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HomeMy WebLinkAboutWICKHAM, JOHN (2)FRANK A. KUJAWSKI, JR., President TELEPHONE ALBERT J. KRUPSKI, JR., Vice-President (516) 765-1892 JOHN M. BREDEMEYER, III JOHN L. BEDNOSKI, JR. ttENRY P. SMITH BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall, 53095 Main Road P.O. Box 728 Southold, New York 11971 April 14, 1989 Mr. John Wickham Main Road Cutchogue, N.Y. 11935 Dear Mr. Wickham: We have received a coordination request from the N.Y.S.D.E.C. on your application for concrete slab placement. Please submit an application to the Town Trustees so that your D.E.C. permit may be processed and a Town permit processed as well. /yery truly yours~ - '-/~rreasn.k A. 'Ku~awski, Jr. Board of Trustees FAK: jas 95-19-3 (5/88) 7e DEC APd~[CATI©~' b ]~M[3ER ~ NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERV~,TION ~ U.S.ARM~ CORPS OF ENGINEERS APPLICATION NO. ~ JOINT APPLICATION FOR PERMIT Please read ALL instructions on back before completing this Application. Please type or print cleariy in ink. Attach additional information as needed ~ARTICLE 9, TITLE 1, ARTICLE 43 6NYCRR 646 (LAKE GEORGE RECREATION ZONE ~ARTICLE 15, TITLE 3 (AQUATIC PESTICIDES CONTROL) ~6NYCRR 327 [AQUATIC VEGETATION) ~ 6NYCRR 328 F]SH) ~ 6NYCRR 329(INSECTS) ~ARTICLE 1~, TITLE 5 6NYCRR 608 (PROTECTION OF WATERS] ~For the constmctio~ reconstruction or reBalr o[ a DAM or other impoundment structure ~ ~For the disturbance of a STREAM BED OR BANKS or excavation in or fill of NAVIGABLE WATERS. ~401 WATER QUALITY CERTIFICATION E ~ARTICLE 15, TITLE 15 ~6NYCRR 601 (WATER SUPPLY) ~6NYCRR 602 [LONG ISLAND WELL)  ~A~TICL[ 1~, TILL[ 27 6NYCRR 666 (WILD, SCENIC AND RECREATIONAL RIVERS) ~A~TICLE 24 6NYCRR 662, 6~3 (FRESHWATER WETLANDS) ~A~TICLE 25 6NYCRR 661 (TIDAL WET,ANDS) ~ARTICL[ 34 6NYCRR 505 (COASTAL EROSION) ~ECTION 10 (RIVER AND HARBOR ACT OF 1899) for structures and work in navigable waters of the U.S. ~COASTAL CONSISTENCY CERTIFICATION E[ ~g[CTION 404 (CLEAN WATER ACT OF 1977) for disposal of dredged or Ei][ material in waters of the U.S. ~D ~g[cTIoN 103 (MARINE PRDTECTION. RESEARCH AND SANCTUARIES ACT) for the transportation of dredged materials for dumping into ocean waters. 1. LIST PREVIOUS PERMIT/APPLICATION NUMBERS AND DATES (if any) 2. APPLICANT IS A/AN ~Owner ~Opera~or ~Lessee ~Munic]pa]iW/Governmental Agency (Check as man~ ~s apply) 3. NAME OF APPLICANT (Use Ful[ Name) MAILING ADDRESS TELEPHONE (Where can be reached during day~ . _: ( '. STATE ZIP CODE POST OFFICE .' lf.~- ; / / 7'-'' :. / : 4. NAME OF ~Owner ~Agent'Contac~ Person (Check one] TELEPHONE [Where can be reached during day) MA~L~NG ADDRESS .,~& ~ ~'~ ~ .. ~ :>"'~-~--- POST OFF[CE STATE ZIP CODE 5. PRO ECT/FACIL]TY ~OCATION fMark location on map, see Number la on reverse side] STREET ADDRESS {~f different from applicant) POST OFFICE ~'~' / '~' : ~ ; ~ "' -: ~ ; .... ~t ~: STATE ZIP CODE 6. NAME OE STREAM OR BODY OF WATER : ~, .2. / ~ (/~,; &' , . : ~ ...... : C ": ' " - ':' t? i'- 7. HAS WORK BEGUN ON PROI ECT? If ~ES ~t-~ch explanation on starting work without perm~ includes dates. 8. WILL PROJECT UT L Z~.STATE LAND? ~Yes ~ Show work on map an2,or drawings. ~Yes 9. PROPOS~USE: ~ Private 10. PROPOSED STARTING DATE 11. APPROXIMATE COMPLETION DATE: 12. FEE OF .NYS Permit Only. 13 PROJECT DESCRIPTION: (e.g. quantity ano type of material zo oe excavated, dredge2 or used for fill or rip rap, location of disposal s~tes: type of structure to be installed height of dam: size of impoundent; capacities of p-oposed water sources: extent of distribution svstem: etc 14 WILL THIS PROJECT REQUIRE ADB1TIONAL FEDERAL. STATE AND OR LOCAL PERMITS? ~ Yes ~'o If ves ~lease list 15. CERTIFICATION: I hereb~ affirm that under penality of perjury that information provided on this form and al attachments submitted herewith is true to the best of mv knowledge and belief, False statements made herein are ounishable as a Class A misdemeanor pursuant to Section 210.45 of the Penm Law. Further. the appicant accepts full responsibility for ali aamage direct or ndirect of whatever nature, and 9v whomever suffered arising out of the project described herein and agrees to indemnify, and save harmless the State from suits actions, damages and costs of ever% name and description resulting from said project. In addition. Federal Law 18 U.S.C. Section 1001 3rovides for a fine of no~ more than $10.000 or imprisonment for not more than five years or both where an app icant knowing]y andwil]fulb fa]sifies, conceals or covers up A material fact: or knowingly makes or uses a false fictitous or fraudulent statement [--][ hereb~ authorize the agent named n Number 4. aoove to submit this application on my behalf 'DATE -,~ / SIGNATURE TITLE P[EAgE READ ALLINgT~U(TION$ ON R[VERSE gI~E For UNLIST] PART I--PROJECT INFORMATION I. APPLICANT/SPoNsoR PROJECT NAME ,3. PROJECT LOCATION: Municipality .. 4. PRECISE LOCAYION (Street ~nd road 5. IS PROPOSED ACT~' ~ New~ Expansion ~ Modification/alteration 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OFt~,LAND AFFECTED: Initially ,~¢~ . acres Ultimately , acres 8. WILE PRO~SED ACTIQN COMPLY WITH EXISTING ZONING OR OTHER ~ISTING ~ND USE ~ No If No. describe briefly 9 WHAT IS PRESENT :ND USE IN VICINI~ OF PROJECT? D Residential D Industrial C Commercial ~iculture Oe~cribe'. ~0 DOE~ ACTION INVOLVE A ~ERMIT APPROVAL STATE OR LOCAL)? ~ Y~s ~ I~ ~ Yss ~No If yes, list agency name and permltl~DDroval 12. AS A RESULTOF P~CH;~)~D ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? .' [] Yes ~ o I, CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OFM¥ KNOWLEDGE . Signature: .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