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Home My WebLink AboutTR-44-1-23BOard Of Southold Town Trustees SOUTHOLD, NEW YORK Emergency Storm Damage Permit (~2/24/94) · PERMIT NO .... J..~. ...... ~. .... ~ DATE: ..5./.3.5/.95 ............ ISSUED TO BERYL WILCOX Pursuant fo +ke provisions of Chapf.er 615 of the Laws o{ the State o~ New York, 1893; and Chapter 404 o~ fke Laws o{ fke State o{ New York 1952; and fke Soufkold Town Ordinance en- tiffed "RE~ULATIN~ AND THE PLACIN~ OF OBSTRUCTIONS IN AND ON TOWN WATERS AND PUBLIC LA.NDS and f~ EMOVAL OF SAND, RAVEL OR OTHER MATEm*LS FROM LANDS UNDER TOWN WATERS;" and in accordance with the Resolution of The Board adopted at a meeting held on ...5/25/.95..~... 19....95.., and in consideration of fha sum of $..250....00 ..... paid by ................................................... of $.o.~h~ld N.Y. and subject fo the ......................................... Terms an8 Cona[fions ~[sfe8 on the reverse s[ae hereo~, o~ Soufho~8 To n Trustees au+honzes an8 permits f~e {oilowmg: Construct 103 1.f. of s~one revetmen~ egMnst bluff ~nd b~c~ fill ~ith 100+ c.y. of cle~n s~nd from upland source, construc~ a 4' X 35' timber walkway to stairs for pedestrian access over revetment. L.~. Sou~,,,So~tha~d, a, ~n accoraance w,tn tne aeta,ea specifications as pre~nfed in IN WITNESS WHEREO~, The said Board of Trustees here- 'by causes ifs Corporate Seal fo be affixed, and fhese presents fo be subscribed by a majority of fh.e said Board as of this def, e. ..... : ...... ~ ......... ~-'"'"'~' ~ ~ '. ~,~. ~ :.:~,' ~:,..~.:. A~ Albert J. Krupski, President John Holzapfel, Vice President William G. Albertson Martin H. Garrell Peter Wenczel BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall 53095 Main Road P.O. Box 1179 Southold, New York 11971 Telephone (516) 765-1892 Fax (516) 765-1823 May 26, 1995, En-Consultants Inc Roy Haje 1329 North Sea Road Southampton NY 11968 Re: BERYL WILCOX SCTM ~44-1-23 Dear Mr. Haje,' The following action was taken by the Board of Town Trustees during its regular meeting held on May 25, 1995 regarding the above matter: WHEREAS, En-Consultants Inc., on behalf of BERYL WILCOX applied to the Southold Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town of Southold, application dated March 16, 1995, and, WHEREAS, said application was referred to the Southold Town Conservation Advisory Council for their findings and recommendations, and WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on May 25, 1995, at which time all interested persons were given an opportunity to be heard, and~ WHEREAS, the Board members have personally viewed and are familiar with the premises in question and the surrounding area, and, WHEREAS, the Board has considered all the testimony and documentation submitted concerning this application, and, WHEREAS, the structure complies with the standard set forth in Chapter 37-18 of the Southold Town Code, which will be listed on a separate page, and, WHEREAS, the Board has determined that the project as proposed will not affect the health, safety and general welfare of the people of the town, NOW THEREFORE BE IT, RESOLVED, that the Board of Trustees approves the application of En-Consultants Inc., on behalf of BERYL WILCOX to construct 103 1.f. of stone revetment against bluff and backfill with 100+ c.y. of clean sand to be trucked in from an upland source, and construct a 4' X 35' timber walkway to stairs for pedestrian access over revetment. Located: 56305 North Road, Southold. Permit to construct project will expire two years from the date it is signed. Fees must be paid, if applicable, and permit issued within six months of the date of this notification. Two inspections are required and the Trustees are to be notified upon completion of said project. FEES: None Very truly yours, ~ j~'Kru/p~ Albert President, Board of Trustees AJK/djh cc. CAC Meeting of 4/20/95 New Suffolk Road, New Suffolk CAC was advised that the application was WITHDRAWN. No rdcommendation. No. 1240 Moved by Stephen Angell, seconded by Allan Connell, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH STIPULATIONS of the Wetland Application of JOHN SCHLECHT ~J~-1-2~ to construct 110 +/- I.f. of stone revetment against eroded bluff and backfill with 100 +/- c.y. of clean sand to be trucked in from upland source. Construct 4' x 35' fixed walk and stairway over revetment for pedestrian access. (See Marianne Clarke #1241 and Beryl Wilcox #1242) 56425 North Road, Southold The CAC recommends approval with the stipulation that the sand buried rocks be planted with beachgrass and plant any backfill with non-turf buffer, Vote of Council: Ayes: All Motion carried, No. 1241 Moved by Stephen Angell, seconded by Allan Connell, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH STIPULATIONS of the Wetland Application of MARIANNE CLARKE ~-1-25 to construct 103+/- I.f. of stone revetment against eroded bank and backfill with 75+/- c.y. of clean sand to be trucked in from upland source. Construct a 4' x 35' fixed walk to stairway for pedestrian access over revetment. Remove existing damaged deck. (Also see #1240 and #1241) 56525 North Road, Southold The CAC recommends approval with the stipulation that the sand buried rocks be planted with beachgrass and plant any backfill with non-turf buffer. Vote of Council: Ayes: All Motion carried. No. 1242 Moved by Stephen Angell, seconded by Allan Connell, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH STIPULATIONS of the Wetland Application of BERYL WILCOX ~-1-23 to construct 103+/1 I.f. of stone revetment against bluff and backfill with 100+/- c.y. of clean sand to be trucked in from upland source. Construct a 4~ x 35= timber walkway to stairs for pedestrian access over revetment. (See #1240 and #1241) 56305 North Road, Southoid The CAC recommends approval with the stipulation that the sand buried rocks be planted with beachgrass and plant any backfill with non-turf buffer. Vote of Council: Ayes: All Motion carried. Page 2 Ai,fiefi J. Krupski, President 3ohn Holzapfel, Vice President William G. Albertson Martin H. Garrell Peter Wenczel BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hail 53095 Main Road P.O. Box 1179 Southold, New York 11971 Telephone (516) 765-1892 Fax (516) 765-1823 Office Use Only ~ Coastal Erosion Permit Application ~ Wetland Permit Application Grandfather Permit Application Trustee Lands Permit Application Waiver ~ Received Applicat~pn~ ~-~ ~Clerical Review: ~Completed Applicatioh ~/t~/e Incomplete · SEQRA Classification: e I ~ Type II Unlisted Coordination: (date ~e~t~ ~ CAC Referral Sent: /~t/~' Z-Date of Inspection: .__.~Receipt of CAC Report:(date). )~Lead Agency Determination- ~Technical Review:(date) ~7~/?~ ! . Public Hearing:(date) ~/.~7/~ i Decision: Approved (Y/N)'[date) I~Application Fee:$ ~.~ 14AR I 6 1995 TOWN OF SOUTHOLO Name of Applicant Beryl Wilcox Address 56305 North Road, Southold, New York 11971 Phone Number:(516) 283-0352 Suffolk County Tax Map Number: 1000 - 044-1-23 Property Location: 56305 North Road, Southold (provide LILCO Pole 9, distance to cross streets, and location) Agent: (If applicable) En-Consultants, Inc. 'Address: 1329 North Sea Road, SOuthampton, New York 11968 Phone: 516/283-6360 Board of Trustees Applic~ GENERAL DATA Land Area (in square feet): Area Zoning: R-40 Previous use of property: Intended use of property: ]7~6705 one family dwellin9 No change 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? x No Yes If yes, provide explanation: Project Description (use attachments if necessary): Construct 103± 1.f. of stone revetment against bluff and backfkll with 100± c.y. of clean sand to be trucked in from upland sourQe. Construct a 4' X 35' timber walkway to stairs for pedestrian access over revetment. See also Marianne Clarke and John Schlecht. 2 Board of Trustees Application COASTAL EROSION APPLICATION DATA Purposes of proposed activity: To. prevent continued erosion presently causing severe scouring of owner's upland. Are wetlands present within 75 feet of the proposed activity? x No Yes Does the project involve excavation or filling? No X Yes If Yes, how much material will be excavated? 0 (cubic yards) How much material will be filled? ]00 (cubic yards) Manner in which'material will be removed or deposited: Cl~n sand and b~ckf4]l w~ll b~ trucked in and spread bv pay]oad~r. Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) The subject parcel is one of three adjacent lots frontinG Lonq Island Sound, all of which are bein9 severely scoured by ongoing erosion. The seaward limit of the owner's upland is characterizad by a steep, eroded bank whose drop is vertical in some locations, and undermined, in others, with a change in elevation of 6' - 7' It is expected that the proposed revetment will dissipate wave energy currently scouring this bank and prevent its further erosion. See also Marianne Clarke and John Schlecht. Board of TrUstees Appli~-tion WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: To prevent continued erosion presently causing severe scouring of owner's upland. Area of wetlands on lot: 0 square feet Percent coverage of lot: 0 % Closest distance between nearest existing structure and upland edge of wetlands: N/A feet Closest distance between nearest proposed structure and upland edge of wetlands: . N/A feet Does the project involve ~ or filling? No x Yes If yes, how much material will be excavated? How much material will be filled? 100 Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: 1:1.5 Manner in which material will be removed or deposited: Clean sand backfill will be trucked in and spread by payloader. N/A c~bic yards cubic yards Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason os such proposed operations (use attachments if appropriate): The proposed revetment.is designed to control upland erosion and will be located an average of 30±' from AHW. Therefore, it should have no appreciable effect on coaStal waters. See also Marianne Clarke and John Schlecht. County of Suffolk State of New York Board of Trustees Applicai tn DEPOSES AND AFFIRMS THAT HE. IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS~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 TOWN TRUSTEES HARMLESS AND FREE FROM ANYANDALL 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 PRE~ISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. Sign-~ture SWORN TO BEFORE ME THIS 3 Board of Trustees Applics~ion AUTHORIZATION (where the applicant is not the owner) Beryl Wilcox (print owner of property) residing at 56305 North Road, (mailing address) Mouthold. NY 11971 En-Consultants, Inc, do hereby authorize (Agent) to apply for permit(s) frOm the Southold Board of Town Trustees on my behalf. (Owner,s s~~i ~ature ~ 4 14-16-4 I , PROJECT I.D. NUMBER ~ j 617,' ~ ~ I Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I--PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT ~SPONSOR 1~ 2. PROJECT NAME Beryl Wilcox by En-Consultantsr I c. 3. PROJECT LOCATION: MuniciDality Southold County . Suffolk 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) SEQR 5. IS PROPOSED ACTION: 56305 North Road, Southold SCTM ~1000-044-t-23 [~ New [] Ex0ansion 6. DESCRIBE PROJECT BRIEFLY: [] Modification/alteration SEE ATTACHED 7. AMOUNT OF LAND AFFECH=D: Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? ~'~'~'~'~'~'~'~'~'~' Yes [] No If No, describe briefly 9. WHAT IS PRESENT LAND USE ~N VICINITY OF PROJECT? ~__ Residential [] Inaustrlat [] Commercial [] Agriculture [] ParklForestJOl3en sl3ace ~ Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL. STATE OR LOCAL)? ~' Yes [] No If yes, list agency{s) ana permit/aDprOvals DEC, CeE Letter of No Jurisdiction 11, DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VAUD P~.RMIT OR APPROVAL? [] Yes [] No if yes. list agency name anct permit]aDDroval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? []Yes ~No ApDlicant/SDonsor Signature: I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE name: ~e Wil En-CDnsulkant~: Inc.. Date: Marc.h 14~ 199 If the action is in the Coastal Area, and you are a state agency, comptete the Coastal Assessment Form before proceeding with this assessment OVER PROJECT DESCRIPTION Construct 103± 1.f. of timber revetment against bluff and backfill with 100± c.y. of clean sand to be trucked in from upland source. Construct a 4' X 35' timber walkway and stairs for pedestrian access over revetment. See also Marianne Clark and John Schlecht. Albert J. Krupski, President John Holzapfel, Vice President William G. Albertson Martin H. Gan'ell Peter Wenczel Town Hall 53095 Main Road P.O. Box 1179 Southold, New York 11971 Telephone (516) 765-1892 Fax (516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only ~Coastal Erosion Permit Application _ ~_Wetland Permit Application ~ Grandfather Permit Application w Trustee Lands Permit Application aiver r' - ~ Received Application: $ o~.,~,kI.~. 'i~ Clerical Review: Completed Application __I nc omplete SEQRA Classification: Type I Type II Unlisted Coordination: (date sent) CAC Referral Sent: Date of Inspection: __Receipt of CAC Report: (date) Lead Agency Determination: Technical Review: (date) Public Hearing: (date) __Decision: Approved (Y/N) (date) __Application Fee: $ Name of ApplicantVa-~-~D~v~ ~-. ~ ~.~ &~_~ r_>"~2L Phone Number: (O'~'f~) Suffolk County Tax Map Number: 1000 - Q~- ~D / - ~-'~ Property Location: ~l~S~o~ ~ ~' '~Provide LILCO Pole f, distance to cross streets, and location) Agent: (If applicable) Address: Phone: oard of Trustees Applicat~ ~l GENERAL DATA Land Area (in square feet): Area Zoning: Previous use of property: Intended use of property: 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? ~ No Yes If yes, provide explanation: Project Description (use attachments if necessary): ~oard of Trustees Applicat a County of Suffolk State of New York DEPOSES AND-AFFIRMs THAT HE--EHi IS THE APPLICANT~FOR THE ABOVE DESCRIBED PERMIT~5~) AND THAT~L STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS~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 TOWN TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(~q~, 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 WITH REVIEW OF THIS APPLICATION. -- Signature SWORN TO BEFORE ME THIS 3 3oard of Trustees Applicat n COASTAL EROSION APPLICATION DATA Purposes of proposed activity: Are wetlands pres~ent within 75 feet of the proposed activity? ~ No ~~ Yes Does the projec~involve excavation or filling? N~ ~\ Yes If Yes, how much material will be excavated? How much material will be filled? (cubic yards) (cubic yards) Manner in which material will be removed or deposited: Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) New York State Department of Environmental Conservation s,~ ~, '~ ~, ~ ¥ / ~, -7/ RE: LEAD AGENCY COORDINATION REQ The purpose of this request is to determine under Article 8 (State E mental Quality Review - SEQR) of the Environmental Conservation Law and 6 NYCRR Part 617 the following: Thomas C. Jorling Commissioner 1. Your agency's interest in acting as lead agency; 2. Your agency's jurisdiction in the action described below; and 3. Issues of concern which your agency believes should be evaluated. Enclosed is a copy of the permit application and a completed Part 1 of the Environmental Assessment Form to assist you in responding. Project Location: DEC Project Number: DEC Permits: I60abt-~ /- ¥~s~'-~/a ? 7,1 SEQR Classification- [ ] Type I ~] Unlisted DEC Contact Person: DEC Position: DEC has no objection to your agency or another agency assuming lead agency status for this action, but reserves the right to comment on this action if a positive determination of significance is maoe. -2- [] DEC has no objection to your agency or another agency assuming lead agency status for this action, but we have the following concerns regarding this project {see "comments" below). DEC wishes to assume lead agency status for this action. [] The proposed action has been identified by DEC as occurring wholly or partially within or substantially contiguous to a critical environmental area {CEA)"that was designated by It is the position of this Department that your agency, if it has a juris- diction over the action, should assume the lead agency role based on the existence of the CEA and the fact that the anticipated impacts are primarily of local significance. [ ] Other. (See comments below) Comments (Optional)' Response: Please respond to this request within 30 days of the date of this letter. If no response is received within 30 days, we will assume that you have no objection to DEC. or another agency assuming the role of lead agency, and have no comments to. offer regarding the proposed action at this time. If neither your agency nor any other involved agency, including DEC, has indicated a will- ingness to serve as lead agency within 30 days of this letter: [ ] We will petition the Commissioner of DEC to designate a lead agency for this action. [ ] We will petition the Commissioner of DEC to designate your agency as lead, presuming you have jurisdiction. Please feel free to contact this office for further information or discussion. Sincerely, Enclosures cc: (see distribution list) 14-18-~ {Z/87~--Tex~ '2 '~RO,JEcT I.D. ,NUMBER 617.21 Appendix C State Environmental Quality Review SHORT, ENVIRONMENTAL ASSESSMENT For UNLISTED ACTIONS Only PART I--PROJECT INFORMATION (To be completed by Applicant or Project sponsor) FORM SEQR 1. APPLICANT SPONSOR Beryl Wilcox by En-Consultantsr 3..PROJECT LOCATION: Municioality Southo ld I~ 2. PROJECT NAME T C. County Suffolk PRECISE LOCATION (Street acidress and roa~[ intersections, prominent lanamarks, etc., or proviae map) 56305 North Road, Southotd SCTM 91000-044-1-23 5. IS PROPOSED ACTION: [~ New [] Exoansion [] Mcclifioatien/aJter~tion 6. DESCRIBE PROJECT BRIEFLY: SEE ATTACHED 7. AMOUNT OF LAND AFFECTED: Initially ,41 acres Ultimately .41 acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? ~Yes [] No If No, describe briefly 9. WHAT iS FRESENT LAND USE iN VICINITY OF PROJECT? ~__ Residentia~ ~ ]nclustrial [] Commercial Describe: [] Agriculture [] ParK/FcreStlO~3en s0ace ~ Other 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING. NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL. STATE OR LOCAL)? ~' Yes [] No If yes, list agency(s) aha l~ermit/aoorovals COE Letter of No Jurisdiction, Southold Trustees Coastal Erosion 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? r-~ Yes r~ No If yes. list agency name and DermitJamproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTTNG PERMIT/APPROVAL REQUIRE MODIF{CAT~ON? ~ Yes ~ No t CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Ao~iicantts:~onsor Signature: name: Be~ Wiico~ b~ En-Cbn.~u!~_ants .. Thc', Date: March 1995 If the action ~s in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER '~ !i'i PROJECT DESCRIPTION Construct 103~ 1.f. of timber revetment against bluff and backfill with 100± c.y. of clean sand to be trucked in from upland source. Construct a 4' X 35' timber walkway and stairs for pedestrian access over revetment. See also Marianne Clark and John Schlecht. '::lm,, JOINT APPLICAT" N FOR PERMIT D.S.AR ' CORPS OF ENGINEERS ^PP.CAT O, Pleas~'~read ALL mstructtons on back before completing this application. Please type or print ctearly in ink. Attach additional information as needed. ~']ARTICLF 9, TITLE 1, ARTICLE 43 6NYCRR 646 (LAKE GEORGE RECREATION ZONE) [--TARTlCLE 15, TITLE 3 (AQUATIC PESTICIDES CONTROL) E:]bNYCRR 327 (AQUATIC VEGETATION) E]bNYCRR 328 (FISH)~L~bNYCRR 329{INSECTS) E:] For the construction, reconstruction, or repair of a DAM or other impoundment structure. IAI [~]For the disturbance of a STREAM BED OR BANKS or excavation in or fill of NAVIGABLE WATERS. [2]401 WATER QUALITY CERTIFICATION E]ARTICLE 15, TITLE 15 [::]6NYCRR 601 (WATER SUPPLY) E~bNYCRR 602 (LONG ISLAND WELL) ~-']ARTICLE 15, TITLE 27 6NYCRR 666 (WILD, SCENIC AND RECREATIONAL RIVERS) [::]ARTICLE 24 6NYCRR 662, 663 (FRESHWATER WETLANDS) [~ARTICLE 2S 6NYCRR 661 (TIDAL WETLANDS) E:]ARTI'CLE 34 6NYCRR 505 (COASTAL EROSION) ~-~SECTION 10 (RIVER AND HARBOR ACT OF 1899) for structures and work in navigable waters of the U.S. E]COASTAL CONSISTENCY CERTIFICATION. 2. APPLICANT IS A/AN []Owner E]Operator E]Lessee E~MunicipatitWCovernmental Agency (Check as many as apply) 3. NAME OF APPLICANT (Use Full Name) r--/SECTION 404 (CLEAN WATER ACT OF 1977) for disposal of dredged or fill material in waters of the U.S. J~JSECTION 103 (MARINE PROTECTION, RESEARCH AND SANCTUARIES ACT) for the transportation of dredged materials for dumping into ocean waters. LIST PREVIOUS PERMIT/APPLICATION NUMBERS AND DATES (If anyJ Beryl Wilcox MAILING ADDRESS J TELEPHONE (Where can be reached during day) 56305 North Road I (516) 283-0352 POST OFFICE Southold ISTATE JZIP c°DE NY 11971 4. NAME OF J--/Owner J~Agent/Contact Person (Check one) Inc. Roy L. Haje, En-Consultants, MAILING ADDRESS TELEPHONE (Where can be reached during day) 1329 North Sea Road (516) 283-6360 POST OFFICE STATE ZIP CODE S outhampt on NY 11968 5, PROJECT/FACILITY LOCATION (Mark location on map, see Number la on reverse side) County Suffolk I Town or city Southold I vi,age STREET ADDRESS (if different from applicant) SAME POST OFFICE STATE j ZiP CODE 6.NAME OF STREAM OR BODY OF WATER Long Island Sound 7. HAS WORK BEGUN ON PROJECT? If YES, attach explanation on starting work without permit, include dates, j 8. ~VILL PROJECT UTILIZE STATE LAND? [--]Yes J-~No Show work on map and/or drawings. J r-]Yes ~-"qNo A SA P g q AP s Enclosed 13. PROJECT DESCRIPTION: (~.g. quantity and type of material to be excavated, dredged or used for fiji or rip rap, location of disposal sites; type of structure to be installed; height of dam; size of impoundent; capacities of proposed water sources; extent of distribution system; etc.) 9. PROPOSED USE: [] Private [] Public [] Commercial SEE ATTACHED 14. WILL THIS PROJECT REQUIRE ADDITIONAL FEDERAL, STATE AND/OR LOCAL PERMITS? [] Yes [] No If yes, please i/st: COE Letter of No Jurisdictionr Southold Trustees Coastal Erosion 15. CERTIFICATION: I hereby affirm that under penality of perjury that information provided on this form and all attachments submitted herewith is true to the best of mv knowledge and beJief. False statements made herein are punishabJe as a Class A misdemeanor pursuant to $'ection 210,45 of the Penal Law. Further, the applicant accepts full responsibility for all damage, direct or indirect, of whatever nature, and by whomever suffered, arising out of the prolect described herein and agrees to indemnify and save harmless the State from suits, actions, damages and costs of every name and descnption resulting from said proiect. !n addition. Federal Law, 18 U.S.C. Section 1001 provides f~ a f ne of not more than $10,000 whe~_re an applicant knowmgiy and willfully falsifies, conceals, or c~]rs up a matg~rat fact: or knowingly or imprisonment for ~ot more than five years, or both, ~l hereby authorize the agent named in Number4 above/~/L~mit this~l//on on my beha,f, makes orusesa false fictitousor fraudulent statement. / ~ ~ MsrCh ] 4, ] g_9_~_ ~-/~ dY'"'~J~j: President ~"~"~'~-*~ ¢,:tu~-"', ~ H SEA ROAD SOUTHAMPTON' NY 1! 968 5t6-283-6860 ..................... -- ,J b ~j t~ //