property Tax Service Agenq Y Nr.r .. u•n� . o..r • �i CsnlY o.w Rw�4FYtlw M QJ7 Dir•r. n r �x� s��• s.� --•-- e...--•�-- Y P ,p ,mc,q 7a1a PROPE0.TY IMP Glenn Goldsmith,President �OF s®[��� Town Hall Annex A. Nicholas Krupski,Vice President a®®� ®�® 54375 Route 25 P.O. Box 1179 Eric Sepenoski 3 Southold, New York 11971 Liz Gillooly Elizabeth PeeplesTelephone(631) 765-1892 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application Wetland Permit Application Administrative Permit mendment/Transfer/Extensio Received Application: S' 22 Received Fee: ✓Completed Application: sZ�i•Zy Incomplete: SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: ord inati on:(date sent): 015)LWRP Consistency Assessment Form Sent: -CAC Referral Sent: Date of Inspection: MAY Receipt of CAC Report: Z 5 2022 Technical Review: Public Hearing Held: 4=00 SmirwldTom Resolution: BoardoFT �44ZJD 00'j C ReNve, I-rus 9f Owner(s) Legal Name of Property (as shown on Deed): Cqole- b -D QL 'R "-e-T-r Mailing Address: P 0 gx `1 S Cay-s+ ka v ,-=-n Phone Number: ? .LJ .zI �OIyl'bI ID[ '�o i a6-&Cf Suffolk County Tax Map Number: 1000 - 23rl 0 0 --0 4-0 U -- 00 1000 Property Location: .31� 0 60m, ce A). azc , q 3q (If necessary, provide LILCO Pole #, distance to cross streets, and location) AGENT (If applicable): Mailing Address: Phone Number: Email: Board of Trustees Application GENERAL DATA Land Area(in square feet): f J� '1 r, ff,, Area Zoning: Previous use of property: i(Gsi Intended use of property: leIJ ak Covenants and Restrictions on property? Yes No If"Yes", please provide a copy. Will this project require a Building Permit as per Town Code? Yes `/ No If"Yes", be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes _�V" —NO If"Yes", please provide copy of decision. Will this project require any demolition as per Town Code or as determined by the Building Dept.? Yes __V" No Does the structure (s) on property have a valid Certificate of Occupancy? V Yes No Prior permits/approvals for site improvements: Agency Date No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency?__NZNo Yes If yes, provide explanation: Project Description (use attachments if necessary): Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: (e_J .1, (L;+ e' .-GU'VL 'Se4{b e, UJd_&.(.e Area of wetlands on lot: square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands: ` feet rrN 11 Closest distance between nearest proposed structule�n�uptand� 94)of wetlands: feet Does the project involve excavation or filling? No Yes If yes, how much material will be excavated? 1.o cubic yards How much material will be filled? 7"LO cubic yards Depth of which material will be removed or deposited: 4—(P feet Proposed slope throughout the area of operations: 0 Manner in which material will be removed or deposited: �, �� at Aki A&j Il A Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason of such proposed operations (use attachments if appropriate): � �-�w��. �a1�,w-h�,�-•�, �ss��°�ls �-5�� '��5 �, �t�-� .�e�. i��.�,f '��' a,� _VV1e_ 5 i l_ d' ra&44 �' fit ; es-k at JLLU)i��r -fix,"� � bi,c� s d-As�. y �r�n 5 i spa s ,r wc�r2 �� V c ,s►Sal AD a uz. ✓ A ".16 i n c.0 A0_11441L� on l (1r' (a&_ u4A, we. iv Temy-t' OLUV 617.20 Appendix S Shout Environmental Assessment Form Instructions for Completing Part l -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part l based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part I -Project and Sponsor Information Name of Action or Project: �n i I�1 O � � y � reAe.�ee r Jh c Sys Project Location(desr/.c��ribe,and attach a location map): 700 Brief Description of Proposed Action: 11J i �� Qh �/l i4�iJCC. V e. ons 4 Qeu&urs� /A . 30 sb-l Name of Applicant or Sponsor: Telephone:G1z "I I �' `�� ��•� E-Mail Je6 cC b�•�Cvv► Address: City/PO: State: Zip Code: I 161 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and.the environmental resources that may be affected in the municipality and proceed to Part 2. If no,continue to question 2. 2. Does the proposed action require a permit,approval or funding from any other governmental Agency? NO YES If Yes, list agency(s)name and permit or approval: El 3.a.Total acreage of the site of the proposed action? L + acres b.Total acreage to be physically disturbed? 1 acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? _acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial ❑Commercial (Kesidential (suburban) ❑Forest ❑Agriculture El Aquatic ❑Other(specify): ❑Parkland Page I of 4 5. Is the proposed action, NO YES N/A a. A permitted use under the zoning regulations? ❑ 2 ❑ b.Consistent with the adopted comprehensive plan? ❑ ❑ 7 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? ❑ R 7. Is the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO YES If Yes, identify: 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES b.Are public transportation service(s)available at or near the site of the proposed action? ❑ c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? ❑ 9.Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements,describe design features and technologies: �j ❑ L"J 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: < ❑ r 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: &R2ki,�p A,c,7�� R ❑ 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic CNOYESPlaces? b.Is the proposed action located in an archeological sensitive area? 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies regulated by a federal,state or local agency? ❑ 10 b. Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? �j El Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: [ 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: ❑Shoreline El Forest ❑Agricultural/grasslands El Early mid-successional ❑ Wetland El Urban Ea Suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats,listed NO YES by the State or Federal government as threatened or endangered? �y ❑ 16.Is the project site located in the 100 year flood plain? NO YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, a. Will storm water discharges flow to adjacent properties? ONO ❑YES ❑ b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: O ❑YES Page 2 of 4 18. Does the proposed action include construction or other activities that result in the impoundment of NO YES water or other liquids(e.g.retention pond,waste lagoon,dam)? If Yes,explain purpose and size: 19. Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES solid waste management facility? If Yes,describe: ® ❑ 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES completed)for hazardous waste? If Yes,describe: ® ❑ I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/s onsor name: ��1[ �- U� Date: 6-/m Signature: Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the.following questions in Part 2 using the information contained in Part 1 and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may occur occur I. Will the proposed action create a material conflict with an adopted land use plan or zoning ❑ ❑ regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? ❑ ❑ 3. Will the proposed action impair the character or quality of the existing community? ❑ ❑ 4. Will the proposed action have an impact on the environmental characteristics that caused the El 1:1establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or El 1:1affect existing infrastructure for mass transit,biking or walkway? 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate ❑ ❑ reasonably available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: ❑ ❑ a.public/private water supplies? b.public/private wastewater treatment utilities? F] El 8. Will the proposed action impair the character or quality of important historic,archaeological, ❑ E]architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, ❑ ❑ waterbodies,groundwater,air quality,flora and fauna)? Page 3 of 4 No,or Moderate small to large impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage ❑ problems? 11. Will the proposed action create a hazard to environmental resources or human health? 0 El Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail, identify the impact, including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration, irreversibility,geographic scope and magnitude. Also consider the potential for short-term, long-term and cumulative impacts. EICheck this box if you have determined, based on the information and analysis above,and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. 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. Town of Southold-Board of Trustees Name of Lead Agency Date President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 ' Board of Trustees Application AFFIDAVIT Po"( ��� ' �� J BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMITS) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL 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 BOARD OF 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, INCLUDING THE CONSERVATION ADVISORY COUNCIL, TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. -39; Z®22 Signature of Property Owner Signature of Pro Owner SWORN TO BEFORE ME THIS ZS DAY OF , 20 Z2— LINDA B.SCH' PkftyPubt ,6tate of New yak fi`3o�esa259 ';. Qrt�lified In SuHglk Cotmlt/ Notary4- i skin t`icoires May s,2o?�-o Board of Trustees Application AUTHORIZATION (Where the applicant is not the owner) Aj I/We, owners of the property identified as SCTM# 1000- in the town of New York, hereby authorizes to act as my agent and handle all necessary work involved with the application process for permit(s) from the Southold Town Board of Trustees for this property. Property Owner's Signature Property Owner's Signature SWORN TO BEFORE ME THIS DAY OF , 20 Notary Public APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees The purpose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOUR NAME: (Last name,first name,middle initial,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate the.other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other",name the activity.) S�-d2.t& 6'a;1fl G& �ll� C)LO-r5 Li Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship.with any officer or employee of the Town of Southold? "Relationship"includes by blood,marriage,or business interest_"Business interest"means a business, including a partnership, in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of the shares. YES NO If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this day of Gt Signature' 31 n- J0.A,--(A (,eh Print Name ' I Form TS I 1 \ Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS f 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its significant beneficial and adverse effects upon the coastal area(which includes all of Southold Town) 3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, each answer must be explained in detail, listing both supporting and non- supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions,it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold's website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# - Lf - I PROJECT NAME S w 0� av, 344- OLOT 5 The Application has been submitted to (check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees L1LJ 1. Category of Town of Southold agency action(check appropriateresponse): (a) Action undertaken directly by Town agency(e.g. capital ❑ construction,planning activity, agency regulation, land transaction) ❑ (b) Financial assistance(e.g. grant, loan, subsidy) (c) Permit, approval, license, certification: ❑ Nature and extent of action: Location of action: 1,00 - ,Vn e•W t((4 3 y Site acreage: Q,, 1 :7 3 Present land use: CV-4 txQ Present zoning classification: v�.r -a 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: (a) Name of applicant: ea-"k GoIZ-6 (b) Mailing address: ko C) ha,,,,y�OW 1--f © (c) Telephone number: Area Code (d) Application number, if any: Will the action bedirectlyundertaken,require funding, or approval by a state or federal agency? Yes ❑ No LJ If yes, which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location, and minimizes adverse effects of development. See LWRP Section III—Policies; Page 2 for evaluation criteria. ❑Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III—Policies Pages 3 through 6 for evaluation criteria ❑ Yes ❑ No 5 Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III—Policies Pages 6 through 7 for evaluation criteria ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages S through 16 for evaluation criteria ❑ Yes ❑ No VNot Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III —Policies Pages 16 through 21 for evaluation criteria Yes ❑ No ❑Not Applicable ��.c. n -!S'Onn� Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III—Policies; Pages 22 through 32 for evaluation criteria. ❑ ❑ Yes No Not Applicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. ❑ Yes ❑ No[ZNot Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes ❑ No �of Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III—Policies; Pages 38 through 46 for evaluation criteria. ❑ Ye�j No 10Not Applicable Attach additional sheets if necessary r WORKING COAST POLICIES Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III.—Policies; Pages 47 through 56 for evaluation criteria. ❑ Yes [:1 No E21N'ot Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. 1:1 Yes El No ICJ Not Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III — Policies; Pages 62 through 65 for evaluation criteria. 1:1Yes F] No 1 I Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. ❑ Yes ❑ No Not Applicable PREPARED BY - TITLE OWW- - DATE ? /U 2