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Home My WebLink AboutTR-5986AAlbert J. Krtipski, 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.: 5986A Date of Receipt of Application: August 26, 2004 Applicant: Jeanne Whatmough SCTM#: 122-3-38 Project Location: 180 North Riley Ave., Mattituck Date of Resolution/Issuance: September 22, 2004 Date of Expiration: September 22, 2006 Reviewed by: Trustee Jim King Project Description: To remove and replace the existing cesspools. 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 attached survey prepared by John C. Ehlers last dated August 4, 2004. 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 ' S07,55'00"E N06°45'00"W 44.00' Riley Avenue) A=22.00' Albert J. t<rupski, President James King, Vice-President .~r tie Foster Ken Poliwoda Peg~' A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, NewYork 11971-0959 Telephone ~631t 765-1892 Fax ,1631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Pernfit Application Wetland Pemfit Application __ Major '¢,'aivee'Amendmeac Changes ece-~eved Application: 5~lO(,e _.-"P, eceived Fee:$ $[',~ --'C-ompleted Application~-)~(/ __Incomplete SEQIL& Classification: Type I __Type II Unlisted__ Coordination:(date senO ~.lff.~ C Referral ...,,l~te of InspectionL ~ __Receipt of CAC Report: Lead Agency Determination:___ - Technical Review: ~ ~ .. ~Held: t' ~;'~inor Od D/_t r~ Southotd Town Board of Trustees Name of Applicant Address /~0 / i -- Phone Number:~j}2/ Suffolk County Tax Map Number: 1000- PropertyLoc,ation: /~/.)'~/. Af~'~2q (provide LIL(~O Pole #, distance to crgss streets, and lo~:ation) AGENT: (If applicable) Address: Phone: Board of Trustees Applica~lon GENERAL DATA Land Area (in square feet): · ~,~ {'~,~,~2.- -~ / ~/~/70 Area Zoning: /'[f,~t d~Z/~..Lt~ d Previous use ofpropeay: ~d' ~ Intended use ofprope~y: ~ ~ ~ Prior permits/approvals for site improvements: .~ t~gency., I I /~d~.Date ___ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? ~o.__ Yes If yes, provide explanation: Project Description (use attachments if necessary):. Board of Trustees WETLAND/TRUSTEE LANDS APPLICATION DATA Area of wetlands on lot: ~z?~-~ _square feet Percent coverage of lot: "~ ff/..~ % Closest distance between nearest existing structure and upland edge of wetlands: ~- C' 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? 0~ cubic yards How much material will be filled? /C~ cubic yards Depth of which material will be removed or deposited: .5 feet Proposed slope throughout the area of operations: ./]J~, .ff[ Manner in which material will be removed or deposited: Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason of such proposed operations (use attachments if appropriate): Board of Trustees Ap~ 7//I COASTAL EROSION APPLICATION DATA Purposes of proposed activity: Are wetlands present within 100 feet of the proposed activity? No L- ,~ Yes Does the project involve excawation or filling? No /Yes If Yes, how much material will be exca~;at.e,d? How much material will be filled? Manner in which material will be removed or deposited: (cubic yards) (cubic yards) Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) PROJECT ID NUMBER PART 1 o PROJECT INFORMATION 617.20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only ( To be completed by Applicant or Project Sponsor') 1. APPLICANT ! SPONSOR 3.PROJECT LOCATION Municipality ~ (~-~/ SEQR 2. PROJECT NAME County .~/~/~ 4. PRECISE L~CATION: S,ieet Ad,ess and.Road Intersections. Prominent land~rkS/~r)C.~¢/~vi~..a~ 5. IS PROPOSED ACTION ~ New ~ Expansion ~dification / alteration DESCRIBE PROJECT BRIEFLY 7. AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 6. WILL ROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? 9 W T IS PRESENT LAND USE IN VICINITY PROJECT? (Choose as many as apply.) ~Residential r~lr~dustrial E~]Commercial OF E~Agriculture E]Park/Forest/OpenSpace E~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 ~4~ If yes, list agency name and permit / approval: 11. DOES ANY, JY ASP~EASP CT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? E~Yes E~ If yes, list agency name and permit / approval: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? {~Yes [~No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sponsor Name Date: 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 o IMPACT ASSESSMENT (To be completed by Lead A~lenc¥) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? It yes, coordinate the review process and use the FULL EAF. B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617 67 I[ No, a negative declaration may be superseded by another involved agency. C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING' (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing Iralflc pa[~ern, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain bdefly: D2 Ae~thefi¢, agricufluml, archaeological, fiistodc, or other natural or cultural resources; or community or naighborhood charactor? ~.plain bhefly: C3. C4. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: I A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other naturat resources? Explain briefly. I C5 Growth, subsequent development, or related activilies likely to be induced by the proposed action? Explain briefly: C6. Long term, short term, cumulative, or other effects not identified in C1-C57 Explain briefly: C?. Other impa~ts (includin9 changes in use of either ({u~'ntit,/orr t~p~ o~ e~err~)'? i::xplain bdefi),: D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA {CEA1? __ [] Yes []No ~ Iifx'es'explain bdefl}~: LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes explain: PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: F~reachadversee~ectidenti~ed~b~ve~determ~newhetheritissubstantia~~~arge'imp~rtant~r~therwisesignificant~ Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (0 magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked yes, the determination of significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. Check this box g you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration, Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessar,/, the reasons supporting this determination. Name of Lead Agency Date Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer (It different from responsible officer) Board of Trustees Applica~on 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 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 1N THIS APPLICATION .&ND AS MAY BE APPROVED BY THE SOUTHOLD IOWN 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 IHIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT IHE PREMISES IN CONJUNCTION WITH REVIISW OF THIS APPLICATION. Signature co SWORN TO BEFORE ME THIS .: DAY OF__ · ' Notary Publ~_c_~.) MELANIE DOROSKI #OTARY PUBUC, State of Ne~ Y~I[ No. 01004634870 Qualified in Suffolk Court/ of Trustees Ap~ AU'I~ORIZATiON (where the applicant is not the owner) (print owner of property) residing at (mailing address) do hereby authorize (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. (Owner's signature) 8 APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics t~rohibits conflicts of interest on the t~art of town officers and emolovees. The nuranse of this form is to orovide information which can alert the town of anssible conflicts of interest and allow it to take whatever action is nee~ssarv to avoid same. 06ast name, first name, qliddle initial, unless you ~ app~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 Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other Of"Other". name the activin..) Do you personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee of 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 (or employment by} a corporation in which the town officer or employee owns more than 5% of the shares. YES NO '%~ If you ansxxered "YES". complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself (the applicantJagent/mprasentative) and the town officer or employee. Either check the appmprime 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) the owner of greater than 5% of the shares of the corporate stock of the applic0nt (when the applicant is a corporation); B) the legal or beneficial owner of any interest in a non-corporate entity (when the applicant is not a corporation); __.C) an officer, director, parmei', or employee of the applicant; or __D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS I /d