HomeMy WebLinkAbout51064-Z TOWN OF SOUTHOLD
BUILDING DEPARTMENT
tix TOWN CLERK'S OFFICE
rs� SOUTHOLD NY
0
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#: 51064 Date: 8/13/2024
Permission is hereby granted to:
Plimpton n Famiy LLC,..
110 Shingle Landing Dr
Rochester, NY 14609
To: Construct additions and alterations to include a HVAC system to an existing
single-family dwelling as applied for as per SCHD, Trustees and DEC approvals.
At premises located at:
12250 New Suffolk Ave, Cutchoguem mITIT
SCTM # 473889
Sec/Block/Lot# 116.-6-11
Pursuant to application dated 6/21/2024 and approved by the Building Inspector.
To expire on 2/12/2026.
Fees:
SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $1,240.00
CO-ALTERATION TO DWELLING $100.00
....a
Total: ..... $1.'34.......-�
0.00
...........
Building _. .
Building Inspector
4C4"
TOWN OF SOUTHOLD—BUILDING DEPARTMENT
x Town Hail Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959
Telephone(631) 765-1802 Fax(631)765-9502 litti?s://www.soudt ioldtowniiv u,ov
D2tc Rcceived
APPLICATION FOR BUILDING PERMIT
For Office Use Oniy
1 �
..ERMF B��iic�in ina�;zciow.. :.,_ ... ..,......
JUN 2 1 2024
Appiicathns and forms must be fiffed out in their entirety.tncompteta
applications w4dt not be accepted. VAwe the Appkam is eot the ow+tet,an BUILDING DEFT.
ownees Authorbatim fwm(Page z)shall be completed. TOWN 1E S0UT11()I -.
DP,`:`120/24
OWNER(S)OF PROPERTY:
Marne:NICOLA P LI .PTON m#1000-116.6.11
'roject.Address:12250 New Suffolk Rd Cutcho ue 11935 N
-- u• � mail:nldoia.pihpEC3f?�?C maii.corn
a'rlc�rle#. 3f-f.3l�f �b
M1 ailing Address:PO BOX 271 CUTCHOGUE NY 11935
CONTACT PERSON:
Name',Kate Samuels
Mailing dress:2 2 i Halm Road Cute t sae NY 11935
Phone ,631 734-6405 Email,kate@sa tuelsandsteelman. 01
DESMN PROIFESSIOMAL IN MA'F :
Name:above
Mailing Address:
Phan #t: email:
CONTRACTOR INFORMATION:
Narne:TBI
Flailing Address:
I
Phone : Email:
DESCRtPiM OF PROPOSED CONSTRUCT10N
DNevu Structure WAddition. r-lAltorntlnn nRonair nrlcmniitinn !'nct o Fctimated Pro ia� .
arl of rt•
❑ether
Will the test be te-grades#? 11Yes igft Will excess ftft use removed from premises? DYes WHO
I
1
PROPERTY INFORMATION
Existing use of property:Residential intended use of property:Residential
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
0 Ns property- Elves No IF E.1, Pi OVIDEA SOP''.
W,Check Box After Reading: The ownertcontt tor/design professional is respondble for all drainage and storm weber Issues as provided by
Chatpter 236 of tha Team Code APKICATION CS HERMY MADE to the for the hownce of*SuRdIng Permit pwsaast to the Zoe*
ordinance of the Taws of soothold,So",Cam",New York aw other appucaMe taws,ordiirwwas or Regsihooes,for the of boodlails,
additions,*iterations 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 buildings)for necessary Inspections.False statements made herein are
w,rc;®c.c„®3 a L`!•e�,A r:?�a�...�a..v .�.,�.,..0 eM.`�.."n,Ae us.cm�uw6,vu e.rs.2 o�,.c!u=..
Application SubrMtted By ipril Sft�U � RAuthwized Agent 00wner
Signature of Applicant: Date: �Z `
r
STATE OF NEW YORK)
COUNTY Of Sa
�bp rT'rliihi c�lvnrn rlanncac and cave that/clha is tho annlira nt
(Nara 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
fJ I.:H _ti-i Si!!, LII(�l.G!! 3LZ tC1lIGnL3 L'JI!LGI IIICS.3 In "!!13 �p I.:l 1i G'LIVI �i t- LI_.G LJ -I"C :JG�:.of HisJ lief [\I:11 V•.=IGLig� al J wG!iGlr fir;LS
that the work will be performed in the manner set forth in the application file the ith.
Sworn before me this
day of 20 WENd
i i aw' q l`Ji DYA.sTAPON
Noly NbrIG,sto of
,4i 1097
PROPERTY OWNER peN.�l HORI "ION q�lu�lif lil
DPW,Izn.8,
(Where the applicant is not the owner)
/ residing at
VV �
do
hereby authorize to apply on
m behalf tot To of v hold Building Department for approval as described herein.
Owner's Signat r to
Print Owner's Name
2
Scott A. Russell 5��'01Kj\\j[WA�� 1E][-
SUP
ERVISOR AAAA,NAA,G IEM[]ENIF
SOUTHOLD TOWN HALL-P.O.Box 1179 Town+ '
53095 Main Road-SOUTHOLD,NEW YORK 11971
o Southold
SOUTHOLD,
CHAPTER 236 - STORMWATER MANAGEMENT REFERRAL FORM
( APPLICANT INFORMATION TO ._ ...... �� _. _._...
.,.m._ BE COMPLETED BY THE APPLICANT
ONLY FOR PROPERTI RG
ES ONE ACRE [N AREA O
APPLICAN p y T: (Pro �ert Owner, Desig n Professional, Agent, Contractor, Other) !'
NAME, Date: g— 2_-2y
Contact Information .�.._ a-�Ylt Sc�mLt� �.m
+j {Signa�wel
�._.T� .u. ._ _ ands�� �an corn
IC-Mail&`I elephnne Numher l Ll0,5 .
Piop erty Address / Location of Construction Site,
.. 2..._��. w N ..._5 u.4 .l _...... A 1 �. .._.._ S.C.T.M. #; 1000
Di7tI ieG:
Section Block Lot
TO BE COMPLETED BY SOUTHOLD TOWN ENGINEERING DEPARTMENT
Area of Disturbance is less than I Acre. No S P_D E.S�Permit is Re aired i
Project does Not Discharge to Waters of the State No S.P.D.E.S._Permit is Bemired
Area of Disturbance is Greater than t Acre & Storm-v`ater Runoff Discharges Directly
to Waters of the State of Nev York. THE APPLICANT MUST OBTAIN a S.P.D.E.S. Permit
�....�
DIRECTLY From N Y.S. D.E.0 Prior- to Issuance of a Buildin-, Permit,
zvca of Disturbance is Greater than I .Acre & Stc}rm-N,®ater Riulnff Flaws Through Southold
TSCPI D E S.4Perm t through the Sout the
holLlState
Tow n lN:etivv ®:lukn e aI_APPt tICANT' MUST OBTAIN
a _ _g
Prior to Issuance ofITa Building PermitReviewed By,
r
cc v
F flR M
.,_x qM P -Tnq rlrYnhPi )()IQ:.
� ...
ry 6
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)444-03651 F:(631)444-0360
www.dec.ny.gov
Nicola Plimpton June 4, 2024
12250 New Suffolk Ave
Cutchogue NY 11935
Re: Application#1-4738-04992/00001
Plimpton Property — 12250 New Suffolk Ave
SCTM# 116-6-11
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 for the
referenced activity. 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.
Enclosed is a permit sign which is to be conspicuously posted at the project site and
protected from the weather and a Notice of Commencement/Completion of Construction.
DEC has documented the summer occurrence of the Northern Long Eared Bat
(NLEB) (Myotis septentrionalis), a species listed as "endangered" by both New York
State and the US Fish & Wildlife Service, within 3 miles of the project location. We
have determined that tree cutting at this location between March 1 and November 30 of any
calendar year may result in the "take" of these endangered species within the meaning of
Environmental Conservation Law (ECL) §11-535. The term "taken is defined in part as the
direct killing or injury of individual members of a protected species, interference with critical
breeding, foraging, migratory or other essential behaviors, or the adverse modification of the
species' habitat. The "take" of a species listed as endangered or threatened is prohibited in
the absence of a permit from this Department issued pursuant to ECL §11-535. In order to
avoid an Endangered Species "take" or the need for an incidental take permit, no tree
cutting activities can be conducted at the project site between the dates of March 1
and November 30 of any calendar year. If you have questions about the presence of
protected species on or near your property, the potential effects of activities on these
species or your responsibilities as a landowner or project sponsor under the Endangered
Species Regulations, please contact the Regional Wildlife Manager at (631) 444-0310.
Nephan
y
ie Sforza
Environmental Analyst
Cc: Katherine Samuels
BMHP
File
t RX Department of
miron m'mental
NEW PORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION
Facility DEC ID 1-4738-04992
PERMIT
Under the Environmental Conservation Law :JCL
Permittee and Facility Information
Permit Issued To: Facility:
NICOLA PLIMPTON PLIMPTON PROPERTY
12250 NEW SUFFOLK AVE 12250 NEW SUFFOLK AVEISCTM # 1000-116-
6-11
CUTCHOGUE,NY 11935 CUTCHOGUE,NY 11935
Facility Application Contact:
SAMUELS & STEELMAN ARCHITECTS
25235 MAIN RD
CUTCHOGUE,NY-11935
(631) 734-6405
Facility Location: in SOUTHOLD in SUFFOLK COUNTY
Facility Principal Reference Point: NYTM-E: 711.172 NYTM-N: 4540.807
Latitude: 40°59'28.0" Longitude: 72°29'22.3"
Authorized Activity: Construct an addition to the first floor of the existing single-family dwelling, a
covered porch, covered entry deck and other residential structures. Install drainage. Remove and replace
wood deck. All authorized activities must be done in strict conformance with the attached site plans
prepared by Katherine Jean Samuels pages 1-3 dated 4/15/2024, pages 1-2 last revised 5/1/2024 and all
stamped "NYSDEC Approved" on 6/4/2024. SAS
Note: All structures and projects proposed more than 300 feet from the Tidal Wetlands boundary are
beyond the jurisdiction of the Article 25 Tidal Wetlands Act. Therefore, in accordance with the current
Tidal Wetlands Land Use Regulations (6NYCRR Part 661), no permit is required to conduct regulated
activities landward of that 300-foot distance.
Permit Authorizations
Tidal Wetlands -Under Article 25
Permit ID 1-4738-04992/00001
New Permit Effective Date: 6/4/2024 Expiration Date: 6/3/2029
Page 1 of 7
AM
NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION
Facility DEC ID 1-4738-04992
NYSDEC Approval
F-
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 Regional Permit Administrator
Address: NYSDEC Region 1 Headquarters
SUNY @ Stony BrookJ50 Circle Rd
Stony Brook,ok,NY 11790 -3409
Authorized Signature: �A�no Date /
Distribution List
SAMUELS & STEELMAN ARCHITECTS
Bureau of Marine Habitat Protection
File
Stephanie Sforza
Permit Components
NATURAL RESOURCE PERMIT CONDITIONS
GENERAL CONDITIONS,APPLY TO ALL AUTHORIZED PERMITS
NOTIFICATION OF OTHER PERMITTEE OBLIGATIONS
NATURAL RESOURCE PERMIT CONDITIONS - Apply to the Following
Permits: TIDAL WETLANDS
1. 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 Katherine Jean Samuels pages 1-3 dated 4/15/2024,pages 1-2
last revised 5/1/2024 and all stamped "NYSDEC Approved" on 6/4/2024.
2. 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 1-4738-04992
3. Notice of Commencement At least 48 hours prior to commencement of the project, the pennittee
and contractor shall sign and return the top portion of the enclosed notification form certifying that they
are frilly 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. 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.
5. 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.
6. Materials Disposed at Upland Site Any demolition debris, excess construction materials, and/or
excess excavated materials shall be immediately and completely disposed of in an authorized solid waste
management facility. These materials shall be suitably stabilized as not to re-enter any water body,
wetland or wetland adjacent area.
7. 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.
8. 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.
9. Seeding Disturbed Areas All areas of soil disturbance resulting from the approved project shall be
stabilized with appropriate vegetation (grasses, etc.) immediately following project completion or prior
to permit expiration, whichever comes first. If the project site remains inactive for more than 48 hours
or planting is impractical due to the season,then the area shall be stabilized with straw or hay mulch or
jute matting until weather conditions favor germination.
lo. No Unauthorized Fill No fill or backfill is authorized by this permit without fiirther written
approval from the department (permit, modification, amendment).
11. No Runoff down Bluff or onto Beach There shall be no discharge of runoff or other effluent on,
in or down the bluff face or onto the beach.
12. Install, Maintain Erosion Controls Necessary erosion control measures, i.e., straw bales, silt
fencing, etc., are to be placed on the downslope edge of any disturbed area. This sediment barrier is to
be put in place before any disturbance of the ground occurs and is to be maintained in good and
functional condition until thick vegetative cover is established.
13. Runoff Directed to Upland Drywells Roof runoff shall be directed to drywells a minimum of 75
linear feet landward of the tidal wetland boundary for immediate on-site recharge.
Page 3 of 7
NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION
Facility DEC ID 1-4738-04992
14. Driveway/Parking Area of Pervious Material Driveway and parking areas shall be constructed of
NYSDEC-approved pervious materials.
15. 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.
16. Maintain Erosion Controls All erosion control devices shall be maintained in good and functional
condition until the project has been completed and the area has been stabilized.
17. 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.
18. 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 in 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.
19. 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.
20. 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.
Page 4 of 7
NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION
Facility DEC ID 1-4738-04992
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.
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.
Page 5 of 7
NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION NOW
Facility DEC ID 1-4738-04992
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 pen-nit;
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 Environmental 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.
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.
Page 6 of 7
NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION
Facility DEC ID 1-4738-04992
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
NEW Department o
YORK
STATE Environmental
Conservation
1 M& M M M
m %jT1 %1w# E
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
SHERRIACHER
Permit Number: 1-4738-04992/00001
-- NYSDEC Region 1 Environmental Permits
50 Circle Road
Stony Brook, NY 11790-3409
Expiration Date: 06/03/2029 Email: dep.r1@dec.ny.gov
Note: This notice is NOT a permit
Glenn Goldsmith,President f3f DI Town Hall Annex
54375 Route 25
A.Nicholas Krupski,Vice President 10 P.O.Box 1179
Eric SepenoskiirALSouthold,New York 11971
Liz Gillooly Telephone(631) 765 1892
Elizabeth Peeples yQ Fax(631) 765-6641
eou 1,M,a
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Permit No.: 10565A
Date of Receipt of Application: April 9, 2024
Applicant: The Plimpton Family LLC
SCTM#: 1000-116-6-11
Project Location: 12250 New Suffolk Avenue, Cutchogue
Date of Resolution/Issuance: May 15, 2024
Date of Expiration: May 15, 2027
Reviewed by: Board of Trustees
Project Description: Construction activity within 100' from the landward edge of
the wetlands for the construction of a 150sq,ft. addition to existing dwelling with
interior and exterior renovation; new deck and porch on seaward side; new entry
porch on landward side; new a/c unit on precast slab; new septic system; and
new drywells.
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 Samuels + Steelman, Architects, received on April 9, 2024,
and stamped approved on February 14, 2024.
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.
41-1- 4"
Glenn Goldsmith, President
Board of Trustees
COUNTY OF SUFFOLK
EDWARD P. ROMAINE
SUFFOLK COUNTY EXECUTIVE
DEPARTMENT OF HEALTH SERVICES GREGSON H.PIGOTT,MD,MPH
Commissioner
PERMIT (_-!0NDITIONS
Project Name: 12250 Sufolk Avenue
Health Services Reference#: R-24-0146
SCTM#: 1000116000600011000
Revision#: 1
The attached plan,when duly signed by a representative of the department, in conjunction with these conditions,
constitutes a permit to construct a water supply, sewage disposal„ and/or collection system for the properly as depicted.
The applicant should take note of any conditions of approval„which may be indicated on the plan or enclosed herein,
Construction must conform with approved plans as well as all applicable standards including Standards for Approval of
Plans and Construction for Sewage Disposal Systems for Single Family Residences.Omissions, inconsistencies or
lack of detail on the plan do not release the applicant from the responsibility of having the construction dome in
conformance with applicable standards. Issuance of this permit shall in no way relieve the design professional of
responsibility for the adequacy of the complete design.
The permit(plan)expires three (3)years after the approval date. Any modification to the approved design requires the
submission of a revised plan and additional fees(if applicable)for approval prior to construction. No Inspections will be
performed by the department if a copy of the approved site plan/survey is not on site during construction or if
the permit has expired.
Permits may be renewed, transferred„ or revised in accordance with the procedures described in Instructions to Renew,
Extend, or Transfer an Existing Permit for Single Family Residences (Form WWM-104).
It is the applicant's responsibility to schedule an inspection of the sewage disposal and/or water supply facilities prior to
backfililing. This includes inspections of the sewage collection and disposal systems„water supply system components
and piping,and final grading as shown on the approved plans.This can be done by calling the department at(631)852
5754,or through the ACA Portal at l�tt s:l/ace- rod.accela,comlSl FFOLKC In certain cases, inspections of the soil
excavation may be required to determine the acceptability of the soils for sewage disposal systems. Excavation
inspections must be confirmed by calling(631) 852-5700 between >3;30a.m.and 9:30 a.m.,the morning of the
inspection.Article IBII of the Code, Septic Industry Elusinesses," rues that all installers of septic systems within
shall possess a valid license from the Office of Consc►mer Affairs. This office gall not perform inspections for or grant final
approval for construction of projects that,are installed by an unlicensed individual. It is, therefore, in your best interest to
utilize a cesspool contractor with a valid license to avoid substantial delays in your project.
Final approval issued by the Department is necessary prior to the occupancy of new buildings,additions to
existing buildings, or for the use of sewage disposal or water supply systems.
WWM-016 Page 1 of 2
►BLE FOR 9 BEDROOMS
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PPED INSIDE LAST ACTIVE GALLEY IN EACH ROW sc 3.0'
HIGHEST EXPECTED
GROUNDWATER
PALE BROWN
G.W. EL. 2.0 FINE SAND SP 6.0'
G.W. EL. 1.5
WATER IN
Q ' PALE BROWN
� FINE SAND ALL SITE DATA SUPPLIED BY NATHAN CORWIN LAND SURVEYING,
Q+' JAMESPORT, N.Y. 10.03.22 REVISED 02.27.23
0
SCTM#1000-116-06-11 / 55,356 SF /1.271
ACRES
ELEVATIONS NAVD 1 988 DATUM
SP 13.0'
TEST HOLE
COUNTY DEPARTMENT OF HEALTH SERVICES
NO SCALE SUFFOLK COU U)
1
TEST MOLE PERFORMED IT FOR APPROVAL OF CONSTRUCTION FOR A
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BY McDONALO GEOSCIENCE 1101.22
PERM
SINGLE FAMILY RESIDENCE AND
Cottage
ED R-24-o�46
ExcAVATIONISPECTIOI EOUIR DATE3/5 O
PTIC SYSTEMFORSANITARY ZjYSTEI 'I APPROVED 8/2 Cn
IS REGULATIONS TOTAL MAXIMUM SEDROOMS�, .
wx
EXPIRES THREE YEARS FROM [� E OF APPROVAL
LOCATED By HEALTH DEPARTMENT E W
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OWTS INSTALLATIONS. THE U
*ENGINEERS CERTIFICATION IS REQUIRED FOR HE BOARD OF HEALTH/ WASTE (n
Design Professional's Certification Required. DESIGN ENGINEER MUST BE CONTACTED WHE
Certification for the MANAGEMENT INSPECTOR IS CONTACTED FOR INSPECTION. ALL SEPTIC
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Submit P.E. or R.A. WATER MAN
installation and Construction of the Sewage Disposal System AND LEACHING FIELD COMPONENTS MUST BE VISIBLE. Q
Use Form WWM-073 C
t be in *NOTE. A MAINTENANCE CONTRACT & CONTINUOUS
MAINTENANCE IS REQUIRED G
t of the existing sanitary system must PROPER FUNCTIONING OF ALL I/A TREATMENT TANKS
Abandonmen 9 FOR THE
p ent's requirements.
_ d conformance With the De artm .. s r M'^^�
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I (P 6zlc Y R svATOVIC
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:D RELOCATED WATERLINE 3 {_
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TO REMAIN AS-IS
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