HomeMy WebLinkAboutTR-5405Board Of $outhold Town Trustees
SOUTHOLD, NEW YORK
PERK41T NO..'~.~0~ ....
DATE: ..°.~Ob~...~.L 200]
ISSUED TO ......... ~.s..gA~ ~....B-E..T..U...P~E.V!.N$ ...................................
Pursuan't to the provisions Of Chapter 61S of the laws of
the State of New Yor~, 1893; and Chapter 404 of the Laws of the
State of New York 19S2: and the Southold ToWn Ordinance
titled ."REGULATING AND THE PLAC;ING OF OBSTRUCTIONS
IN AND ON TOWN WATERS AND PUBLIC LANDS and the
REMOVAL OF SAND, GRAVEL OR OTHER IdATERIALS FROId
LANDS UNDER TOWN'WATERS;-'~. and in accordance with the
Resolution of The B6ard adopted at a meeting held on .~.g..r.....~_~ ....
. g.(~.0.~:'.., and in consideration of the sum of $..~.:.~ ........ paid by
............ Q~a:~...~...l~.~.tk..Ble.xdns .......................................................... : ........... ~ .........
of .................... ~!~.~]?.?~.~ ................ ' .................... N. Y. end subject to the
Terms and Conditions listed on the reverse slde hereof,
of Southold Town Trustees authorizes and permits the following:
Wetland Permit to install a 3'X 130~' catwalk,4'X 12' dock, 3'X 16'
ramp and 6tX 20' float in an "L" configuration secured with two
2-pile dolphins to secure float, and no up-rights on the catwa, lk,
as depicted on revised plan dated Octo.~er .29, 2001 .
afl ~n accordance with the defaiJed specifications as prat, anted in
the orlginefing applk:aflon.
IN WITNESS WHEREOF, The said Board of Trust.s here-
~ causes its Corporate Seal to be affixed, and these p.resents to
subscribed by a majority of the s~id Board as of th~s daf=.
TERMS and CONDITIONS
Oscar & Beth Blevins
m~,g ~ 640 Haywaters Dr., Cutchogue IW. Y~ '~
fofm,'~m~on may be made to d~;~Lrdat a ~ ~
B. That the said Board will be no~ified by the Petmiteee ot ~he coml~tioa Of d~ work "~k-
That the Petmittee vail obtala all o¢~r p.,~i,~ t~l com~tz ~t --.; be a'equl~ mP-
pte.,~tal to ~ pennlt which may be subject to ~'oke upoa f~ute eo ob~Ja ~
'1
AIbE
Otto
Ms. i
Susa
P.O.
East
't J. Krupski, President
;s King, Vice-President
Henry. Smith
Artie Foster
Ken Poliwoda
~er26,2001
usanE. Long
E. Long Permits
Box 46
Marion, NY 11939-0046
BOARD OF TOWN TRUSTEES
TOWN OFSOUTHOLD
Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-1366
RE: OSCAR & BETH BLEVINS
640 Haywaters Dr., Cutchogue
SCTM#104-5-1.2
Dear Ms. Long:
The Board of Town Trustees took the following action during its regular meeting held on
Wednesday, August 29, 2001 regarding the above matter:
WIlE [LEAS, Susan E. Long Permits on behalf of OSCAR & BETIt BLEVINS applied to the
Sout~ old Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town
of So ~thold, application dated May 31,200 l, and,
~ REAS, said application was referred to the Southold Town Conservation Advisory Council
for th fir findings and recommendations, and,
Au~W~2AS, a Public Hearing was held by the Town Trustees with respect to application on
said
9, 2001, at which time all interested persons were given an opportunity to he heard, and,
WIlE
quest:
WHE
conce
WHE
Town
WHE
safety
?.EAS, the Board members have personally viewed and are familiar with the premises in
on and the surrounding area, and,
REAS, the Board has considered all the testimony and documentation submitted
afing this application, and,
?.EAS, the structure complies with the standards set forth in Chapter 97 of the Southold
Code,
'.EAS, the Board has determined that the project as proposed will not affect the health,
and general welfare of the people of the town,
NOW THEREFORE BE IT,
RESOLVED, that the Board of Trustees approve the application of OSCAR & BETH
BLEVINS to install a 3'X 130' catwalk, 4'X 12' dock, 3'X 16' ramp and 6'X 20' float in an "L"
configuration secured with two 2-pile dolphins to secure the float, and no up-fights on the
catwalk, as depicted on revised plan dated October 29, 2001.
BE IT FURTHER RESOLVED that this determination should not be considered a determination
made for any other Department or Agency, which may also have an application pending for the
same or similar project.
Permit to construct and complete project will expire two years from the date it is signed. Fees
must be paid, if applicablorand 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: $648.00
Very truly yours,
Albert I. Krupski, Jr.
President, Board of Trustees
AJK/lms
DEC
Ru~ 29 1 04:32p Sus~ E. Lon~ 516 ?-3455
p.l
Memo
To:
From:
Subject:
Date:
Susan Long
Chris Arfsten
Blevins application 1-4738-0095g/00003
August I, 2001
Attached is a photocopy of the plans for the Blevins proposed dock showing the modification we
discussed on the phone July 31, 2001. I tried faxing this document to you but was unsuccessful m
dc ing so. I have not gotten in touch with Jimmy King yet, I will keep you posted on wether I will
be meeting at thc site with thc Trustees in August.
Ru~ 29 Ol O~:30p Susa E. Lon~ 516~?-3~55
SUSAN E, LONG PERMITS
FAX TRANSMITTAL
Nlmber of pages, including cover
DEPARTMENT OF STATE
George E. Pataki
Randy A. Daniels
Division of
Coastal Resources
41 State Street
Albany. NY 12231-0001
August 28, 2001
Albert
Presid
Board
Town
Town
53095
South~
Dear P
We re(
above-~
lead ag
from
If you I
me at (
Enclosr
J. Krupski, Jr.
:nt
of Town Trustees
)f Southold
Hall
Route 25
~ld, NY 11971-0959
Re.'
F-2001-0555
U.S. Army Corps of Engineers/New York District Permit
Application
Oscar & Beth Blevins - Install 360' Catwalk Assembly
Cutchogue Harbor, Town of Southold, Suffolk County
SEORA Lead A~encv Coordination
'esident Krupski:
eived your State Environmental Quality Remew Act Lead Agency Coordination letter regarding the
eferenced proposal. The Department of State has no objection to the Board of Town Trustees assuming
racy responsibility for this proposal. Also enclosed is a copy of a letter requesting additional information
e consultant.
ave any questions regarding this matter and State agency coastal consistency obligations, please contact
518) 474-4516 (e-mail wfeldhus~dos.state.ny.us).
Sincerely,
William Feldhusen
Coastal Resources Specialist
Consistency Review Unit
x:bice: ~5181 474 6000 Fax: t518~ 473-2464 E mail coastal(,~do, ,tale.ny.us
P.O.
East
i E. Long, Pcmlits
3ox 46
vlarion, ICI' 11939-0046
June 24. 200I
Re: F-2001-0555
U.S. Amty Coq)s of Engmeer~,/New York District Pem~it
Application
Oscar & Beth Blevms -Install 360' Catwalk Assembly
Cutchogue Harbor. Town of Soulhold, Sut'~blk Count5,
Request for Necessary Information and Data
Dear vis. Long:
The I~epmlment or'State received _vour Federal Consistency Assessment Form and consistency ce~tilication aud
suppohing intbmtation regarding the above matter on June 28,200l.
Pursuant to I5 CFR Part 930.58, the following data and mfocmation is necessary to enable the Department of
State to adequately assess the coastal zone effects of this proposed activity:
Thc proposed walk'x~ay and dock would cross several hundred feet of vegetated wetlands that are an important
comptlnent of the State designated Cutchogue Harbor and Wetlands Significant Coastal Fish and Wildlife Habitat
(narraqi~e copy enclosed) and sensitive to the type of activity proposed. Please discuss altematives that were
consid~:red and consider whether this route ntinimizes habitat impact. /\ctual photographs would assist in >our
responle-
Please IPro,, ~dc a cop_',' oF the surve.v and ~he deed with a metes and bounds description to support the survey.
['lease Iprov~de thc mtbm~at~on requested above as soon as possiblc. It' this necessary illtbt marion and data is
not pro~qded within thirty days of the date of this letter, the De[ artment of State may close the file regarding thts
proposbd acHvity. It' the Department cluses thc file and docs not conctu' w)th the conMstency certilicat~on
p~ovid&d tbr th~s proposed activity, the consistcnc.,, provisions of the tbdetal C'oastal Zone Management .\ct
Federal agency authorlzathm of thc activity.
prohibi
Albert J. Krupski, President
Jam~s King, Vice-President
Henry Smith
Artie Poster
Ken Poliwoda
Town Hall
53095Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-1366
August 9, 2001
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Re: Lead Agency Coordination Request
Dear Reviewer:
The purpose of this request is to determine under Article 8 (State Environmental
Quality Review Act-SEQRA) of the Environmental Conservation Law and 6
NYCRR Part 617 the following:
1. Your jurisdiction in the action described below;
2. Your interest in assuming the responsibilities of lead agency; and
3. Issues of concern that you believe should be evaluated.
Enclosed please find a copy of the proposal and a completed Environmental
Assessment Form (EAF) to assist you in your response.
Project Name:
Requested Action:
Oscar & Beth Blevins
Install 4'X 312' catwalk, 4'X 12' dock,
3'X 16' ramp and 6'X 20' float in "L" configuration
secured with two 2-pile dolphins to secure float.
SEQRA Classification:
( ) Type I,
(X) Unlisted
Contact Person: Albert J. Krupski, Jr.
(631) 765-1892
Page 2
Lead Agency Coordination Request
The lead agency will determine the need for an environmental impact statement
(ELS) on this project. Within thirty (30) days of the date of this letter, please
respond in wr ting whether or not you have an nterest n be ng ead agency. If no
response is received from you, it will be assumed that there is no objection to the
Board of Trustees assuming lead agency status.
Comments:
Please feel' free to contact this office for further information.
Very truly yours,
Albert Krupski, Jr.
President
CC:
Army Corp. of Engineers
Dept. of State
(*Maps are enclosed for your review)
14-16-2 {~'/9S);-- 7c
617.20
Appendix A
State Environmental Quality Review
FULL ENVIRONMENTAL ASSESSMENT FORM
SEQR
Purpose: The full FAF is designed to help applicants and agencies determine, in an orderly manner, whether a project
or action may be significant. The question of whether an action may be significant is not always easy to answer. Frequent-
ly. there ar~ aspects of a project that are subjective or unmeasureable. It is also understood that those who determine
significanc~ may have little or no formal knowledge of the environment or may not be technically expert in environmental
analysis. In~ddition, many who have knowledge in one particular area may not be aware of the broader concerns affecting
the questio~n of significance.
The full £^F is intended to provide a method whereby applicants and agencies can be assured that the determination
process has been orderly, comprehensive in nature, yet flexible enough to allow introduction of information to fit a:proiect
or action. /
Full EAr C(
Pad
Part
Identify '
Upon re,,
informat;
lead age,
D
mponents: The full EAF is comprised of three parts:
1: Provides objective data and information about a given project and its site. By identifying basic project
data, it assist5 a reviewer in the analysis that takes place in Parts 2 and 3.
2: Focuses on Identifying the range of possible impac~ts that may occur from ~, project or action. It provides '
guidance as to whether an impact is likely to be considered small to moderate or whether it is a potentially-
large Impact. The form also identifies whether an impact can be mitigated or reduced.
3: If any impact in Part 2 is identified as potentially-large, then Part 3 is used to evaluate whether or not the
impact is actually important.
DETERMINATION OF SIGNIFICANCE--Type I and Unlisted Actions
he Portions of EAF completed for this project: ri Part I I-I Part 2 I-1Part 3
Jew of the information recorded on this EAF (Parts I and 2 and 3 if appropriate), and any other supporting
on, and considering both the magnitude and Importance of each impact, it is reasonably determined by the
~cy that:
The project will not result in any large and important Impact(s) and,-therefore, Is one which will not
have a slgnlflcant Impact on the environment, therefore a negative declaration will be prepared.
Although the project could have a significant effect on the environment, there will not be a ~lgnlficant
effect for this Unlisted Action because t~e mitigation measures described In PART 3 have been required,
therefore · CONDITIONED nesatl .ye declaration will be prepared.*
The project may result In one or'mom large and Important impacts that may have · slgnlflcant impact
on the environment, therefore · positive declaration will be prepay'ed.
nditloned Negative Declaration is only valid for Unlisted Actions
Name of Action
Name of Lead Agency
Print or TYpe Name of Responsible Officer in Lead Agency
SignatUre of Responsible Officer I~ Lead Agency
Title of Responsible Officer
Signature of Preparer (if different from responsible officer)
Date
1
PART 1--PROJECT INFORMATION
Prepared by Project Sponsor
NOTICE: This document is designed to assist in determining whether the action proposed may have a significant effect
on the environment. Please complete the entire form, Parts A through E. Answers to these questions will be considered
as part of the application for approval and may be subject to further verification and public review. Provide any additional
information you believe will be needed to complete Part~ 2 and 3.
It is expected that completion of the full EAF will be dependent on information currently available and will not involve
new studies, research or investigation. If information requiring such additional work is unavailable, so indicate and specify
each instance.
NAME OF ACTION
LOCATION OF ACTION (Inolude Street Adelresl, Munh~lplllly and C;mJnty)
NAME OF APPUCANT/SPONSOR
NAMF OF OWNER (1! dl~l~'e~Q
ADDRESS
J6USINES~ TELEPHONE
.16~3f) Y77.$
' J ~U~INII~( ) TELF.~dOflE ·
DESCRIPTION OF ACTION
~'X ;~.-o~ ]::/..oAT
~ ~LI~H ~ N.~ Tb
STATE.
C?,~) p-Pt~ F_
Please Complete Ead~ question--Indicate N.A. it' not applicable
A. Site Desodptlon
Physical setting of overall project, bo~ developed ~tnd undeveloped areas.
1. Present land use: f'lOrban rllndustrlal nCommerclal ~lResldenflaJ (suburban)
C]Forest . rlAgrlculture ~Other
2. Total acreage of project area: ,~ ,,~'~e, acres.
APPROXIMATE ACREAGE
Meadow or 8rushland (Non-a~rlcultural) "~:~ ~ acres
Fore/ted ~ ~ ~ acres
Agricultural (Includes orchards, cropland, pasture, etc.) --C~ - acres
Wetland (Freshwater or tidal as per Articles 24, 25 of ECL) .-q*~' acres
Water Surface Area iT,S' ~' acres
Unvegetated (Rock. earth or fill) ~ ~ -- acres
Roads. buildings and other paved surfaces - ,o - acres
Other (Indicate type) --~, -' acres .
3. What is predominant sou type(s) on prolect slte~ 'L)t:q.A~D
a. SoU drainage: '~Well drained % of site
rlpoorly drained % of site
PRESENTLY
AFTER COMPCETION
-- ~) -- acres
-- ~5 -' acres
- 0 ~' acres
~, .-~ acres
~,5' .t acres
~ ~ ~ acres
b. If any agrlcultuf~al land ls iiwolv~,~d, how many acres of soil are classified within soll group I through 4 of the NYS
Land Classification System~' /~1~ acres. (See I NYCRR 370).
4. Are there bedrock outcroppings on project slteJ [~Yes ~No "
a. What is depth to bedrockt /~//A (in feet)
2
[~Rural (non-farm)
R~s t~b~rfl · E
r'lModerately well drained, % of site
5. ^pproxim,~/e percentage of probdsed project site with slopes: ~0-10% % F-I10-15% . %
[315% or greater %
6. Is project substantially contiguous,to~.or contain a building, site. or district, listed on the State or the National
Registers of Historic Places? DYe~ ~No
7. Is project substantially contiguous to a site listed on the Register of National Natural Landmarks? DYes
8. What is the depth of the Water table? /~/A (in feet)
9. Is site I;cated over a primary', principal, or sole source aquifer~ I::]Yes ~No
l0 Do hunlting, fishing or shell fishing opportunities presently exist in the proj~<~t area? ~.Yes I-INo ...
11. Does p~oject site contain any species of plant or;ani~nal life that is identified as th}eatened or endangered?
ID-lYes ~No According to ~IJ<AN, E. Lr~N R
Identify each species ·
· '12. Are there any unique or unusual land forms on the project site? (i.e., cliffs, dunes, other geological formations)
~Yes I~No Describe
13. Is the I~oject site presently used by the community or neighborhood as an open space' or recreation area?
It:lYes I~No . If yes, explain
14. Does the present site include scenic views known to'be importa~'t to the communlty~
gYes ~No "
15. Stream~within or contiguous to projec~ area:
4' Hame of Stream and name of River to which it Is tributary
16. Lakes, I~nds, wetland areas withla or'contiguous to project area:
a. Name HA~ LUAT'E-t~<- 'C,(~LI~ -, t"~.O~ t" EIb-I~ I~, b. Size (In acres) ,~ .,5'-'1"
17. Is the $1t~ served by existing p~b!te utilities? ~Yes r'lNo
a) If YesI does sufficient capacity exist to allow Connection? I-lyes I-INo
b) If Yest will improvements be necessary to allow connection? C:]..Yes.. I-INo ~l/a
18. Is the si~e located in an agricultural district certified pursuant to A~rlculture and Markets Law, Article 25-AA,
Section 3~)3 and 304~ r'lyes ~No
19. I~ the site located in or substantially conUguous to a. CrlUcal Er~';'Iro;nmental Area designated pursuant t6'Article 8
of the ECL. and 6 NYCRR 6177 I'lyes ~No ';
20. Has the slte ever been used for the .disposal of solid or hazardous wastesr I-Wes .l~No
B. Project Desoript;on'
1. Physical di~ensions and s. cale of project (fill In dimensions as appropriate)
a. Total ~:ontlguous acreage owned or controlled' by proJ.ect sponsor ~-t- acres.
b. Projec~ acreage to be developed: ~/A- · acre's Inltl'~lly,;.. ~/I,,/r acres ultimately.
c. Project acreage to remain undeveloped HI,'~ acres. '
d. Lengt~ of project, in miles: /'J I A' (If approprlate~:
e. 'If the IbroJect Is an expansion, Indicate percent of expansion proposed ,N/,~' %;
f. Humbelrof off-stre'et parking spaces existing N},~ ; proposed N,],~ .
g. Maxim~dm vehicular trips generated per hour AJ J~' · (upon' completion of project)~'
h. If reslc~entlal: Number and type of housing units:
One ,~mlly Two F~,mlly Muitlple Family Condominium
Initially v' .,,,
Ultimately,
I. Dimenslons (in feet) of largest proposed structure ~ height; width; ~ length.
J. Linear t~eet of frontage along a public thoroughfare3ProJect will occ, upy· is? fL
2. How much natural material (i.e., rock. earth, etc.) will be removed from the sitei'
3. Will disturbed areas be reclaimed~' OYes DNo ~N/A
a. If yes. for what intended purpose is the site being reclaimed?
b. Will topsoil be stockpiled for reclamation? OYes ONo
c. Will upper subsoil be stockpiled for reclamationS' OYes nNo
4. Nov~ many acres of vegetation (trees, shrubs, groun~ covers) will be removed1~rom site~ ' --O - ac~Fes.
$. will any mature forest (over 100 years old) or other locally-important vegetation be removed by this project~'
OYes illlNo
6. Il~ single phase project: Anticipated period of construction ON.Er months, (including demolition).
7. If multi-phased:
a. Total number of phases anticipated (SNE, (number).
b. Anticipated date of commencement phase 1 -%E.P'[' month ,-~ oO (
c. Approximate completion date of final phase month
d. Is phase 1 functionally dependent.on subsequent phases~' nyes I-INo
8. Will blasting occur during construction[. C]Yes ~No
9. Number of jobs generated: during construction · ~ ; after.project is complete
10. Number of jobs eliminated by this project -O-
11. Will project require relocation of any projects or facilities~ OYes ~No If' yes. explain
12. Is surface liquid waste disposal involved[. C3Yes I~No
a. if yes, indicate type of waste (sewage, Industrial, etc.) and amount
b. Name of water bod~, into which effluent will be discharged ,N/A
13. Is subsurface liquid waste disposal involved[. C]Yes [3No Type
'14. Will surface area of an exlsti,nj'.water body increase or decrease by proposalt' CIYes eaNo
Explain
15. Is project or any portion of project located in a 100 year flood plain? rlyes C)No
16. Will the project generate solid waste[.' C]Yes I~No
a. tf yes, what is the amount per month N'I~A tons
b. If yes, will an existing 'solid waste facility be used[. I'IYes
c. if yes, give name . MIA ; location N~
d. Will any wastes not go into a sewage dlspos,al system or into a sanitary landflll~ OYes ,~No
e. l/ Yes, explain NIA
tons/cubic yards
year, (including demolition).
year. ..
17. Will the project involve the disposal of solid wastel
a. If yes, what is the anticipated rate of disposal['
b. If yes, what is the anticipated site life(.
10. Will project use herbicides or pesticldes~' I-lyes
t-lyes I~No
/~/[,,~ tons/month,
years.
~No
19. will project routinely produce odors [more than one hour per day)? C]Yes ~No
20. Will project produce operating noi~e exceeding the local ambient noise levels[' C)Yes
21. Will project result In an Increase in energy use~' OYe~ ~No
If yes , indicate typ~(s)
22. If water supply is from wells, indicate pumping capacity i~]A gallons/minute.
23. Total anticipated water usage per day /~/A gallons/day.
24. Does prolect involve Local, State or Federal funding[, nYes ~i~No
If Yes. explain
~No
25: Approvals Required:
Submittal
Type Date
City, Town. V'Hlage Board DYes ~INo
City. To~vn, Village Planning Board OYes ,~No
City, To',~n Zoning 8oard nYes JJJNo
City. CoUnty Health Department OYes ~No
Other Lo~al Agencies ~Yes I-]No
Other Re~gional Agencies.' OYes ~No
State Agencies ~Yes ONo
Federal ,~gencies I~L"fes ONo
C. Zoning and Planning Information
1. Does proposed action !nvolve a planning or zoning decisionl C]Yes
· If Ye~, indicate decision required:
C3:~oning amendment Ozoning variance Ospecial use permit ' r'lsubdivislon Osite plan
Dr~ew/revision of master plan Oresourc'e management plan Ooth~r N
2. What ls the zoning classification(s)of the site? R.=~ Jb~=ktTI AL
3. What i~ the maximum potential development of the site if developed as permitted by the present zoning?
4. What i~ the proposed zoning of the slte?
5. What i~ the maximum potential development of the site if developed as permitted by the proposed zoning?
6. Is the l:~roposed action consistent with the recommended uses in adopted local land use plans? ~Yes ONo
7. What a;e the predominant land use(s) and zoning classifications within a ~4 mile radius of proposed action?
8. Is the I~roposed action compatible with adjoining/surrounding land uses within a ~,~ mile? I~lVes I-INo
g. If the p~oposed action is the subdivision of land; I~ow many lots are proposed?
a. JWhat is the minimum lot size proposed? AJJ~4
10. Will prbposed action require ~ny authorization(s) for the formation of sewer or water districts? OYes ~3No
11. Will th~ proposed action create a demand for any community provided services (recreation, education, police,
fire prc~tection)? OYes ~No
a. Jif yes, is existing capacity sufficient to handle projected demand? r'lYes ONo
12. Will th~ proposed action result In the generation of traffic significantly above present levels? OYes' J~No
a. If yes, is the existing road network adequate to handle the additional traffic? i-lYes
D. Informational Details
Attach ~ny additional information as ma? be needed to clarify your project. If there are or may be any adverse
impacts assok:lated with your proposal, please discuss such impacts and the measures which you propose to mitigate or
avoid them, J
E. Verification '-
I certlfyJthat the information provided above is true to the best of my knowledge.
Applicant/Sp)nsor Name 4' ~Z.~L,SLF.~ ~/~2I~E~ ,/./-,~,l.~T'~e.w'it,,l~ Date
Signature. ,~4x.n,O,y~.~__.. ~ Title "~."~O~(*IL~,J~ ,, [
If the action ; In the Coastal Area, and you are a slate agency, complete the Coastal Assessment Form before proceeding
with this a~e ~sment. ,.
Part 2--PROJECT IMPACTS AND THEIR MAGNITUDE .'
Responsibility of Lead Agency
General Informs(ion (Read Carefully)
· In completing the form the reviewer should be guided by the question: Have my responses and determinations been
reasonablel The reviewer is not expected to be an expert environmental analyst.
· The Ezamples provided are to assist the reviewer by showing types of impacts and wherever possible the threshold of
magnitude that would trigger a response in column 2. The examples are generally applicable throughout the State and
for most situations. But, foUr'any specific 'project or site other examples and/or lower thresholds may be appropriate '
for a Potential Large Impact response, thus requiring evaluation in Part 3.
· The impacts of each proiect, on each site, in each locality, will vary. Therefore, the examples are illustrative and
have been offered~as guidance. They do nqt constitute an exhaustive list of impacts and thresholds to answer each question.
· The number ol examples per question does not indicate the importance of each question.
· In identifying impacts, cgnsider long term, short term and cumlative effects.'
Instructions (Read carefully)
a. Answer eaoh of the 20 questions In PART 2. Answer Yes II there will be any Impact.
b. Maybe answers should be considered ss Yes answers.
c, If answering Yes to a question then check the ,,pproprlate box (column 1 or 2) to Indicate the potential size of the
Impact. If Impact threshold equals or exceeds any example provided, check column 2. If Impact will occur but
threshold Is lower than exa£nplo,'-,check column 1~ '
d. Iden(Ifylng that an Impact will be potentially la,;ge (oolu'mn 2) does nbt mean that It Is also necessarily significant.
Any large Impact must be evaluated In PART 3 to determine slgnlfloanco. Identifying an Impact In column 2 simply
asks that It be looked at further.
e. If reviewer has doubt about size of the Impact then consider the Impact as potenUally large and pr~eed to PART 3.
f. If a potentially large Impact cbeoksd In column 2 can be mitigated:by change(s) In the project to a small to moderate
impact, also check the Yes box In column 3. A No response indicates that such a reduction Is not possible. This
must be explained in Part 3.
IMPACT ON LAND ....
1. Will the proposed'action result in a physical change t.o the project site?
ONO OYES
Examples that would apply to column 2
· Any construction on slopes of 15% or greater, (15 f~ot tlse per 100 O
foot of length), or where the general slopes in the pro~ect area exceed
10%.
· Construction on land where the depth to the water table Is less than [~
3 feel
· Construction of paved parking area for 1,000 or more vehicles. O
· Construction on land where bedrock is exposed or generally'within O
3 feet of existing ground surface.
· Construction that wif[ continue for more than 1 year or involve more [~
than one phase or stage.
· Excavation for mining purposes that would remove more than 1,000 I-I
tons of natural material [i.e., rock or soil) per year.
' Construction or expansion of a sanitary landfill. [~
· Construction in a designa~ed floodway. []
· Other impacts C~
I 2 3
Small to Potential .Can Impact 8e
Moderate . Large Mitigated By
Impact ' Impact ~ Project Change
I--I I-lyes I'-INo
[] OYes nNo
rl OYes C]No
0 OYes ONo
0 OYes C]No
O Oyes E]No
[] OYes
["1 OYes ONo
OYes
2. Will there be an effect to any unique or unusual land forms found on
the site~' (i.e., cliffs, dunes, geological formations, etc.)ONO C~YES
· Specific land forms:.
Oyes ONo
6
IMPACT ON WATER
3 will proposed action affect any water body designated as protected~
(Under Articles 15.24.2S of the Environmental Conservation Law. ECL)
ONO OYES
Examples that would apply to column 2
· Developable area of site contains a protected water body.
· Dredging more than 100 cubic yards of material from channel of a
protectec stream.
· Extension of utility distribution facilities through a protectedwater body.
Construc{ion in a designated freshwater or tidal wetland.
~ Other impacts: /
1
Small to
Moderate
Impact
[]
O
[]
[]
O
2
Potential
Large
Impact
O
O
[]
[]
[]
3
Can Impact 8e
Mitigated By
Project Change
OYes []No
OYes ON•
[]Yes []No
l-lyes []No
[]Yes ~No
supply sys
· Proposed,
· Liquid effl
do not
· Proposed
day.
4. Will proposed action affect any non-protected existing or new body
of waterl~. ON• ' I~YES
Examplel' that would apply to column 2'
· A 10% in,crease or decrease in the surface area of any body of water
or more than a 10 acre increase or decrease.
· Construction of a body o! water that exceeds 10 acres of surface area.
· Other imlacts:
5. Will Prol~osed Action affect surface or groundwater
quality o~r quantity~' I-INO OYES
Examples~hat would apply to column 2
· Proposed ,Action will require a discharge permit.
· Proposed IAction requires use of a source of water that does not
have appi~val to serve proposed (project) action.
· Pr•posed ,~kction requires water supply from wells with greater than 45
gallons p~r minute pumping capacity.
· ConstructiOn or operation causing any contamination of a water
kction will adversely affect groundwater.
Jent will be conveyed off t~e site to facilities which presently
;t or have inadequate capacity.
~,ction would use water in excess of 20,000 gallons per
· Pr•posed ~ction will likely cause siltation or other discharge into an
existing bo~y of water to the extent that there will be an obvious visual
contrast to natural conditions.
· Proposed ~ctlon will require the storage of petroleum or chemical
products gteater than 1.100 gallons.
· Proposed ,~ction will allow residential uses in areas without water
and/or sewer services.
· Proposed A~ction locates commercial and/or industrial uses which may
require ne~ or expansion of existing waste treatment and/or storage
facilities. ] '
· Other imtacts:
6. Will proposed action alter drainage flow or patterns, or surface
water runc~ffl mN• OYES
Examples ~hat would apply to column 2
· Proposed AFtion would change flood water flows.
O
0
[]
[]
[]
[]
[]
[]
O
[]
[]
[]
O
[]
[]
[]
[]
[]
[]
[]
O
[]
O
[]
O
OYes ON•
OYes •No
[]Yes []No
[:]Yes ON•
[:]Yes •No
[:]Yes [:]No
[]Yes •No
OYes [:]No
[]Yes ~]No
[]Yes ~]No
OYes ON•
nyes I-IN•
OYes E~No
OYes ON•
OYes •No
OYes ON•
Proposed Action may cause substantial erosion.
Proposed Action is incompatible with existing drainage patterns.
Proposed Action will al{ow development in a designated floodway.
Other impacts:
1 2
Small to Potential
Moderate Large
Impact Impact
3
Can Impact Be
Mitigated By
Project Change
O O IDYes E]No
ID [] IDYes ONo
ID C] IDYes ONo
ID [] OYes OHo
IMPACT ON AIR
. Will proposed action affect air quality) nNO {:]YES
Examples that would apply to column 2
Proposed Action will induce 1,000 or more vehicle trips in any given
hour.
Proposed Act[on will result in the incineration of more than 1 ton of
refuse per hour.
Emission rate of total contaminants will exceed S lbs. per hour or a
heat source producing more than 10 million BTU's per hour·
Proposed action will allow an increase In the amount of land committed
to industrial use.
Proposed action will allow an increase in the density of industrial
development within existing industrial areas.
Other impacts:
O O' OYes ONo
O ID IDYes ONo
O O OYes IDNo
O n IDYes I--1No
O O OYes ONo
O El. IDYes ONo
IMPACT ON PLANTS AND ANIMALS
· Will Proposed Action affect any threatened or endangered
species;' FINO r'lyEs
Examples that would apply to column 2
Reduction of one or more species listed on the New York or Federal
list. using the site, over or near site ct found on the site.
Removal of any portion of a critical or slsnlficant wildlife habitat.
Application of pesticide or herbicide more than twice a year, other
than for agricultural purposes.
Other impacts:
OYes I-INo
OYes ONo
,. Will Proposed Action substantially affect non-threatened or
non-endangered species;.~ [:]NO [:]YES
Examples that would apply to column 2
' Proposed Action would substantially interfere with any resident or
migratow fish, shellfish or wildlife species.
Proposed Action requires the removal of more than 10 acres
of mature forest (over 100 years of age} or other locally important
vegetation.
IMPACT ON AGRICULTURAL LAND RESOURCES
0. Will the Proposed Actlor~ affect agricultural land resources)
ONO OYES
[:~arnpies that would apply to column ~'
The proposed action would sever, cross or limit access to agricultural
land (includes cropland, hayfields, pasture; vineyard, orchard, etc.}
n o IDYes r"JNo
[] n IDYes F'INo
8
· Construction activity would excavate or compact the soil profile of
agl'icultural land.
· Th~ proposed action would irreversibly convert more than 10 acres
of Jagricultural land or, if located in an Agricultural District. more
than 2.5 acres of agricultural land.
· Th~ proposed action would disrupt or prevent installation of agricultural
lan~ management systems (e.g., subsurface drain lines, outlet ditches,
stri~ cropping); or create a need for such measures (e.g. cause a farm
fiel~ to drain poorly due to increased runoff)
· Ot~er impacts:
1
Small to
Moderate
Impact
2
Potential
Large
Impact
3
Can Impacl
Mitigated
Project Chan~
[~Yes ~r~,,
[~]Yes ~N
E~Yes ~N,
[]Yes
IMPACT ON AESTHETIC RESOURCES
11. ~/iJJ proposed action affect aesthetic resources? CINO OYES
(If necessary, use the Visual EAF Addendum in Section 617.20,
~ppendix tR.)
E~amples that would apply to column 2
· Proposed land uses, or project components obviously different from
or id sharp contrasi to current surrounding land use patterns, whether
man-made or natural.
· Pro~:~sed land uses, or project components visible to users of
aesthetic resources which will eliminate or significantly reduce their
enjo~,ment of the aesthetic qualities of that resource.
· Project components that will result in the elimination or significant
screening of scenic views known to be important to the area.
· Othlr impacts:
IMP/~,CT ON HIST. ORIC AND ARCHAEOLOGICAL RESOURCES
12. Will Proposed Action impact any site or structure of historic, pre-
historic or paleontological importance? C]NO nyEs
Examples that would apply to column 2
* PropPed Action occurring wholly or partially within or substantially
contiguous to any facility or site listed on the State or National Register
of historic places.
· Any i~mpact to an archaeological site or fossil bed located within the
proje~:t site.
· Propclsed Action will occur in an area designated as sensitive for
archaeological sites on the NYS Site Inventory.
· Othe~ impacts:
[]
[]
[]
E]
[]
[]
[]
[]
[]
[]
[]
[]
[]Yes
[]Yes
[]Yes
[]Yes •N~
[]Yes [-']Nc
[]Yes I-'1 N~
[]Yes
[]Yes []N~
IMPACT ON OPEN SPACE AND RECREATION
13. WilI Propo~d Action affect the quantity or quality of existing or
futdre open spaces or recreational opportunities?
E[a~nples that would apply to column 2 C]NO dYE5
· The I~rmanent foreclosure of a future recreational opportunity,
· A ma or reduction of an open space Important to the community.
· Other impacts:
9 ~
[]
[]
[]
[]
[]
[]
[]Yes
[~Yes
[]Yes [~N~
IMPACT ON CRITICAL ENVfRONMENTAL AREAS
will Proposed Action impact the exceptional or unique character-
istics of a critical environmental area (CEA) established pursuant to
subdivision 6 NYCRR 617.14(g) ~ DNO DYES
List the environmental characteristics that caused the designation of
the CEA,
1
Small In
Moderate
Impact
2
Polar{rial
Large
Impact
3
Can Impact Be
Mitigaled By
Project Change
Examples that would apply to column 2
Proposed Action to locate within the CEA~
Proposed Action will result in a reduction in the quantity of the resource?
Proposed Action will result in a reduction in the quality of the resource['
Proposed Action will impact the use, function or enioyment of the
resource~
Other impacts:
[]
[]
[]
[]
[]
[]
~Yes
[]Yes F"l No
I-)Yes m"lNo
[~Yes ("]No
[]Yes [~No
IMPACT ON TRANSPORTATION
5 Will there be an effect to existing transportation systems['
· DNO DYES
Examples that would apply to column 2
Alteration of present patterns of mogement of people and/or goods.
Proposed Action wi{I result in major traffic problems.
Other impacts:
[]
OYes [~No
OYes []No
[Yes []No
IMPACT ON ENERGY
v,'ill proposed action affect the community's sources olr fuel or
ener§y supply:~ {]NO DYES
E~amples that would apply to column 2
' Proposed Action will cause a greater than 5% increase in th~ use of
any form of enerl[y in the'municipality.
, Proposed Action will require the creation or extension of an energy
transmission or supply system to serve more than SO single or two family
residences or to serve a major commercial or industrial use.
· Other impacts:
(~] Yes {]No
[]Yes {]No
[Yes
1 2
NOISE AND ODOR IMPACTS Small to Potential
17 will there be objectionable odors, noise, or vibration as a result Moderate Large
of the Proposed Acta'on? OHO DYES Impact Impact
EXamlPles that would apply to column 2
· Blasting within 1.500 feet of a hospital, school or other sensitive [] []
facility.
Odors/will occur routinely [more than one hour per day). O O
; Pr•posted Action will produce operating noise exceeding the local [] l'-I
ambient noise levels for noise outside of structures.
· Propo~ed Action will remove natural barriers that would act as a
noise !creen.
· Other impacts:
IMPACT ON PUBLIC HEALTH
18. Will Proposed Action affect public health and aafety~ .
CINO DYES '
Examples that would apply to column 2
· Proposed Action may cause a risk of explosion or release of hazardous
substances (i.e. oil, pesticides, chemicals, radiation, etc.) in the event of
accidect or upset conditions, or there may be a chronic Iow level
discharge or emission.
· Proposed Action may result in the burial of "hazardous wastes" in any
form e. toxic, poisonous, highly reactive, radioactive, irritating,
infectiou: etc.)
· St•rag( facilities for one million or more gallons of liquified natural
§as or ~,ther flammable liquids.
· Propos~ action may result in the excavation or other disturbance
within ,000 feet of a site used for the disposal of solid or. hazardous
waste.
· Other "npacts:
IMPACT ON GROWTH AND CHARAQTER
OF COMMUNITY OR NEIGHBORHOOD
19. Will ~roposedactJonaffectthecharacteroftheexlstlngcommunlb/~'
nNo aYES
Exam ,les that would apply to column 2
· The per nanent population of the city, town or village in which the
project J~ located b likely to grow by more than $%,
· The mu dclpal budget for capital expenditures or operating services
will increase by more than 5% per year as a result of this project.
· Proposed action will conflict with officially adopted plans or goals.
· Proposed action will cause a change in the density of land use.
· Proposed Action will replace or eliminate existing facilities, structures
or area~of historic importance to the community.
· Develol~ment will create a demand for additional community services
(e.g. schools, police and fire, etc.)
· Proposed Action will set an important precedent for futura'projects.
· Proposed Action wrll create or eliminate employment.
· Other mpacts:
3
Can Impact Be
Mitigated By
Project Change
OYes []No
[]Yes ~]No
[]Yes []No
[] O OYes []No
[] [] []Yes ~-INo
O O OYes I-IN•
[] [] OYes []No
[] [] OYes ON•
[] O OYes •NO
0 O OYes []No
O [] OYes •No
O O []Yes []No
O O OYes []No
[] [] OYes •No
O O OYes •No
[] [] OYes E]No
[] [] OYes •No
[] O OYes •No
O [] OYes []No
20. Is the
If any ac~
e, or is there likely to be, public controversy related to potential adverse environmental impacLSt
nH• nYES
m In Pall 2 Is Identified as i potential large Impact or Il you cam'tot determine the magnitude of Impact, proceed to Part
11
Part 3--EVALUATION OF THE IMPORTANCE OF IMPACTS
Responsibility of Lead Agency
'ar( 3 rnus~ be prepared if one or more impact(sD is considered to be potenlially large, even il' the impact(s) may b~
nitigated.
nstructlons
)iscuss the following for each impact identified in Column 2 of Part 2:
· Briefly describe the impact.
'.. Describe (if applicable) how the impact could be mitigated or reduced to a small to moderate impact by project change(s).
~.' Based on the information available, decide if it is reasonable to conclude that this impact is important.
To answer the question of importance, consider:
The probability of the impact occurring
The duration of the impact
ILS i~:reversibility, including permanently lost resources of value
Whether the impact can or will be controlled
The regional consequence of the impact
Its potential divergence from local needs and goals
· Whether· known ob)ections to'the proje~:t relate to this Impa~:t.
(Continue on attachments)
6 ] 7.20 SEQ R
Appendix B
State Environmental Quality Review
Visual EAF Addendum
This form .may be used to provide additional information relating to Question !] of Part 2 of
lhe Full EAF.
(To be completed by Lead Agency)
Distance Between
Visibility
1. Would the project be visible from:
· A parcel of land which is dedicated to and available
to the public for the use, enjoyment and appreciation
of natural or man-made scenic qualities?
· An overlook or parcel of land dedicated to public
observatlo, n, enjoyment and appr~clatlon of natural
or man-made scenic qualities7
· A site or structure listed on the Rational or State
Registers of Historic Places?
· State Parks?
· The State Forest Preserve?
· National Wildlife Refuges and state game refuges?
· National Natural Landmarks and other outstanding
natural features?
· National Park Service lands?
· Rivers designated as Hatlonal or State Wild, Scenic
or Recreational?
I. ~ny transportation corridor or' high expos.ute, such
as part of the Interstate System, or.Amtrak?
I. ^ governmentally established or designated Interstate
or Inter-county foot trail, or one formally proposed for
I establishment or designation?
I' A site, area, lake, reservoir or highway designated as
scenic?
I, Niunlclpal park, or designated open space?
Project and Resource (in Miles)
O.~A V4.V2 V2,3 3.5 5+
0 [] [] O []
[] [] [] []
[] [] [] 0 []
[] [] [] [] []
[] [] [] O' []
[] 0 [] [] []
0 [] [] [] []
[] [] [] [] []
[] [] 0 [] 0
[] [] [] [] []
[] 0 [] [] 0
[] [] [] [] []
County road?
State?
Local road?
Is the visibility of the project seasonal? (i.e., screened by; summer foliage, but visible during other
[]Yes F-IN•
~.re any of the resources checked In question I used by the public during the time of year
during which the project will be visible?
[]Yes OHo
1
DESCRIPTIOH OF EXISTIHQ VIS(JAL EHVIROHMEHT
4. From each item checked tn question i, check those which generally describe the
environment.
surrounding
Within
*V4 mile * ! mile
Essentially undeveloped [] []
Forested [] []
Agricultural [] []
Suburban residential [] []
Indus[rial [] []
Commercial [] []
Urban [] []
River, Lake, Pond [] []
Cliffs, Overlooks [] []
Designated Open Sp;ace [] []
Flat [] []
HIHy [] []
Mountainous [] []
Other [] []
HOTE.: add attachments as needed
5. Are there visually similar projects within:
· ~,5 mile I']Yes C~Ho
· 1 miles DYes E]Ho
'2 miles D-[yes [r-]Ho
'3 miles
· Distance from project site are provided for assistance. Substitute other distances as appropriate.
EXPOSURE
6. The annual number o[ viewers likely to observe the proposed proJect Is
HOTE: When user dat~ Is unavailable or unknown, use best estimate.
COhrTEXT
7. The situation or activity In which the viewers are engaged while viewing the proPOsed action is
' FREQUEHCY
Holidays/
^ctlvlty Dally Weekly Weekends Seasonally
Travel to and from work [] [] [] []
Involved in recreational activities [] [] [] []
Routine travel by residents [] [] [] []
At a residence [] [] [] []
At workslte [] [] [~ []
Other [] [] [] []
JUN I 9 2001
('631) 765-1892
P.O. l~ox 11~
SoW. boM. Ne~ Yc~ 11971
$0UTKOLD TO~'N
CONSER~rATION ADVISORY COD-'Ncrr.
At!the meeting of the Southold Town Conservation Advisory Council held Tuesday,
Jun. e 12, 2001, the following recommendation was made:
Moved by Scott H.ilary, seconded by Bill McDermott, it was .
RESOLVED to recommend to the Southold Town Board of Trustees DISAPPROVAL of
th~ Wetland Permit Application of OSCAR & BETH BLEVINS 104-5-1.2 to install a 4'X
31i2' catwalk, 4'X 12' dock, 3'X 16' ramp and 6'X 20' float Jn an "L" configuration secured
with two 2-pile dolphins to secure float.
640 Haywaters Dr., Cutchogue
fTr~e CAC recommends Disapproval because of the such as
gmentation of the natural corridors and aesthetics.
V(~te of Council: Ayes: All
MOtion Carried
.nega?~e,/.Lmpacts
Field h~spection 8/14/02
PUBLIC NOTICE
US Army ~orps
of Engineers
New York gistdct
Jacob K. Jab'its Federal Building
New York, r;rLY. 10278-0090
ATTN: Reg~Jlatory Branch
In replying rear to:
Public Notice Number:
Issue Date:
Expiration Date:
200!-00917-L2
January 2, 2002
February 1, 2002
To ~¢/hom It May Concern:
Th{ New York District, Corps of Engineers has received an application for a Department of the Army
per,nit pursuant to Section 10 of the Rivers and Harbors Act of 1899 (33 USC 403).
API~LICANT: Oscar and Beth Blevins
455 Mason Drive
I Cutchogue. NY 11935
ACTIVITY:
WATERWAY:
LO(~ATION:
Construct a Pier Assembly, Install a Fence
Haywaters Cove, Little Peconic Bay
Cntchogue, Town of Southold, Suffolk County, New York
/
A detailed description and plans of the applicant's activity are enclosed to assist in your review.
The deq:ision whether to issue a permit will be based on an evaluation of the probable impact, including
cumulative impacts, of the proposed activity on the public interest. That decision will reflect the national
concernI for both protection and utilization of important resources. The benefits which reasonably may be
expected to accrue from the proposal must be balanced against its reasonably foreseeable detriments. All factors
which rOay be relevant to the proposal will be considered including the cumulative effects thereof; among those
are conservation, economics, aesthetics, general envi/onmental concerns, wetlands, historical properties, fish
and-wik~life values, floodplain values, land use, navigation, shoreline erosion and accretion, recreation, water
supply'and conservation, water quality, energy needs, safety, food and fiber production, mineral needs,
consideration of property ownership and, in general the needs and welfare of the people.
The Corps of Engineers is soliciting comments from the public; Federal, state, and local agencies and officials;
Indian T~ibes; and other interested parties in order to consider and evaluate the impacts of this proposed activity.
Any conlments received will be considered by the Co~s of Engineers to determine whether to issue, modify,
condidofl or deny a permit for this proposal. To make this decision, comments are used to assess impacts on
endangered species, historic properties, water quality, general environmental effects, and the other public
interest factors listed above. Comments are used in preparation of an Environmemal Assessment and/or an
Environmental Impact Statement pursuant to the National Environmental Policy Act. Comments are also used
to determine the need for a public hearing and to determine the overall public interest of the proposed activity.
ALL COMMENTS REGARDING THE PERMIT APPLICATION MUST BE PREPARED IN WRITING AND
MAILED TO REACH THIS OFFICE BEFORE THE EXPIRATION DATE OF THIS NOTICE, otherwise,
it will be~lPresumed that there are no objections to the activity.
Any persgn ma)' request, in writing, before this public notice expires, that a public hearing be held to collect
informatiCn necessary to consider this application. Requests for public hearings shall state, with particularity,
the reaso~ why a public hearing should be held. It should be noted that information submitted by mail is
considere~t just as carefully in the permit decision process and bears the same weight as that furnished at a
public he~ring.
CENAN-OP-RE '
PUBLIC NOTICE NO. 2001-00917-L2
Our preliminary determination is that the activity for which authorization is sought herein is not likely to affect
any Federally endangered or threatened species or their critical habitat. However, pursuant to Section 7 of the
Endangered Species Act (16 USC 1531), the District Engineer is consulting with the appropriate Federal agency
to determine the presence of and potential impacts to listed species in the project area or their critical habitat.
The Magnuson-Stevens Fishery Conservation and Management Act, as amended by the Sustainable Fisheries
Act of 1996 (Public Law 104-267), requires all Federal agencies to consult with the National Marine Fisheries
Service (NMFS) on all actions, or proposed actions, permitted, funded, or undertaken by the agency, that may
adversely affect Essential Fish Habitat (EFH). The proposed work, fully described in the attached work
description, could cause the disruption of habitat for various lifestages of some EFH-designated species as a
result of minor turbidity generated during installation of piles. However, the District Engineer has made the
preliminary determination that the site-specific adverse effects are not likely to be substantial. Further
consultation with NMFS regarding EFH impacts and conservation recommendations is being conducted and will
be concluded prior to the final decision.
Based upon~ review o.f the latest published version of the National Register of Historic Places, there are no
known sites eligible for, or included in, the Register within the permit area. Presently unknown archeological,
scientific, prehistorical, or historical data may be lost by work accomplished under the required permit.
Pursuant to Section 307 (c) of the Coastal Zone Management Act of 1972 as amended [16'USC 1456 (c)], for
activities under consideration that are located within the coastal zone of a state which has a federally approved
coastal zone management program, the applicant has certified in the permit application that the activity complies
with, and will be conducted in a manner that is consistent with, the approved state coastal zone management
program. By this public notice, we are requesting the state's concurrence with, objection to, or waiver of the
applicant's certification. No permit decision will be made until one of these actions occur. For activities within
the coastal zone of New York State, the applicant's certification and accompanying information is available from
the Consistency Coordinator, New York State Department of State, Division of Coastal Resources and
Waterfront Revitalization, Coastal Zone Management Program, 41 State Street, Albany, New York 12231,
Telephone (518) 474-6000. Comments regarding the applicant's certification, and copies of any letters to this
office commenting upon this proposal, should be so addressed.
In addition to any required water quality certificate and coastal zone management program concurrence, the
applicant has obtained or requested the following governmental authorization for the activity under
-consideration:
New York State Department of Environmental Conservation permit
It is requested that you communicate the foregoing information concerning the activity to any persons known
by you to be interested and who did not receive a copy of this notice. If you have any questions concerning
this application, you may contact this office at (212) 264-3912 and ask for Craig Spitz.
For more information on New York District Corps of Engineers programs, visit our website at
http://www.nan.usace.army.mil
FOR THE DISTRICT ENGINEER:
Richard L. Tomer
Acting Chief, Regulatory Branch
Enclosures
CENAN-OP-RE
PUBLIC NOTICE NO. 2001-00917-L2
WORK DESCRIPTION
Th~ applicants', Oscar and Beth Blevins, have requested Department of the Army authorization
to Iconstruct a pier assembly and install a fence in Haywaters Cove, Little Peconic Bay at
Cuichogue, Town of Southold, Suffolk County, New York.
Th& work would involve the installation of a 3-foot by 130-foot pile-supported pier, to be
eleyated a mmunum of 3.5 feet above the grade of vegetated wetlands, a 4-foot by 12-foot pier,
a 3~-foot by 16-foot ramp, and a 6-foot by 20-foot float to be secured to two 2-pile dolphins.
Tho proposed project would also involve installation of approximately 375 linear feet of split rail
fence along the east property line, of which approximately 300 linear feet would traverse the
vegetated wetlands.
Th~ disruption of EFH may occur from a localized increase in turbidity during installation of
the ~>roposed structures, particularly driving of piles. However, this disturbance is expected to
be short term and fish populations would likely flee to adjacent areas that are not h~ing disturbed
and Iwhere feeding success will not be impacted. It is expected also that the pilir~gs would serve
as an attachment surface for invertebrates, thus supporting greater biological diversity at the
project slte.
The I stated purpose of the proposed work is to provide a mooring facility for the applicants'
· vess, ~l(s) and to prevent trespassers from entering the property.
3
Laud of Applic~t
TAX LOT (1000-104.00-05.00-001,002)
AREA -~ 2.5548 ACRES =
..111,~88 SOUARE FEET
VACANT PARCEL
GRASSY TIDAL HAR:~HLAND ."'~'"""'-""~
Proposec~: Install ~' x / 3 o' catwalk,
4' x 12' dock. 3' x 16' ramp and
6' x 20' floa~ in '%" coafiguration
with two 12-pi/e dplpkhas to secure'float
Sheet 1 of 2
DEPAR*
U~. ARMY El
JACOB K.
NEW'
~MENT OF THE ARMY
IG~NEE~ DI~'~ ~uCT, NEW YORK
IAVt'TS FEDERAL BU'd.D~G
'ORK, I~Y. 1O278-0O90
U.S. OFFICIAL MAIL'
PENALTY mt
PRIVATE : -- m~
U,E .oo -034:
125_1454 U.S. POSTAGE e
TOWN OF SOUTHOLD BOARD OF TRUSTEES
TOWN HALL 53095 MAIN ROAD
PO BOX 728
SOUT}{OLD NY 11971-0728
GEORGE E. PATAKI
STATE Of NEW YORK
DEPARTMENT OF STATE
4 I STATE STREET
ALBANY, NY 1223~-000I
March 26, 2002
Susan E. Long, Permits
P.O. Box 46
East Marion, NY 11939-0046
Re:
F-2001-0555
U.S. Army Corps of Engineers/New York District Permit
Application #001-00917-L2
Oscar & Beth Blevins - Install 130' X 3' Catwalk, 4' X 12' Dock,
3' X 16' Ramp, and a Perpendicular 6' X 20' Float
Cutchogue Harbor, To,,,rn of Southold, Suffolk County
NYS DEC #1-4738-00958/00003
General Concurrence - Proposal Modified To Be Consistent
Dear Ms.[ong:
The Department of State received additional information regarding your modified proposal on March 25, 2002. The
modified proposal involves relocating the proposal to Mason Drive, reducing the size of the catwalk assembly, and
reducing the length of the proposed fence so that the fence is only located above the line of MHW.
The Department of State has determined that this proposed activity, which has been modified to be consistent with
the New York Coastal Management Program, meets the Department's general consistency concurrence criteria.
Therefore, further review of the proposed activity by the Department of State and the Department's concurrence with
an individual consistency certification for it is not necessary.
When communicating with us regarding this matter, please contact William Feldhusen at (5 l 8) 474-4516 and refer
to our file #F-2001-0555.
SR:wf
COE/New York District - Craig Spitz
NYSDEC/Region I - John Pavacic
Town Trustees - Albert J. Kmpski Jr
Supervisor of Consistency Review and Analysis
New York Coastal Management Program
UUI
31
Land o~App/ican~
TAX LO]' (1000-104.00-05.00-001,00~')
AREA : ~.~4~{ ACRES
111,288 SOUARE FEET
VACANT PARCEL
GRASSY TIDAL HAREHLAND
/ Scale: 1": 50'
P.O. 3ox 46 ' ·
~ Mafio~ ~ 11939-004~ ~
(631)1477-3455
Land of Applicant
TAX LOT (1000-104.00-05.00-001.002>
AREA = 2.5548 ACRES =
111.288 SOUARE FEET
VACANT PARCEL
GRASSY TH)AL MARSHLAND
Scale: 1" =
Prep, red by:
Sus~ E. Long Permits
PropoSed: Install'~' x 130' catwalk,
4' x 12' dock, 3' x 16' r. mp and
6' x 20' float in "L" configuration
with tWo 2-pile dplphins to secure float
R~-V:
R~v: ~oI-
Sheet 1 of 2
~: N~TALL RPeRox.
Land of Applicant
TAX LOT (1000-104.00-05.00-001.00~>
AREA : i~.5548 ACRES :
~' 111,288 SQUARE FEET
VACANT PARCEL
~ GRASSY TIDAL MARSHLAND
~N~TALL ~P~I~X. 3frs
Scale: 1" = 50'
Sus~fi E. Long' Permits
P.O. Box 46
East Marion, NY 11939-0046
(631)147%3455
~tch~e, ~ 11935
Propot, ed: Install3' x 13 0' catwalL
4' x 12' dock, 3' x 16' ramp and
6' x 20' float i~ "L" coa~guration
with t~,o 2-pile dolphins to secure float
~?,~u_$7~q~ ~P~r a^~. ~,nc~
May 29f2001 ~ ""
Rg-V: IL o o[ Sheetlof2
640 Haywaters Drive /
Mason Drive Property
Cutchogue, NY 11935
631-734-2567 home
July 15, 2002
I Southold Town
I Board of Trustees
1153005 Route 25
[P.O. Box I 179
Southold. NY 11971-0959
Reference: Dock Permit for above property - end of Mason Drive
'[here is no specific timeframe for dock inspections that was noted in the Board of
Trustees letter of pemfi~. approval, therefore I contacted a Trustee staff member today to
make arrangements regarding an inspection. She suggested that I make the request in
¢/riting. Accordingly, please make arrangements for an inspection.
~[ind regards,
Oscar Blevins
-I
JUL ! ?
DEPARTMENT OF STATE
George E. Pataki
Randy A. Daniels
Secretary of State
Division of
Coastal Resources
41 State Street
AIban3; NY 12231-0001
November 1, 2001-
Susan E. Long, Permits
P.O. Box 46
East Mar on, NY 11939-0046
Dear Ms. Long:
NOVI9
F-2001-0555
U.S. Army Corps of Engineers/New York District Permit
Application
Oscar & Beth Blevins - Install 360' Catwalk Assembly
Cutchogne Harbor, Town of Southold, Suffolk Count)'
NYS DEC ttl-4738-00958/00003
Request for Necessary Information and Data
The Department of State received your letter regarding the above matter on November 1, 2001. Pursuant to 15
CFR Part 930.58, the following data and information is necessary to enable the Department of State to adequately
assess the coastal zone effects of this proposed activiw:
Without a clear documentation of the o,~mership and nature of the ownership of the involved property, the
:onsistency of the proposal cannot be evaluated. Please provide a copy of the survey for all of the property
involved in this proposal and the deed with a metes and bounds description to support the survey. The proposed
fence appears to be partially located within the wetland and thus may have potential significant negative impacts.
What is the location of MHW in relation to the end of Mason Drive?
?
The proposed walkxvay and dock would still cross over a hundred feet of vegetated wetlands that are an important
:omponent of the State designated Cutchoguc Harbor and Wetlands Significant Coastal Fish and Wildlife Habitat
narrative copy enclosed) and sensitive to the type of activity proposed. Please discuss alternatives that were
onsidered and consider whether this route minimizes habitat impact. Actual photo~aphs would assist in your
esponse concerning the consistency of the revised proposal with NYS CMP Policies #2, #7, and #19.
'lease call me at (5 l g) 474-4516 if you have any questioas and ~efcr to our file #F-2001-0555. Please provide
he information requested above as soon as possible. If this necessary information and data is not provided
vithin thirty days of the date of this letter, the Department of State may close the file regarding this proposed
ctivity. If the Department closes the file and does not concur with the consistency certification provided for
his proposed actwity, the consistency provisions of the federal Coastal Zone Management Act prohibit federal
ency authorization of the activity.
Sincerely.
William Feldhusen
Coastal Resources Specialist
Consistency Review Unit
COk,'NY District - Marc Helmann
NYS DEC/Region I - John Pavacic
Town Trustees - Albert J. Krupski Jr.
Albert Jl Krupski, President
James KbS, Vice-President
tenry Smith
,~cie Foster
[en Poliwoda
TO:
' Pie~
has
Town Hall
53095 Main Road
P.O. Box 1179
Southold, New York 11971
Telephone (516) 765-1892
Fax (516) 765-1823
BOARD OF TOV~N TRUSTEES
TOWN OF SOUTHOLD
,se be advised khat your application, dated .~; 211G;
been reviewed by this Board, at the regular meeting of
.~;~QP~ and the following action was taken:
__~)Application Approved (see belew}
(__) Application Denied (see below)
Application Tabled (see below)
If ~our application is approved as noted above, a permit fee is
now~due. Make check or money order payable to the Southold Town
TruStees. The fee is computed below according to the schedule
of rates as set forth in the instruction sheet.
The following fee must be paid within 90 days or re-application
~e~s will be necessary_.
COMPUTATION OF PERMIT FEES:
TO~AL FEES DUE: $
BY:
PRESIDENT, BOARD OF TRUSTEES
BOARD OF TRUSTEES
3 200
Land of Applicant
TAX L0T (1000-104.00-05.00-001,00~)
AREA = E'.5548 ACRES
Ill,;BSB SOUARE FEET
VACANT PARCEL
GRASSY TIDAL HARSHLAND
Scale: 1" = 50'
Pre[ ared by:
Sus~ n E. Long Permits ·
P.O Box 46
~ Marion, ~ 11939-0~6
(63] ~ 477-3455 ~,
,red for' ~
640 la~at~s ~
Cut, 119B ~
~o~e, ~
4,x 2', dock, 3' x 16' ra~ and ~
~ x ~0~ fl~t ~ '%" collation ]
~o 2 ~fle do~hi-~ to ~c~e float]
May 2~, 2001 She~
Alberl J. Krupski, President
James King, Vice-President
Henry Smith
Artie Poster
Ken Poliwoda
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-1366
ORIB, INAL
Office Use Only
.,~eaStat Erosion Permit Application
tland Permit Application ~'"Major __ Minor
Waiver/Amend ment/C h.anges
~'~ Received Application: ~]
--"~eceived Fee:$ 15~00~
,..~%mpleted Application/b 131~
Incomplete
SEQ~ Classification: ~~" ~' ~
Type I~Type II Unlisted/~~.
~AC Refe~al Sent: 51~
~ate of Inspection:
Receipt of CAC Repo~:
Lead Agency Determination: ~
Tec~ical Review:
~ublic Hearing Held: ~[0 [
Resolution:
Nane of Applicant
Address
Phone Number:(
Suffolk County Tax Map Number: 1000 - I0 c~ _ ,_5- - /, ,,2 ~,
Property Location: ¢ ~D ~qt,4-L] \4)A-T _~F~ _% 'D~, ]
(provide LILCO Pole #, distance to cross streets, and location)
AGENT:
(If'applicable)
'v.o ·
Address:
Phone:G-3/- ¥'7 7 - .~2.~,~_~-~-~,
~oard of Trustees Application
GENERAL DATA
A
Pi
IE
Pi
If
Pre
~nd Area (in square feet):
evious use of property:
tended use ofpropeny:
ior permits/approvals for site improvements:
Agency Date
/~ No prior permits/approvals for site improvements.
s any permit/approval ever been revoked or suspended~ by a governmental agency?
Yes
,es, provide explanation:
,,'4//4
iect Description (use attachments if necessary):
Board of Trustees Application
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose oftheproposedoperations: f;x.~.~ c~ec.b~-
Are
Pen
Cio:
edg,
Cio:
edg,
t of wetlands on lot: ~2, SS ~ 8'. square feet
ent coverage of lot: ot J~..ec ~ ~t2~/o,, 3e. xx~utndLJ~ ']. 31o%'
est distance between nearest existing structure and upland
~ of wetlands: feet
est distance between nearest proposed structure and upland
'. of wetlands: feet
Does the project involve excavation or filling?
///'/No Yes
If yes, how much material will be excavated? 14lA cubic yards
I
Ho~v much material will be filled? ~ I/Jr cubic yards
Detth of which material will be removed or deposited: 3/[.4
Pro ~osed slope throughout the area of operations:
Manner in which material will be removed or deposited:
feet
St~l
:ment of the effect, if any, on the wetlands and tidal waters of the town that may result by
~n of such proposed operations (use attachments if appropriate):
617.21
Appendix C
State Environmental Quality Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only
/
PART I--PROJECT INFORMATION (To be completed Dy Applicant or Project sponsor)
I1. ~PPLJCANT/SPONSOR C~/ ' 9. PROJECT NAME
SEC
5. IS PROPOSED ACTION:
I ~-~New [] Ex~an,t~
6, D'~SCRIBE PROJECT S.qlEFLY:
-I
7. AMOUNT OF ~NO AFFECTED:
Proposed: Install 4' x 312' catwalk,
4' x 12' dock, 3' x 16' ramp and
6' x 20' float in '%" coa~figuration
with two 2-pile dolphins to secure float
Ye$ ~ No If NO. describe briefly
W~NL ,=ROROSED ACT[ON COMPLY NITH ~XISTING ZONING OR OTHER g~(ISTING LAND US.: ~ESTRICTICNS?
[] Agriculture ~ Park/Poresb'Ooen soace r'~ O[~er .
10. DOES ACTION INVOLVE A PERMIT APPROVAL. OR le~e~'l~<3. NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL.
ST TE OR LOCAL)?
~ Yes [] NO if yes. list agency(s) anc~ germiUaoorovals
11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
~~es ~NO It yes. list agency name and pe~Juaoorovat
12. AS{~¢esRESULT,.~NoOF PROPOSED ACTION WILL
EX ST NG PERMIT/APPROVAL REQUIRE ~IODIFICATION~
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE EEST OF MY KNOWL=OGE
If the action is in the Coasl~al Area, and you are a state agency, complete the
Coastal Assessment Form before proceeding with this a~.,~es.3men~
OVER
1
NOTICE TO ADJACENT PROPERTY OWNER
BOARD OF TRUSTEES, TOWN OF SOUTHOLD
In the matter of applicant:
~ 5~_T~ DL~V{M SCTM#1000- I0~- ~-}.~
YOU ARE HEREBY GIVEN NOTICE:
1. That it is the intention of the undersigned to request
Permit from the Board of Trustees to:
2. That the property which is the subject of Environmental
Review.-/s located adjacent to your property and is described as
follows:
3. That the project which is subject to Environmental Review
under Chapters 32, 37, or 97 of the Town Code is open to public
comment on:~gN~ ~.~DO} You may contact the Trustees Office at
765-1892 or in writing.
The above referenced proposal is under review of the Board of
Trustees of the Town of Southold and does not reference any
other agency that might have to review same proposal.
OWNERS NAME:
ILING ADDRESS: c R0~ L ~
PHONE ~: g~l
Enc.: Copy of sketch or plan showing proposal for your
convenience.
Bid of Trustees Applicatio~
County of Suffolk
State of New York
.DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE
DESCRIBED PERMIT(S) AND THAT ALL STATEMEI~TS CONTAINED HEP~EIN ARE
TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL
WO~< 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 F_ARMLESS AND FREE FROM ~ AND ALL DAMAGES AND CLAIMS
ARISING UNDER OR BY VIRTUE OF SAID. PERMIT(S), IF GRANTED. IN
COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES,
THEIR AGENT(S) OR REPRESE/~TATIVES(S), TO ENTER Oh"DO MY PROPERTY
TO INSPECT THE PRF24ISES IN CONJUNCTION WITH REVIEW OF THIS
APPLICATION.
Signature
Notary Public
CLAIRE L~ GLEW
Notary Public, State of New York
NO. 01GL4879505
Qualified in Suffolk
A]be~ J. Krupsk/, Preeiden$
Jame~ King, Vice-President
I Hem-y Smith
Ken Poliwoda
E. Lon~
51~-477-345S
p.?
Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York li971-0959
Telephone (631) 765-1892
Fax (631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
BOkRD OF TRUSTEES: TOWN OF SOUTHOLD
Inlthe Matter of the Application
of
coO.TY oF SUFFOLK)
STATE OF NEW YORK)
AFFIDAVIT OF POSTING
being duly swor~, depose and say:
That on the I~'hda¥ of~-~--, 200~, I personally posted the
prQperty known as &~ ~A~tOATE~ % DW~ ~
by[placing the Board of Trdstees official poster where it can
eas[ily be seen, and that I have checked to be sure the poster
ha~ remained in place for eight days prior to the date of the
~l/c hearing. Date~heari.g noted thereon to be
~,F I!E~POR
C OWLEY MARIN
CONSTRUCTION
BULKHEADING ° DECKS ° DOCKS" BEACH S%MRS
TE L. E'~X 1601 ~ 4, Y-1772
11944 901-2706
~ ~, r~,~ O~ in ~-'~-~ ~.. authorize
Name address city, state
Frowley and Susan E. Long to act as agent in applying for the permits that are necessary for work to be done
property described above.
Signature and Date
q-. ,:,q / - o/
PROOF OF MAILING OF NOTICE
ATTACH CERTIFIED MAIL RECEIPTS
Name: Address:
CERTIFIED MAIL RECEIPT CERTIFIED MAIL
TotalPo~tage&F~es 0 ~'.~'q 06/1. r'-I (EndorsementRequi~j
/
nj
._~_&hI£..._~.:.....,5.~5.F-E.15I.E,..~. ........... rn .~]5_T__}ig_~ .F--.,-..~5~-,fl lY/ m
/
STATE OF NEW YORK
C?UNTY OF SUFFOLK
that on ~he II day of
U.S. Postal Se,'vlce
CERTIFIED MAIL RECEIPT
CUTCHOt.~, NY 119a5
0.~ UNIT Ilk 0939
Postage $
CerUfled Fee 1 · ~
Retum Receipt Fee
(Endorsement Required)
residing at
being duly sworn, deposes and says
,~[ , deponent
mgiled a true copy of the Notice set forth in the Board of
T~ustees Application, directed to each of the above named
persons at the addresses set opposite there respective names;
t%at the addresses set opposite the names of said persons are
t~e address of said persons as shown on the current assessment
r~ll of the Town of Southold; that said Notices were mailed at
t~e United States Post Office at ~A~T ~AEIb~ ~ , that
sgid Notices were mailed to each of said persons b~ (certified)
(~egistered) mail.
S;orn to before me this
d~y of 2~UN~_ ,~t~D
Notary P
NOTICE TO ADJACENT PROPERTY OWNER
BOARD OF TRUSTEES, TOWN OF SOUTHOLD
Inlthe matter of applicant:
/
YO~ ARE HEREBY GIVEN NOTICE:
SCTM#1000- ;O9- ~-1,~
2.
Rev
fol
3.
und
com
765
The
Tru
That it is the intention of the undersigned to request a
mit from the Board of Trustees to:
That the property which is the subject of Environmental
iew.-is located adjacent to your property and is described as
lows:
That the project which is subject to Environmental Review
er Chapters 32, 37, or 97 of the Town Code is open to public
~ent on:_~k~_~!.~d9OI You may contact the Trustees Office at
-1892 or in writing.
above referenced proposal is under review of the Board of
stees of the Town of Southold and does not reference any
oth.~r agency that might have to review same proposal.
OWN.".RS NAME: ~.~F_ ~ ]SET~ ~ ExJ/N~
ISING ADDRESS:c~0~L~ ~AR;~ ~o~E,
PHONE ~: G~I ~77- Bq C~~ ~
I lq 3q -oo~ b
Enc~: Copy of sketch or plan showing proposal for
your
convenience.
Land of Applicant
TAX LOT (1000-104.00-05.00-001.002)
AREA : 2.5548 ACRES
111,28~ SOUARE FEET
VACANT PARCEL
GRASSY TIIIAL NARSHLAND
~ Scale: 1": 50'
Susan E. Long Permits · -'~"~_~r~ sc,
P.O. Box 46 ' ~"~" re~~'s' ~e
~ M~ ~ 11939-0046 ~ ' %
(63 ll) 477-3455 % & ~
~t~o~c, ~ 1193~ ~ ~
Prop&seal: hst~ll. 4' x 312' catwalk,
4' x 12' dock, 3' x 16' r,m- ~md
6' x ~0' float in "L" confi~ration
with two 2-pile dolphins to secure float
May 21, 2001
Sheet 1 of 2
't~r°P°se~ ¢'k 3 , "~
-]un ~'1 01.1 03:SOp
Albert Jl Krupski, President
James King, Vice-President
teno, Smith
ie Fos~r
Ken Poliw~a
E. Lon~
518-477-3455
Town Hall
.53095 Route 25
P.O. Box 1179
Southold, New York 11971.0959
Telephone (631) 766-1892
Fax (631) 765-1366
BOAP~ OF TOWN TRUSTEES
TOWN OF SOUTHOLD
/
BOARD OF TRUSTEES: TOWN OF SOUTHOLD
In lthe Matter of the Application
of
COUNTY OF SUFFOLK)
STATE OF NEW YORK)
AFFIDAVIT OF POSTING
I, -~ARI C~U~LF~ , residing at (~F NFo
being duly sword, depose and say:
I IaTh of-,,%---U~E, %, I posted
· h~t on the day 200 pe~sona~ly the
prpperty known as &~5 ~A~ ~AT~ ~C
by placing the Board of Trdstees official poste~ where ir can
e~sily be seen, and that I have checked ~o be sure the poster
h~s remained in place for eight days prior to the date o~the
lic hearing. Date hearing noted thereon to be
Sworn
~{ day of ~HF-- 200 {
N~tary Public