HomeMy WebLinkAbout51012-Z TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
ter,„ SOUTHOLD, NY
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES
WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS
UNTIL FULL COMPLETION OF THE WORK AUTHORIZED)
Permit #: 51012 Date: 7/31/2024
Permission is hereby granted to:
Orient Moon LLC
97 S Broadway
Nyack, NY 10960
To: construct single-family dwelling as applied for per DEC & SCHD approvals.
At premises located at:
420 Willow Terrace Ln, Orient
SCTM # 473889
Sec/Block/Lot# 26.-2-10
Pursuant to application dated 3/5/2024 and approved by the Building Inspector..
To expire on 1/30/2026.
Fees:
SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $3,014.00
CO-NEW DWELLING $100.00
Total: $3,114.00
Building Inspector
nip TOWN OF SOUTHOLD—BUILDING DEPARTMENT
Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959
Telephone(631)765-1802 Fax (631) 765-9502
Date Received
APPLICATION FOR BUILDING PERMIT
For Office Use Only
EC WE
PERMIT NO. ✓ Building
Inspector:---k-
-k-J]
Applications and forms must be filled out in their entirety.Incomplete
applications will not be accepted. Where the Applicant is not the owner,an
Owner's Authorization form(Page 2)shall be completed.
Date:5/22/23
OWNER(S)OF PROPERTY: Willow Moon LLC
Name: (Gary Blankfort or Deborah Blankfort) SCTM#1000-26-02-10
Project Address:420 Willow Terrace, Orient NY
Phone#:845-641-3257 Email:debbie@baerhomes.com
Mailing Address: 97 S Broadway,Nyack,NY 10960
CONTACT PERSON:
Name:Charles Thomas
MailingAddress:PO Box 877 Jamesport NY 11947
Phone#:516-702-3519 Email:cdthomas63@aol.com
DESIGN PROFESSIONAL INFORMATION:
Name:Charles Thomas
MailingAddress:PO Box 877 Jamesport NY 11947
Phone#:516-702-3519 Email:cdthomas63@aol.com
CONTRACTOR INFORMATION:
Name:TBD
Mailing Address:
Phone#: Email:
DESCRIPTION OF PROPOSED CONSTRUCTION
IgNew Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project:
❑Other
Will the lot be re-graded? ❑Yes RNo Will excess fill be removed from premises? Dyes BNo
1
PROPERTY INFORMATION
Existing use of property:Vacant Intended use of property:Single Family Residence
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
this property? '❑Yes WNo IF YES, PROVIDE A COPY.
❑ Check Box After Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by
Chapter 236 of the Town Code. APPLICATION IS HEREBY MADE to the Building Department•for the issuance of a Building Permit pursuant to the Building Zone
Ordinance of the Town of Southold,Suffolk,County,New York and other applicable Laws,Ordinances or Regulations,for the construction of buildings,
additions,alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code,
housing code and regulations and to admit authorized inspectors on premises and in building(s)for necessary inspections.False statements made herein are
punishable as a Class A misdemeanor pursuant to Section 210.45 of the New York State Penal Law.
MQ
Application Submitted By(print name):Charles Thomas Pik OCWnt&WAuthorized Agent ❑Owner
Signature of Applicant: Date: �0,7f57/,7
CONNIE D.BUNCH
Notary Public,State of New York
STATE OF NEW YORK) No.OIBU6186050
SS: Qualified in Suffolk County
COUNTY OF ) Commission Expires April 14,2
being duly sworn, deposes and says that(s)he is the applicant
(Name of individual signing contract) above named,
(S)he is the
(Contractor,Agent, Corporate Officer, etc.)
of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this
application;that all statements contained in this application are true to the best of his/her knowledge and belief; and
that the work will be performed in the manner set forth in the application file therewith.
Sworn before me this
544-Nday ofM9SA C_ F 209 •w
Notary Public
PROPERTY OWNER AUTHORIZATION
(Where the applicant is not the owner)
I, DPY;oyu n residing at
G, o � ;��� do hereby authorize 4� �. t,f.l' to apply on
my behalf to the Town of Southold Building Department for approval as described herein.
w
a5
Owner's Signature Date
Print Owner's Name
2
w
NEW YORK Department O Application For Permit Transfer
sTATEOF and Application for Transfer of Pending Application
OPPORTUNITY �,rl' '�r" tilr"te'n""ka,�,
Conservation NOTE: Please read ALL Instructions before completing
this application. Please TYPE or PRINT clearly in Ink.
PART 1-TRANSFEREE(New Owner/Operator/Lessee/Applicant)Completes:
1. List Permit Number(s)And Their Effective And Expiration Dates: List Pending Application Number(s):
#1-4738.04698/00001 effective:1/3/2020 expiration:1/3/2025 #1-4738-04698/00001
2. Name Of Transferee: Telephone Number(Daytime): Transferee is Wan: (check all that apply)
Orient Moon LLC (914) 522.5426 O Owner ❑ Operator
Mailing Address: Email: ❑ Lessee ❑ Applicant
239 South Greenbush Road debble@baerhomes.com 13 If other than an individual,provide
Post Office City,State,Zip Code: Taxpayer ID Number:
Orangeburg,NY 10962
3. Name Of Facility/Project: 4. Facility Contact Name: Telephone Number(Daytime):
Orient Moon House Cale Environmental Services (631) 369.9445
Location(or Street Address,P.O.City,State,Zip Code,If applicable): Mailing Address: Email: Info@ColeEnvlronmental
420 Willow Terrace,Orient,NY 11957 425 Montauk Highway Services.com
Town/Village/City: County: Post Office City,State,Zip Code:
Southold Suffolk East Ouogue,NY 11942
5. Has Work Begun On The Project?
Yes ❑ No m If"No,"proposed starting date: Summer 2024 Approximate completion date Fall 2024
If there will be=modifications to the current or eroeosed o eration or construction,khe transferee must attach a statement s2ecifying the details.
6. CERTIFICATION: This certifies that the Transferee seeks to be the legally responsible party for operations or project development either
authorized by the permits identified above or proposed In applicatlons Identified above. The Transferee has a copy of the permits) andlor
application(s)and understands and will comply with all conditions in the referenced permit(s)and supports the content of referenced application(s).
Facility operations/project scope/discharges/emissions will remain the same as authorized or as proposed in pending applications. Further, I
hereby affirm that under penalty of perjury that information provided on this form and all attachments submitted herewith Is true to the best of my
knowledge and belief.False statements de herein are punishable as a Class A mdsd meanior pursuant to Section 210.45 of the Penal Law,
Printed Name and Title of Transferee /f
Signature of Transferee Date
PART 2-TRANSFEROR(Present or Former Own er/Operator/Lessee/Applicant)Completes:
1. Narne Of Transferor: Telephone Number(Daytime): If other than an individual,provide
David Cassaro N/A Taxpayer ID Number:
Mailing Address: Email:
73 Pine Street N/A
Post Office City,State,Zip Code:
Garden City NY 11530
2. Name Of Facility/Project,if different from Facility Name in Part 1:
3. CERTIFICATION:This certifies that ownership,operation,or a lease for the facility identified in Part 1 of this form❑ will be/X was conveyed to
the party Identified as the Transferee on _11/1/2021 (date). I affirm that this conveyance includes the rights and
obligations of the permits,approvals,or applications identified above.
Printed Name and Title of Transferor David Cassaro/Prior Owner aka "Seller"
Signature of Transferor Date
PART 3-PERMIT TRANSFER VALIDAT -ON S TI epartment Of Environmental Conservation Completes:
)�Transfer of permit approved,effective as of w - Transferee subject to conditions of original permit,without exception.
❑ Transfer of permit approved,with the following m ci flcati ns or contdngsrncles related to thls Permit Transfer.
0 0
u a
❑ See attached revised permit page(s).
m ❑ Transfer of application approved, flee attached for additional Information required, m
o ❑ Transfer danled„ rew application required. Please coca jets the enolo�dlllloatdon and return It to the undersigned Regional Permit O
mhetrator at the address listed on the reverse sid this form. z
NYSDEA4Rh4ITADMfNISTRAT0R SIGNA RE Ohs;
copies to: -
(rev.S/16)
I
NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION
Division of Environmental Permits,Region 1
SUNY @ Stony Brook,50 Circle Road,Stony Brook,NY 11790
P:(631)444-0365 1 F:(631)444-0360
www.dec.ny.gov
PERMIT MODIFICATION REISSUANCE AND TRANSFER
July 23, 2024
Orient Moon LLC
239 S Greenbush Rd.
Orangeburg, NY 10962
Re: Application #1-4738-04698/00001
Orient Moon LLC Property: 420 Willow Terrace
SCTM# 1000-26-2-10
Dear Permittee:
The Department of Environmental Conservation (DEC) has completed a review of your
request to modify, transfer and reissue the above referenced permit which expires
January 2, 2025. Pursuant to the Uniform Procedures Regulations (6NYCRR Part 621)
your permit is hereby transferred to the current property owner and reissued with a new
expiration date of January 2, 2030.
Please be advised that this is the maximum permit term and a new permit application
for a new permit will be re uired to conduct regulated activities after the datespecified
above.
It also has been determined that the proposed modifications will not substantially
change the scope of the permitted actions or the existing permit conditions. Therefore,
the permit is hereby modified to authorize the reconfiguration of the permitted dwelling
and accessory structures as per the plans prepared by CMT Architect, last revised
6/24/2024 and stamped NYSDEC approved modification 7/10/2024.
This letter is a modification to the original permit and must be available at the job site
whenever authorized work is in progress.
All other terms and conditions remain as written in the original permit. Please see the
attached transfer forms authorizing the permit transfer.
incerel
rrsmsi-it
Scott
Administrator
cc: Cole Environmental Services
BMHP
File
<N1�rrotiit C9eprtan�nt�ir
as ad�w Erwv#conrnent'I!
Conservation
C NEW Department of
YORK
STATE Environmental
conservation
NOTICE
The Department of Environmental Conservation (DEC) has issued permit(s) pursuant
to the Environmental Conservation Law for work being conducted at this site. For further
information regarding the nature and extent of work approved and any Departmental
conditions on it, contact the Regional Permit Administrator listed below. Please
refer to the permit number shown when contacting the DEC.
Regional Permit Administrator
SHERRI AICHER
Permit Number: 1-4738-04698/00001
- - NYSDEC Region 1 Environmental Permits
50 Circle Road
Stony Brook, NY 11790-3409
Expiration Date: 1/2/2030 Email: dep.r1@dec.ny.gov
Note: This notice is NOT a permit
NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION
Division of Environmental Permits,Region 1
SUNY @ Stony Brook,50 Circle Road,Stony Brook,NY 11790
P:(631)444-0365 I F:(631)444-0360
www.dec.ny.gov
January. 3, 2020
David&Mary Cassaro
73 Pine Street
Garden City,NY 11530
Re: NYSDEC# 1-4738-04698/00001
Cassaro Property,420 Willow Terrace, Orient
Construct House,Drive,Pool,Septic
Dear Permittee:
In conformance with the requirements of the State Uniform Procedures Act(Article 70,
ECL) and its implementing regulations (6NYCRR, Part 621) we are enclosing your permit.
Please carefully read all permit conditions and special permit conditions contained in the
permit to ensure compliance during the term of the permit. If you are unable to comply with any
conditions,please contact us at the above address. This permit must be kept available on the
premises of the facility at all times.
Also enclosed please find a permit sign which is to be conspicuously posted at the project
site and protected from the weather.
Sincerely,
Kevin Kispert
Environmental Analyst II
Enclosures
KAK/file
cc: NYSDEC MHP
Patricia C.Moore,Esq
NE" YORK Department of
��r
� ��x��m Environmental,
Conservation
NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION
Facility DEC ID 1-4738-04.698
PERMIT
Under the Environmental Conservation Law ECL
Permittee and Facility Information
Permit Issued To: Facility:
DAVID &MARY JANE CASSARO CASSARO PROPERTY
73 PINE ST 420 WILLOW TERRACE LN11000-26-2-10
GARDEN CITY,NY 11530 ORIENT,NY 11957
Facility Application Contact:
PATRICIA C MOORE
51020 MAIN RD
SOUTHOLD,NY 11971
(631) 765-4330
Facility Location: in SOUTHOLD in SUFFOLK COUNTY Village: Orient
Facility Principal Reference Point: NYTM-E: 726.499 NYTM-N: 4557.1-66
Latitude: 41°08'03.2" Longitude: 72°18'05.4"
Authorized Activity: Construct a new single family dwelling with decking,pervious driveway,pool,
and septic systemall as shown on the attached survey prepared by John T.Metzger, last revised
10/16/19, stamped "NYSDEC Approved" on 1/3/2020.
DEP ARNO
Permit Authorizations
Tidal Wetlands-Under Article 25
Permit ID 1-4738-04698/00001
New Permit Effective Date: 1/3/2020 Expiration Date: 1/2/2025
E::::�����N�YSD�ECpproval
By acceptance of this permit,the permittee agrees that the permit is contingent upon strict
compliance with the ECL,all applicable regulations,and all conditions included as part of this
permit.
Permit Administrator:KEVIN A KISPERT,Deputy Permit Administrator
Address: NYSDEC Region 1 Headquarters
SUNY @ Stony Brook150 Circle Rd
Stony Brook,NY 11790 -3409
Authorized Signature: Date
Page 1 of 7
NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION
Facility DEC ID 1-4738-04698
Distribution List
PATRICIA C MOORE
Marine Habitat Protection
KEVIN A KISPERT
Permit Components
NATURAL RESOURCE PERMIT CONDITIONS
GENERAL CONDITIONS,APPLY TO ALL AUTHORIZED PERMITS
NOTIFICATION OF OTHER PERMITTEE OBLIGATIONS
Permit.Attachments
Site Plan 10/16/2019
NATURAL RESOURCE PERMIT CONDITIONS -Apply to the Following
Permits: TIDAL WETLANDS
1. Regulated Activities Authorized By This Permit This permit authorizes only those regulated
activities/structures identified under the section Description of Authorized Activity.NYSDEC does not
issue after-the-fact or as-built permits.This permit does not authorize activities, or legitimize the
existence of structures,which would have required.a permit.but for which no permit or other
authorization has been granted NYSDEC.
2. Conformance With Plans All activities authorized by this permit must be in strict conformance
with the approved plans submitted by the applicant or applicant's agent as part of the permit application.
Such approved plans were prepared by ohn T.Metzger, last revised 10/16/19, stamped "NYSDEC
Approved" on 1/3/2020.
3. Notice of Commencement At least 48 hours prior to commencement of the project,the permittee
and contractor shall sign and return the top portion of the enclosed notification form certifying that they
are fully aware of and understand all terms and conditions of this permit. Within 30 days of completion
of project,the bottom portion of the form must also be signed and returned, along with photographs of
the completed work.
4. Post Permit Sign The permit sign enclosed with this permit shall be posted in a conspicuous
location on the worksite and adequately protected from the weather.
Page 2 of 7
NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION
Facility DEC ID 1-4738-04698
5. Tidal Wetland Covenant The permittee shall incorporate the attached Covenant(or similar
Department-approved language)to the deed for the property where the project will be conducted and
file it with the Clerk of SUFFOLK County within 30 days of the effective date of this permit. This
deed covenant shall run with the land into perpetuity. A copy of the covenanted deed or other
acceptable proof of record, along with the number assigned to this permit, shall be submitted within 90
days of the effective date of this permit to
Marine Habitat Protection
NYSDEC Region 1 Headquarters
'SUNY @ Stony BrookJ50 Circle Rd
Stony Brook,NY11790-3409
Attn:Compliance
6. Failure to Meet Permit Conditions Failure of the pennittee to meet all the conditions of this
permit is a violation of this permit and grounds for an.order to immediately cease the permitted activity
at the project site.
7. All Structures Must Be At Least 100 Feet Landward Of The Wetland Boundary This permit
authorizes the construction of new single family dwellings with accessory structures and septic systems
located in the adjacent area at the prescribed minimum setback only. Structures located in tidal
wetlands, or structures in the adjacent area but located less than 100 feet from the wetland boundary, are
not authorized.
8. Development Restrictions New single family dwelling, accessory structure and septic system
projects authorized by this permit must meet all of the applicable development restrictions of 6 NYCRR
Part 661.6(a) (1), (2), (3), (4), (5), (7), and Part 661.6(b):
-The 75 foot minimum wetland setback requirement for all principal structures•and all non-water-
dependent structures exceeding 100 square feet in area.
-The.100 foot minimum wetland setback requirement for all components of the septic system.
-The requirement that all components of the septic system be installed at an elevation at least 2 feet
above the seasonal high groundwater elevation for the site.
-The 20%maximum adjacent area coverage limitation for impervious structures and surfaces.
-The 75 foot minimum wetland setback requirement for all hard surface driveways,roads,parking areas
and similar impervious surfaces exceeding 500 square feet in area.
9. Sanitary Systems above Groundwater Sanitary system(bottom of tank and leaching pools) shall
be located a minimum of 2 feet above seasonal high groundwater.
Page 3 of 7
NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION
Facility DEC ID 1-4738-04698
10. Straw Bales or Other along West Side of Property A row of staked straw bales or approvable
erosion control devices shall be placed at the edge of the limit of clearing and disturbance along the
west side of the property prior to commencement of any regulated activities, and must remain in place
and in good, functional condition until the project is completed and all disturbed areas are stabilized
with vegetation.
11. Roof Runoff Directed to Drywells Roof ninoff shall be directed to drywells with the capacity to
store/recharge the runoff from a 2 inch/24 hours precipitation event. All drywells shall be located a
minimum of 75 feet landward of the tidal wetland boundary
12. No Drywells in or near Wetland Dry wells for pool filter backwash shall be located a minimum
of 100 linear feet landward of the tidal wetland boundary.
13. Direct Runoff Away from Tidal Wetland and Buffer Roads, driveways, and parking areas shall
be graded to direct runoff away from tidal wetlands and protected buffer areas.
14. Driveway/Parking Area of Pervious Material Driveway and parking areas shall be constructed
of NYSDEC-approved pervious materials.
15. No Pool Discharges to Wetland There shall be no draining of swimming pool water directly or
indirectly into wetlands or protected buffer areas.
16. Clean Fill Only All fill shall consist of clean sand, gravel, or soil(not asphalt, slag, flyash,broken
concrete or demolition debris).
17. Contain Exposed,Stockpiled Soils All disturbed areas where soil will be temporarily exposed or
stockpiled for longer than 48 hours shall be contained by a continuous line of staked haybales/silt
curtains (or other NYSDEC approved devices)placed on the seaward side between the fill and the
wetland or protected buffer area. Tarps are authorized to supplement these approved methods.
18. No Disturbance to Vegetated Tidal Wetlands There shall be no disturbance to vegetated tidal
wetlands or protected buffer areas as a result of the permitted activities.
19. No Construction Debris in Wetland or Adjacent Area Any debris or excess material from
construction of this project shall be completely removed from the adjacent area(upland)and removed to
an approved upland area for disposal. No debris is permitted in wetlands and/or protected buffer areas.
20. Storage of Equipment,Materials The storage of construction equipment and materials shall be
confined within the project work area and/or upland areas greater than 75 linear feet from the tidal
wetland boundary.
21. Vegetate All Disturbed Areas The permittee shall revegetate all exposed faces and disturbed
areas to prevent soil erosion prior to the project completion or expiration date of this permit,whichever
comes first.
22. Concrete Leachate During construction,no wet or fresh concrete or leachate shall be allowed to
escape into any wetlands or waters of New York State, nor shall washings from ready-mixed concrete
trucks, mixers, or other devices be allowed to enter any wetland or waters. Only watertight or
waterproof forms shall be used. Wet concrete shall not be poured to displace water within the forms.
Page 4 of 7.
NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION
Facility DEC ID 1-4738-04698
23. Precautions Against Contamination of Waters All necessary precautions shall be taken to
preclude contamination of any wetland or waterway by suspended solids, sediments, fuels, solvents,
lubricants, epoxy coatings,paints, concrete, leachate or any other environmentally deleterious materials
associated with the project.
24. State May Require Site Restoration If upon the expiration or revocation of this permit,the
project hereby authorized has not been completed,the applicant shall,without expense to the State, and
to such extent and in such time and manner as the Department of Environmental Conservation may
lawfully require,remove all or any portion of the uncompleted structure or fill and restore the site to its
former condition. No claim shall be made against the State of New York on account of any such
removal or alteration.
25. State May Order Removal or Alteration of Work If future operations by the State of New York
require an alteration in the position of the structure or work herein authorized,or if, in the opinion of the
Department of Environmental Conservation it shall cause unreasonable obstruction to the free
navigation of said waters or flood flows or endanger the health, safety or welfare of the people of the
State, or cause loss or destruction of the natural resources of the State,the owner may be ordered by the
Department to remove or alter the structural work, obstructions, or hazards caused thereby without
expense to the State, and if,upon the expiration or revocation of this permit,the structure, fill,
excavation, or other modification of the watercourse hereby authorized shall not be completed,the
owners,shall,without expense to the State, and to such extent and hi such time and manner as the
Department of Environmental Conservation may require,remove all or any portion of the uncompleted
structure or fill and restore to its former condition the navigable and flood capacity of the watercourse.
No claim.shall be made against the State of New York on account of any such removal or alteration.
26. State Not Liable for Damage The State of New York shall in no case be liable for any damage or
injury to the structure or work herein authorized which may be caused by or result from future
operations undertaken by the State for the conservation or improvement of navigation, or for other
purposes, and no claim or right to compensation shall accrue from any such damage.
GENERAL CONDITIONS - Apply to ALL Authorized Permits:
1. Facility Inspection by The Department The permitted site or facility,including relevant records,,
is subject to inspection at reasonable hours and intervals by an authorized representative of the
Department of Environmental Conservation(the Department)to determine whether the permittee is
complying with this permit and the ECL. Such representative may order the work suspended pursuant
to ECL 71-0301 and SAPA 401(3).
The permittee shall provide a person to accompany the Department's representative during an inspection
to the permit area when requested by the Department.
A copy of this permit, including all referenced maps, drawings and special conditions, must be available
for inspection by the Department at all times at the project site or facility. Failure to produce a copy of
the permit upon request by a Department representative is a violation of this permit.
Page 5 of 7
NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION
Facility DEC ID 1-4738-04698
2. Relationship of this Permit to Other Department Orders and Determinations Unless expressly
provided for by the Department, issuance of this permit does not modify, supersede or rescind any order
or determination previously issued by the Department or any of the terms, conditions or requirements
contained in such order or determination.
3. Applications For Permit Renewals,Modifications or Transfers The permittee must submit a
separate written application to the Department for permit renewal,modification or transfer of this
permit. Such application must include any forms or supplemental information the Department requires.
Any renewal,modification or transfer granted by the Department must be in writing. Submission of
applications for permit renewal,modification or transfer are to be submitted to:
Regional Permit Administrator
NYSDEC Region 1 Headquarters
SUNY @ Stony BrookJ50 Circle Rd
Stony Brook,NY 11790-3409
4. Submission of Renewal Application The permittee must submit a renewal application at least 30
days before permit expiration for the following permit authorizations: Tidal Wetlands.
5. Permit Modifications, Suspensions and Revocations by the Department The Department
reserves the right to exercise all available authority to modify., suspend or revoke this permit. The
grounds for modification, suspension or revocation include:
a. materially false or inaccurate statements in the permit application or supporting papers;
b. failure by the permittee to comply with any terms or conditions of the permit;
c. ' exceeding the scope of the project as described in the permit application;
d. newly discovered material information or a material change in environmental conditions,
relevant technology or applicable law or regulations since the issuance of the existing permit;
e. noncompliance with previously issued permit conditions, orders of the commissioner, any
provisions of the Environrriental Conservation Law or regulations of the Department related to
the permitted activity.
6. Permit Transfer Permits are transferrable unless specifically prohibited by statute,regulation or
another permit condition. Applications for permit transfer should be submitted prior to actual transfer of
ownership.
Page 6 of 7
NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION
Facility DEC ID 1-4738-04698
NOTIFICATION OF OTHER PERMITTEE OBLIGATIONS
Item A: Permittee Accepts Legal Responsibility and Agrees to Indemnification
The permittee, excepting state or federal agencies, expressly agrees to indemnify and hold harmless,the
Department of Environmental Conservation of the State of New York, its representatives, employees,
and agents.("DEC")for all claims, suits, actions, and damages,to the extent attributable to the
permittee's acts or omissions in connection with the permittee's undertaking of activities in connection
with, or operation and maintenance of,the facility or facilities authorized by the permit whether in
compliance or not in compliance with the terms and conditions of the permit. This indemnification does
not extend to any claims, suits, actions, or damages to the extent attributable to DEC's own negligent or
intentional acts or omissions, or to any claims, suits, or actions naming the DEC and arising under
Article 78 of the New York Civil Practice Laws and Rules or any citizen suit or civil rights provision
under federal or state laws.
Item B: Permittee's Contractors to Comply with Permit
The permittee is responsible for informing its independent contractors, employees,agents and assigns of
their responsibility to comply with this permit, including all special conditions while acting as the
permittee's agent with respect to the permitted activities, and such persons shall be subject to the same
sanctions for violations of the Environmental Conservation Law as those prescribed for the permittee.
Item C: Permittee Responsible for Obtaining Other Required Permits
The permittee is responsible for obtaining any other permits, approvals,lands, easements and rights-of-
way that may be required to carry out the activities that are authorized by this permit.
Item D: No Right to Trespass or Interfere with Riparian Rights
This permit does not convey to the permittee any right to trespass upon the lands or interfere with the
riparian rights of others in order to perform the permitted work nor does it authorize the impairment of
any rights, title, or interest in real or personal property held or vested in a person not a party to the
permit.
Page 7 of 7
SITE PLAN OF PROPERTY /1 j
SITUATED AT TEST HOLE DATA /_-_
ORIENT
TOWN OF SOUTHOLD >o�+Ei
SUFFOLK COUNTY, NEW YORK
S.C.TAX No. 1000-26-02-10
SCALE 1'=20'
AREA=23.742
0.543 ac. .- .
TIIS SIZE Pl/J!HAS e@l PRFPANm
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REFEREGHEALTH DEPARTMENT
ENCE 0 R10-17-0043
Charles M.Thom i I as
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SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
CE ON SEPTEMBER 30. 2005 ..._ ...
F C CTION hOR A Suffolk Counntv �►e a t of Health Services
PERMIT FOR APPROVAL OF ONSTRU
-EL 0.0' Call (631) 852-5754, 48 hours in
DARK BROWN SILTY LOAM OL SIN 11= FAMILvR S 1 DEN E N LY
—EL 1.0' i
advance, to schedule nspections
BROWN SILT MIL _ ...-_....
-EL 5.4'
Design Professional's Certification Requ
WATER IN BROWN SILT ML DATE 2/291 R-24-0142
Sub
m P.E. or R.A. CeMficatlon for tl-
-EL 6.0' APPROVED a I1 Io and Construction of the Sewage Dig
FOR MAXi F 4 ROOMS Use Form WV M-07
WATER IN PALE BROWN FINE
TO COURSE SAND SW EXPIRES THREE YEARS FROM D, OFE_ VAL
-EL 12.0'
RESIDENCE _` RESIDENCE
WELL WATER(150.0'+) ( CP 1 ( CP WELL WATER(150.0'+)
Cp
( CP
`V�TIO� NSPEC�TLO� ' ��!UI F' E APPROVED IN ( cP �
ACCORDANCE WITH
BOARD O F REVIEW 1 s.o' R.O.W. o GRAVEL DRNEWAY
22'3�'��»W OVERHEAD WIRES 36.23'
FOR SANITARY SkYSTEM
DETERMINATION ......_.� N._ ._ .... ..._.. �.
DATED 1/2/08 o
by HEALTH DEPARTMENT
- - ... _
, .. .
POOL WYWELL
SE A
PIPE -o
Biwa o
R f:
.g;• �.. ._.. .... CHAMBER valwne( al) ea..
�...,. ..,, Sedimentation Chamber 277 .
Anaerobic Filtration Chamber 278
Aerobic Contact Filtration Chamber -127 L— --- - - - ---- --- ----- ----^ ""-"' """-"
�f" 3 L.., ra.e Chamber 63
CM&AHR
x Stoinfection Chamber A Disinfection LINE OF DECK ABOVE
Total Volume 749
1711=PIPE
JA Avard7'jeMcdw Aerobic6rYet9a I peIPECi"dP&; f,umino skate 1 db""4 u,
W Aerobic MedUat PP/PE h89 n &�nYe, 57% DELI( v,
AIR LFT PUP Slower 28lldt" ...
coax r.�
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CHAMBER Volume( al) I /"
hamber 277 2 MLDB0 SET BACI(
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tFlltratianChamber 127
LINE OF DEC( ABOVE w. ""
Cp
amber 4 �d ( CP �"'1_
d`WAI Vaalurrtt 749 I
O A /
!"ECGF lC4t°i iCi 95, o O
PP/PE Fillin Rate 32% � ° LOT 14
.,Media 1PVC/PP/PE Fillin Rate l6% loy.
DECKRESIDENCE
O
PP/PE
P/PE Fillin Rate 57�n � � ,. a
1 WELL WATER(136.
2.8 CrAl 1
LOT 16
FRP " ",
PE
PVC/'PP� RESIDENCE F11tll CIFJW AND HYAR
Plastic/Cast Iron t8-4' GRADE
WELL WATER(150.0'+) Y '
nal) Pll stir e Tast Iron
PANE � � 10
PROBED T CaNrROL TO BE AVSTALlID
. .� " STORY HOUSE .. IN OIMfS �. / FEIDER AND CONTROL
4 EDR MS PANE
� lO OWIS COITIROL
EL 6 6' LP
/ AND AM BLOWER
NOTE NO SURFACE WATER/wElUNDS 1..
r MBE WITHIN 3DO FT OF THE PROPERTY FRESH VENT
Y DIAL
1 .3 s s LP TO HOUSE VENT
y� as 10.4 N.S1 OkB E1
OPWNG
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n °
ow
D-BOX
Owncover � _... —.ROO� � � W/ PDB-12 RISER AND
WFO-FLAW 3WO-4 LEVELERS
( CP 1 LP LP .�" L I TO GRADE WITH LOOM OMER
® ASSEMBLY No " 10 ST HOLE r�
cn tv 1 I FL 8.7'
CP
MEDIA / »rr's-. W N
VNt4
"IISYNV AfSEMBLY
.......„ink_...,;. O q I
EL 9.3'
TEST WELL PROP. WELL
EL 12.6'
3—B VIEW 160. 0'
OVERHEAD WIRES
S 22'30'00"E - -- —O
— OVERHEAD WIRES z
z
cn z
ALMUSTBE TERRACE
ATE o W � 371' TO CROSS STREET
WELL AND WILL � KING STREET
tv c N
FINAL SURVEY
SHOWN-CONTROL PANEL MOUNTED ON
ON 4'X4' PRESSURE
TREATED WOOD POSTS
AIR BLOWER
INSULATED WEATHER
RESISTANT BLOWER n[
ENCLOSURE RESIDENCE
RESIDENCE WELL WATER (117.0')
WELL LOCATION UNKNOWN
SEPTIC 150.0'
Z EXISTING HEALTH DEPARTMEN'
AIR LINE TO
FWICLEAN OW
REFERENCE # R 10- 17-0043
ELECTRICAL SUPPLY
TO SLOWER