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Home My WebLink AboutTR-6074A Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 6074A Date of Receipt of Application: February 3, 2005 Applicant: Mary Raynor SCTM#: 116-4-21 Project Location: 575 Beachwood Rd., Cutchogue Date of Resolut. ion/Issuance: February 16, 2005 Date of Expiration: February 16, 20e07 Reviewed by: Board of Trustees Project Description: To upgrade the existing septic system. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 97 of the Southold Town Code. The issuance of the Administrative Permit allows for the operations as indicated on the survey prepared by William R. Simmons, Jr. dated June 22, 1989 and amended by Henry Raynor on February 3, 2005. Special Conditions: None If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth in Chapter 97 of the Southold Town Code, a Wetland Permit will be required. This is not a determination from any other agency. Albert J. Krupski, Jr., President Board of Trustees Albert J. Krupski, President James King, Vice-President Artie Fester Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, Ne~v York 11971-0959 Telephone (631) 765-1892 Fax (631~ 765-,1,,~0~(~ [ BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only __Coastal Erosion Permit Application / _~7~tland Permit Application a/Administrative Permit A me ndment/T rans .feL/Erxt e nsio n ~lk~ce~vved Application: oq-/'.5/O~ ~l~eceived Fee:$ O?~O-- . . .~Completed Application Incomplete ___SEQRA Classification: Type I___Type I! Unlisted __Coordination:(date sent). CAC Referral Sent: -~5ate of Inspection:. Receipt of CAC Report: Lead Agency Determination:__ Technical Review: ,---P-ublic Hearing Held: o0-//~'/0 Resolution: FEB ,:, ~ 1 Board of Trustees Name of Applicant Address PhoneNumber:({:~} ,:~ ~ '- <g' ~-~"~} Suffolk County Tax Map Number: lO00- Prope.y Location: 5-95" (provide LILCO Pole #, distance to cross s~ects, and location) AGENT: (If applicable) Address: Phone: Board of Trustees Application Land Area (in gquare feet): Area Zoning: ~ - ~ Previous use of property: Intended use of property: GENERAL DATA 'R IE .~'1 bE ~ TAL Prior permits/approvals for site improvements: Date Agency __ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? ~ No Yes If yes, provide explanation: Project Description (use attachments if necessary): Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations:~ Area of wetlands on lot: [ )a~o square feet Percent coverage of lot: ~ % Closest distance between nearest existing structure and upland edge of wetlands: (~' feet Closest distance between nearest proposed structure and upland edge of wetlands: ,-~.~ feet Does the project involve excavation or filling? No ~j~ Yes If yes, how much material will be excavated? (~ cubic yards How much material will be filled? ~ ,~t~ cubic yards Depth of which material will be removed or deposited: C) Proposed slope throughout the area of operations: -~ ~ Manner in which material will be removed or deposited: feet Statement of the effect, if any, on the w~lands and tidal waters of the town that may result by reason of such proposed operations (use attachments if appropriate): I PROJECT ID NUMBER PART 1 - PROJECT INFORMATION 617.20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Ordy ( To be completed by Applicant or Project Sponsor) SEQR I APPLICANT / SPONSOR 2. PROJECT NAME 3 PROJECT LOCATION Municipality (~__.. k.t._'-~' ~__. {,.J~l~ ~ ~l-.{~ County 5 I,jC ~ ~bll~ 4. PRECISE LOCATION-'Street 'Adde-~ ~nd Road Intersections, Prominent landmark~ etc -o-r-provide map 5, IS PROPOSED ACTION: [] New 6. DESCRIBE PROJECT BRIEFLY ii-1 Expansion [~ModiflcalJon / alteration 7. AMOUNT OF LAND AFFECTED Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? [~Yes [] No If no, describe briefly: 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as rr~ny as apply.) [~Residential r'~lndustfial F~Comrnercial [~Agficulture ~]ParklFomst/OpenSpace ~]Other (describe) 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) r'~Yes [~o if yes, list agency name and permit / approval: 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? [-~lYes ~No If yes, list agency name and permit / approval: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? [2Y*s I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sponsor Name Date: Signature ~'~ ~ ~/~ If the action Is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment PART II - IMPACT ASSESSMENT (To be completed by Lead A~lenc¥) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.47 Jf yes, coordinate the review process and use the FULl. EAr. [~] Yes [~No B WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.67 If No, a negative declaration may be superseded by another involved agency. C. COULD ACTION RESULT IN ,~NY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C 1. Existing air quality, surface or groundwater quality or quantity, noise levels, exis§ng traffic pattem, sol~d waste production or disposa~ potenaal for erosion, drainage or fl~ding problems? Explain briefly: C4. A mmmuniW's existing plans or goals as officially adopted, or a change in us~ or in~nsi~ ~ use o~ land~ ethel natura~ msou~ce~ ~laffi "': .... , ' *'"' ' ' ' ....... C5. Gro~h subsequent development or related acti~t~es flkely to be mdu~ by the proposed acUon? Explarn D. ~LL THE PROJECT ~VE AN IMPACT ON THE ENVIRONMENTAL C~CTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA [C~? (If ~es, explain briefly: ~Yes ~No E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If ~'es explain: PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: F~reachadvemeeffectidenti~edabeve~determinewhetheritissubstantia~arge~important~r~therwisesigni~cant Each effect should be assessed in connection with its (al setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (el geographic scope; and (fl magnitude. If necessary, add attachments el' reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed, ff question d of part ii was checked yes, the determination of significance must evaluate the potential impact of the proposed action on the environ mental characteristics of the C EA. Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULl FAF and/or prepare a positive declaration. Check this box if you have determined, based on the informabon and analysis above and any supporting documentation, that the proposed actio~ WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessapJ, the reasons supp~arting thi~ determination. Name of Lead Agency Date Title of Responsible Officer print or Type Name of Responsible Officer in Lead Agency Signature of Responsible Officer in Lead Agency Signature of Preparer (If different from responsible officer) NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES~ TOWN OF SOUTHOLD In the matter of applicant: YOU ARE HEREBY GIVEN NOTICE: 1. That it is the intention of the undersigned to request a Permit fi'om the Board of Trustees 2. That the property which is the subject of Environmental Review is located adjacent to your property and is described as follows: ,.~t7 ~' i~ ~:2.~ IO~ ~ D That the project which is subject to Environmental Review under Chapters 32, 37, and/or 97 of the Toxvn Code is open to public comment on: . 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: ~(kCLULI ~'~. MAILING ADDRESS: ~ r'l ~ .~.~;-t~,~,c~l \'"~ f'-. Enc: Copy of sketch or plan showing proposal for your convenience. Board of Trustees Application Coumy of Suffolk State of New York BE1NG DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. Signature SWORN TO BEFORE ME THIS DAY OF ,20~ Notary Public APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM Thc Town of Southold's Code of Ethics omhibits conflicts of interest on thc hart of town officers and emvlovccs. Thc nuroose of this form is to orovide information which can alert thc town of nossiblc conflicts of interest and allow it to tekc whatever action is I~¢assarv to avoid same. (Last na~e, fa~t name, x~iital~ initial, unless you are ap~l);ing in the name of someone else or other entity, such as a company. If so, indicate the other person's or company's name,) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zoue Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other", name the activity.) Do you personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee o f the Town of Southold? "Relationship" includes by blood, marriage, or business interest "Business interest" means a business, including a partnership, in which the town officer or employee has even a partial ownership of (gr employment by) a corporation in which the town officer or employee owns mom than 5% of the shares. YES NO ,~ If you answered "YES", complete the balance of this form and date and sign where indicated. Name o f person employed by the Town of Southold Title or position of that person Describe the relatiouship between yourself (the applicant/agent/representative) and the town officer or employee. Either check the appmpeiate line A) through D) and/or describe in the space provided. The town officer or employee or his or her spouse, sibling, parent, or child is (check all that apply): A) tbe owner of greater than 5% of the .shares of the corporate stock of the appliclmt (when the applicant is a congoration); B) the legal or beneficial owner of any in.rest in a non-corporate entity (when th~ applicant is not a co~oration); ___C) an officer, director, partner, or employee of the applicant; or D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS I Submitted this Signature Print Name day of. 200 Dee. iS, 2004 Southold Town Trustees Main Road Southold, N.Y. 11971 DEC 1 5 L .; Southold Town Board of Trustees Dear Mr. Krupski, [ a~ beginning the process of rebuilding our cottage at 575 Beachwood Rd., Cutchogue, N.Y, Associated with the rebuild, ! am anticipating upgrading the septic system~ort our property. Enclosed sketch is where I believe our septic s~z~ctures are located; and want to farthest fi.om the wetlands on the other side of Beachwood Road. utilizes this area as it is the Please |et me know if there are any issues I should be addressing with our Town Trustees. ¥o. _u~s. truly, Mary R. Raynor ~