HomeMy WebLinkAboutTR-6333A
.
James F. King, President
Jill M. Doherty, Vice-President
Peggy A. Dickerson
Dave Bergen
.
Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-6641
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Permit No.: 6333A
Date of Receipt of Application: April 13, 2006
Applicant: Ronald and Eileen Breuer
SCTM#: 116-4-3.1
Project Location: 100 Dean Drive, Cutchogue
Date of Resolution/Issuance: April 19, 2006
Date of Expiration: April 19, 2008
Reviewed by: Board of Trustees
Project Description: Re-vegetate the buffer area 50' x 36' in accordance
with the planting plan submitted, with the addition of high marsh wetland
grasses (Spikegrass: Distichlis spicata and Salt marsh hay: Spartina
patens) planted landward of the existing wetland vegetation, install shed
24' from the buffer area, a parking area 28' from the buffer and all as
depicted on the survey prepared by Joseph Ingegno and received April 13,
2006 by the Board of Trustees.
Findings: The project meets all the requirements for issuance of an
Administrative Permit set forth by the Board of Trustees.
Special Conditions: Final inspection
If the proposed activities do not meet the requirements for issuance of an
Administrative Permit set forth by the Board of Trustees, a Wetland Permit will be
required.
This is not a determination from any other agency.
r&<~
James F. King, Vice-President
Board of Trustees
.
James F. King, President
Jill M. Doherty, Vice-President
Peggy A. Dickerson
Dave Bergen
John Holzapfel
.
Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-6641
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES
72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN
APPOINTMENT FOR A PRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO
SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE
PERMIT.
INSPECTION SCHEDULE
Pre-construction, hay bale line
15t day of construction
-7 y, constructed
~ Project complete, compliance inspection.
.
.
James F. King, President
Jill M. Doherty, Vice-President
Peggy A. Dickerson
Dave Bergen
John Holzapfel
Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-6641
TO:
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
~J.J f;)leV\~
Please be advised that your application dated
reviewed by this Board at the regular meeting of
following action was taken:
1..(//3101,
'-Illq/Ob
,
has been
and the
L-~ Application Approved (see below)
L-) Application Denied (see below)
L-) Application Tabled (see below)
If your 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 Chapter 97 of the Southold Town
Code.
The following fee must be paid within 90 days or re-application fees will be necessary.
l.>iJ0
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COMPUTATION OF PERMIT FEES: ~
-h "" (
TOTAL FEES DUE: $ )D r.,
BY: James F. King, President
Board of Trustees
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A - 3281
Town 01 Southold
Sullolk County, NY
The People of the State of New York .s.
FIRST NAME
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MIDDLE INITIAL
LAST N~ (DEFENDANT)
STREJr A~~E~ ve r
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APT. NO.
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UCENSE OR REGISTRATION NUMBER
OPERATOR
OWNS VEHICLE
DYES DNO
DATE EXPIRES
PLATE NO
STATE PLATE TYPE
ON,V DN,J o N,Y DN,J 0 DPASS o COMM 0
VEHICLE MAKE 0
D BUICK 0 eN'" 0 CADILLAC 0
0 FOOD 0 OLD' 0 PLYM
D TOYOTA D VOLKS D
600Y D ,,~ 0 'O~ D '" D Mn
mE 0 TRUCK C TRAILER D ,^N D
VINNUMBER
DODGE
PONTIAC
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THE PERSON DESCRIBED ABOVE IS CHARGED AS FOLLOWS
PLAC:.~F ?,?CURRENCEj '-J
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-pA~FOF~NSE AM
:5' ~';J(._ 0
VlOLAllON OF SECTION sueD
.A?T~PECIFY)
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o SPEEDING
MPHINA
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TIME PM
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OTHER OFFENSE
MISDEMEANOR 0
FACiUAL PART (NOT FOR TYS)
THE ABOVE NAMED OEFENDANT DID ON THE STATED DATE, TlME AND PLACE
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The Foregoing IS based on (pe"'Or>a1 knowladge) andlor (inIormation 8. beliefj,lhe"""",e t>eingthQaltaC hed.womdeposition(.)oI
dated
PARKING SCHEDULED FINE $
CONTACT COURT 0
THE PERSON DESCRIBED ABOVE IS SUMMONED TO APPEAR AT !.; ~~) ",
SOUTHOLD TOWN JUsnce COURT, $309S ROUTE jlS, SOUTHOLD, NY 11971
ClATEOF~flANCE(I>IOTFOAT\I8J
ON
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FAlSE STATEMENTS HEREIN ARE PUNlSKolSLEAS A CIJISS A MISDEMEANOR PURSUANT TO SECTION2tO.45 OF THE PL,N,V,$
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BADGE"
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Town of Southold
Suffolk County, NY
A - 3281
The People ot the State of New York .s.
lAST ~ (DEFeNOANl) FIRST NAME <I
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CIlY ~ STATE
DI')< -:11$ ..v Y-
UCENSE OR REGIS'n'lATlON NUMBER
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STATE
MIDDLE INmAL
APT. NO.
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PLATE NO.
DATE EXPIRES
STATE Pl.ATETYPE
o N.Y. o N.J. o N.Y. ON.J. 0 OPASS o COMM 0
VEHICLE MAKE
0 BUICK 0 OHEV 0 CADIllAC
0 FORO 0 OI.OS 0 PCYM
0 TOYOTA 0 VOU<S 0
,ooy 0 'OR 0 'OR 0 'us 0 MCV
TYPE 0 T''''01< 0 _LE' 0 VAN 0
V1N NUMBER
o DODGE
o POtIT1AC
o s.w.
MISDEMEANOR 0
FACTUAL PART (NOT FOR 1'VB)
STATED DATE. TlME AND PLACE
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TheFONogoingis~on(P&r.Ol'\!llknowll<lg.)and/Or(InIo~.>M&.bel~l).h.ourcebelngthl&ttachlcllWOmo.pc*ilion(l)01
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PARKING SCttEOULED FINE $ CONTACT COURT 0
THE PERSON DESCRIBED ABOVE IS SUMMONED TO APPEAR AT ~ 1I...Ie(
SOUTHOLD TOWN JU9TlCE COURT, uoee ROUTE 215, SOOTHOLD, NY 11171 00 tI'7
I ..n"..""".:-"o<rn"'. I l"'. 7
ON Ar~..1 Ul;;..~" AT f"9-
FALSE STATEMENTS HEREIN AI'tE PUNISHABLE AS A CLASS A MISDEMEANOR PURSUANT TO SECTION210.4S OF THE P~N,Y,S.
DATE
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SADGE
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1. Agency !tI New York $t~te. . . .. 3.0RI 14 l(7Orig b.~:~N~~O 16. Incident No.
e -,,>,,+i... ?;;"LV . INCIDENT AEPoRT 1 NY 0 <"'-S- DSupp
7. Report Day 1~~t'l /~ lot:.I';qq~' ~Gbc~l1'~" L 10. Day 1111. Date 12. Time o~~rred~..ls~~Y l~jDatellY 10(.. ~~~~
(.,4+ OR/From, Ii I 'f Il' -01'70
.., '.-l 0 ~ I 0"
.. 16. Incident Type 17. Business Name 18. Weapon(s) A
Ii 70""",,- <:.o.L u :..I...i: D"'-
19. Incident Address (Street No., Street Name, Bldg. No., Apt. No.) 1~20. City, State, Zip (0 CUT DV) 12~;a;5e B.
/00 ~ C_,J,t,Ju, 7w.....
.1 ~"OMjN<; "UB' L/el. DEll 'AU "'1 ;<:.:: Nl"'~:q~ OFFeNsE . .. .CISI 23. No. of Victims C
1 rc:: 91~ ~O - !.vo I~..._.'l-
I 2 24. No. 01 Suspects D.
3 I...n.
~5; PerSij~:ryp~; ~~_~#~~~t: PJ';iO-<?t~~-: ~t;='~'!:$biJJhtei\'~~' ':PR ~ Fel'S~,fleportti't9:'- WI~i(n~~-_ ';Nfj;llot, tn!e,;Y;ewed VI'",Victlm:',126. Victim also complainant DY ON E
I 'iYPt1 ~O JIA~Ir{~~; FIRst,t.lltibl~, TIT!-~! '., ,,, . ~f$l# No:,'$T~ ~Me;'a~(Nq.; ~PT: NO., CiTY, '!TATt. ZIP,' .' ':~ilieP/1df1$;~q.; ..
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27. Data of Birth 128. Age 29. Sex 130. Race 131. Ethnic 132. Handicap 33. Residence Status o Temp Rss. - Foreign Net. J.
I,':' I I OM OF []Whila o Btack o Other 0 Hispanic 0 Unk. DYes o Residenl o Tourisl o Student o Other
DU [] Indian o Asisn DUnk. 0 Non-Hispanic DNo o Commuter o Military o Homefess DUnk.
34:'i~,:/(~O'135. Name (Last, First, Middle) 36. Alias/Nickname/Maiden Name (Last. First, Middle) 137. Apparent Condition K,
o Impaired Drugs 0 Mental Dis. 0 Unk.
o Impaired Alec Olnj/UI 0 App Norm
38. Address (Street No., Street Name, Bldg. No., Apt. No.. City, State, Zip) j39. Phone No 40. Social Security No. L.
o Home
o Work
41. Date of Birth 142. Age 43. Sex 144. Race 145. Ethnic 146. Skin 147.occupationL!',,: M.
/.1:' I OM OF []While o Black o Other 0 Hispanic 0 Unk. OUght 0 Dark 0 Unk.
o U [] Indian o Asian DUnk. [] Non-Hispanic o Medium [] Other
48. Height 49. Weight 1 ~O\.:~i') I ~'N~'r"1 52. Glasses I ia. Build 154. Employer/School [ 55. Address N.
I. [] Yes 0 Contacts [] Small [] Large
, o No [] Medium I!lliIIri
56. Scars/Marks/Tattoos (Describe) 57. Misc.
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2
IAl3i l S A:,:rl iAF\! i- il 'ABU..:
3
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4
59. Vehicle 60. license Plate No. 161 Slate 62. Exp. Yr, I 63. Plate Type 164. Value lC. =
Status FunD
.. .. Partial 0 5
65. Veh. Yr, 66. Make 167. Model 168. Style 169. VIN. =
6
r \, 70. Color(s) 171 Towed By: 172. Vehicle Notes 7
., To: =
73, B
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"W' 74. Inquiries (Check all that apply) 75. NYSPIN Message No. i 76. Complainant Signature a:' ..
! DDMV o Want/Warrant o Scofflaw
DCrim. History o Stolen Property o Other use -cover
ll!' sheet
77.2ffice'c"r'ICCI"d;jCk) 17";;_ 79, Supervisor's Signature (Include Rank) 180. ID No. 84/
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III 5
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~ 81. Statils 'lI0per;~J Closed (If Closed, check box below) 1-1 Unfounded ~;St"~; 1.01:: 183. Notiti,dTDT / 01
'J VICI. Refused to Coop.J Arrest ' Pros, Declined I J Warrant Advised
~ DCBI i:J Juv. - No Custody CJ Arrest- Juv L Offender Dead DExtrad. Declin o Unknown Pages
DCJS-320S (10/03)
"FALSE STATEMENTS ARE PUNISHABLE AS A CRIME, PURSUANT TO THE NEW YORK STATE PENAL LAW.
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New York State Depal,ent of Environmental cons!ation
Division of Fish, Wildlife & Marine Resources, Region One
Marine Habitat Protection
Buildin9 40 - SUNY, Stony Brook, New York 11790-2356
Phone: (631) 444-0295 FAX: (631) 444-0297
3/21/2006
Notice of Violation
Ronald Breuer
100 Dean Drive
Cutchogue, NY 11935-2505
Date of Violation: On or before 3/1412006
Location of Violation: 100 Dean Drive, Cutchogue
Tax Map ID #
Permit # (if applicable):
Dear Sir/Madam:
Records of this Department indicate that you are in violation of the Environmental
Conservation Law (ECL):
D
D
D
D
D
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Article 15, Protection of Navigable Waters
Section 15-0505.1 6NYCRR Part 608
Article 15, Wild, Scenic and Recreational Rivers Act
Section 15-2709.2 6NYCRR Part 666
Article 13, Protection of Marine Waters
Section 13-0345.2
Article 17, Prohibition Against Pollution of Marine Waters
Section 17-0503.2
Article 24, Freshwater Wetlands Act
Section 24-0701.1 6NYCRR Part 662
Article 25, Tidal Wetlands Act
Section 25-0401.1 6NYCRR Part 661
~
-...
~
Denise Sheehan
Commissioner
Page 1.
.
...
In that you caused, or permitted _e caused: Clearing of vegetation an!cement of fill in an area
of IOO'x50' and a 30'xI5' parking area in adjacent area to tidal wetland without permit to do so.
Placement of fill in a high marsh area of 25'x48' and placement soild waste in high marsh area of
lO'xIO' in a New York State Regulted Tidal Wetland without the benefit of a permit to do so.
Contravention of this/these Article(s) of the ECL is a violation and/or a misdemeanor
punishable by a fine of no more than $10,000 per violation. Penalties may be assessed for each day
that the violation continues.
Please be further advised that violations of the ECL which are not resolved may be the subject
of an administrative hearing pursuant to Title 6 of the Official Compilation of Codes, Rules &
Regulations of the State of New York (6NYCRR, Part 622).
You are hereby advised to cease your operation at the referenced location immediately.
Please contact the following office within thirty (30) days of receipt of this letter, so that we
may attempt to resolve this matter. Failure to contact this office within this time period will result in
this matter being referred to the Department's Regional Attorney for further enforcement action.
To schedule an appointment for a compliance conference in this matter, please contact
The Compliance Unit at (631) 444-0295. Compliance conferences will be held with the Regional
Manager of Marine Habitat Protection.
Very truly yours,
~
~-r-
Charles T. Hamilton
Regional Supervisor of
Natural Resources
Stony Brook
cc: Jimmy King - Town of Southold Trustees
Certified Mail # 7005 182000029464 1603
NOV# 06CTH94
Page 2.
m~rch 15,2006 Field Inspeln
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Project Description (with attachments survey plan, Exhibits A &'8)
We will replenish the buffer area 50' x 36' with 120 bush blueberry plants
(Vacciunum angustifolium) staggered at 4 ft intervals (OC). Sow wild flower seeds
between bushes to also assist in reducing soil erosion, A mulch path 6 ft wide 6" in
height would run the length with two bird feeders on the side 25 ft apart (OC). (see
survey map plan & exhibit A).
The edge of the 50 ft buffer zone for 150 ft in back of the house. would
plant 6 Eastern Red cedar trees (Juniperus virginianus) 4' high with (30) Northern
Bayberry plants (Myrica pensylvanica) in-between the trees. A mulch buffer zone 4 ft
wide and 8" high would run at the base of the these plantings, For wild life 3 bird
feeders would be installed approximately 40' apart. Here too wild flower seeds would
be sowed behind the bushes to also assist in reducing soil erosion.
After the 50 ft buffer zone zoysia seed ( 25 Ibs) would be planted to retain
the soil. To insure growth, 30 yards of high quality screened top soil would be.used in
this area.
A tool shed (exhibit B) would be placed in the upper wood land, 24 feet
from the buffer zone, 39 ft from driveway and 46 ft from curb. A parking space for the
RV would be established adjacent to the curb, 28 feet from the buffer zone. Red cedar
(Juniperus virginianus) 14 would placed 10 ft apart (OC) on three sides of this space
(see survey map plan ),
All dead branches piled on ground would be chipped and used for mulch. Only organic
fertilizer will be used on vegetation. An irrigation system will be used to support the
growth of the plantings.
rX~,b,-r A
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So { "36" ;:::.. / is ()U ~(n~H t:~ s<0::: /:; 0 0 ":1 (
I 20 ~~
Albert tJ. Krupski, President
James King, Vice-President
Artie Foster
Ken Poliwoda
Peggy A. Dickerson
. . (j~
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~~ ~r SOUlf;a?c-.~
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Town Hall
53095 Route 25
P.O. Box 1179
Southold, Now York 11971-0959
..
Telephone (631) 765-1892
Fax (631) 765-6641
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Office Use Only
_Coastal Erosion Permit Applicat~
___Wetland Permit Application Administrative PCl'lnit
Amendment/Transfer/Extension
3eceived Application: IfIG/tic
,,-Received Fee:$
;: Completed Application r. :l,7l51,;;
~Incomplete
_SEQRA Classification:
Type I______Type 1I____Unlisted._
__Coordillation:(date sent)~~_~
LWRP Consistency Assessment Porm
=CAC Referral Sent:__~_ ------
~Date of Inspcction:______
____Receipt ofCAC Report:______
_Lead Agency Determination:___~,~_
Technical Review:
<;Public Hearing Held:~1J!flJ., --
_Resolutioll:~.__.___~..._
,--
APR 1 '1 1")'1,.....".....
~ L';_'O
Name of Applicant
'Ro."",\cl -I Z, lee'"
~'relA(('v
Address
IOeJ
1)V\1'\. PI{' \~~ C.l.dc"'<l~1 ,flY //935
Phone Numbcr:(()~~ _} S 4 -1_$ J 5, tYJ !c-3 /) if 9 'J - 7 '-I (g
j/b- ()~-'-LI
/DD DR!;"- "b.....''''..... C:r,.:tch"'SlAIJAJ'f 1/'155
Suffolk County Tax Map Number: 1 000 -
Property Location:
7/A
.. . 'lI::t(proYide LILCOPo!e #,_distancetocross streets, and location)
. AGENT: A / If
^i ________
(If applicable)
Address:
Phone:
te S C <A L -- <3 (VVV' ,u.J
P,5-1--<..1,\., 5r'-""~
(Srllc,~1
~ ~rd of Trustees APPli~io'"
GENERAL DATA
Land Area (in square feet)
J,e; ,fJ~
Area Zoning: "-K' 'l. S' Ide YI f,ll I
Previous use of properly: -""K e ~ " de", 1- -, 'i J
Intended use of property: K.R s: ,~ll~fl '1 L
Prior permits/approvals for site improvements:
Agency
Date
;11 / fJ
.
L No prior permits/approvals lor site improvements,
Has any permit/approval ever been revoked or suspen}led by a governmental agency'!
V No Yes
--
If yes, provide explanation:,.
1/ /I!'
Project Description (use attachments ifnecessary):
~e-e.
Nfl.J(~ P"'S-<- (In''' p/".s AffClch"J
..
..
Project Description (with attachments survey plan, Exhibits A & B)
We will replenish the buffer area 50' x 36' with 120 bush blueberry plants
(Vacciunum angustifolium) staggered at 4 ft intervals (DC). Sow wild flower seeds
between bushes to also assist in reducing soil erosion. A mulch path 6 ft wide 6" in
height would run the length with two bird feeders on the side 25 ft apart (DC). (see
survey map plan & exhibit A).
The edge of the 50 ft buffer zone for 150 ft in back of the house, would
plant 6 Eastern Red cedar trees (Juniperus virginianus) 4' high with (30) Northern
Bayberry plants (Myrica pensylvanica) in-between the trees. A mulch buffer zone 4 ft
wide and 8" high would run at the base of the these plantings. For wild life 3 bird
feeders would be installed approximately 40' apart. Here too wild flower seeds would
be sowed behind the bushes to also assist in reducing soil erosion.
After the 50 ft buffer zone zoysia seed ( 25 Ibs) would be planted to retain
the soil. To insure growth, 30 yards of high quality screened top soil would be used in
this area.
A tool shed (exhibit B) would be placed in the upper wood land, 24 feet
from the buffer zone, 39 ft from driveway and 46 ft from curb. A parking space for the
RV would be established adjacent to the curb, 28 feet from the buffer zone. Red cedar
(Juniperus virginianus) 14 would placed 10ft apart (DC) on three sides of this space
(see survey map plan).
All dead branches piled on ground would be chipped and used for mulch. Only organic
fertilizer will be used on vegetation. An irrigation system will be used to support the
growth of the plantings.
4It ~rd of Trustees APPli4llio~
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations:3 l> h. h e"'-_ w~t!!, ~<I 6& f~ lr
o..yH, {.Y VQ').e1..f'Oh _~~~~~ltJ );.:E~:_,~_reS_~'IU(
C< "c/ }'vi" I Y> t" 'n'" v e (\ .
Area of wetlands on lot: 1/'1 A C \r e square feet
Perccnt coverage oflot:
25
%
Closest distance between nearest existing structure and upland
edge of wetlands: I ().) feet
Closest distance between nearest proposed structure and upland
edge ofwetlands:~___feet
Does the project involve excavation or filling?
No
v
Yes
!fyes, how much material will be excavated? ,vI A cubic yards
How much material will be filled?
3D
cubic yards
""
Depth of which material will be removed or deposited: Z
.fCet
Proposed slope throughout the area of operations: ~ '... A I ,.u~__~ l,.-:; "
Manner in which material will be removed or deposited:
. --
r v (,t c Ie. dr..ys
<\ \0') So h" H I
-t'f
,
'.> 0' I
I
whul
L\'y\u~
D v..... r
y (". k~
Statement of the effect, ifany, on thewetl<I1ldsand tidalwater13 oftlle town that may result by
reason of such proposed operations (use attachments if appropriate):
E."h"hC"- -€~,->i,,,~ Y~~.tt"t,dn c."t~J reclL,c-<.
\; ~ I J -t \r ~) S I ~ 1') ~ (> t c V' cl ~ . l\ e \-I \) " y <:>" '" . "" \ C. k J (, c t I V ~
To (,'(1t".1 1Ai11~( IJe .....<, pJ."t~"",rJi"lt
..
..
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..
. .
.
, PROJECT 10 NUMBER
PART 1. PROJECT INFORMATION
1. APPLICANT I SPONSOR
1("""ld IC
617.20
APPENDIX C
STATE ENVIRONMENTAL QUALITY REVIEW
SHORT ENVIRONMENTAL ASSESSMENT FORM
for UNLISTED ACTIONS Only
( To be completed by Applicant or Project Sponsor)
SEQR
2. PROJECT NAME
3.PROJECT LOCATION:
\..-
S' C1 -(fa / k'
Municipality County
4. PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks ate M Of orovide Il\ap .. \. ,f.. \
I () 0 i) ~"l.. 0 y- i 11.(, cJ~ I ~.M 01 f)!-'VI-, (';".A/v-l. (1..J1-cVt .4.~.<<Jl/
. evnl n e.w 'At,e/YU(.G .4o-t-V<< /,,,V.J;
5. IS PROPOSED ACTION: D Nnw 0 Expansion G:d Modification I alteration
6. DESCRIBE PROJECT BRIEFLY:
7. AMOUNT OF LAND AFFECTED:
Initially acres Ultimately acres
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS?
o Yes 0 No If no, describe briefly:
~T is PRESENT LAND USE IN VICINITY
L.:1 Residential D Industrial D Commercial
OF PROJECT? (Choose as many as apply.)
DAgricu"ure D Park I Forest I Open Space
D Other (describe)
10. OOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL
AGENCY (Federal, State or local)
DYes ~o If yes, list agency name and permit I approval:
11. DOES
DYes
A~A}PECT OF THE ACTION HAVE A CURRENTlY VALID PERMIT OR
LJ1NO If yes, tist agency name and permit I approval:
APPROVAL?
12. AS A ~uy OF
Yes l.Y1fo
I CERTIFY
PROPOSED ACTION Will EXISTING PERMIT I APPROVAL REQUIRE MODIFICATION?
Applicant
THAT THE iNFORMATION
7
(
PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Signature
Date:
'/, j 2 ja L'
If the action Is a Costal Area, and you are a state agency,
complete the Coastal Assessment Form before proceeding with this assessment
'.
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PART \I - IMPACT ASSESSMENT (To be comDleted b(l.;;;d Age~)
A. DDES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.47 If yes, coordinate the review process and use the FULL EAF.
DYes DNa
B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative
declaration may be superseded by another involved agency.
DYes DNa
c. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be l1an~wrjlten, if legible)
C1. Existing air quality, surlace or groundwater quality or quantity, noise levels, existing traffic pattern, solid waste production or disposal,
potential for erosion, drainage or flOOding problems? Explain briefly; I
I .. ... ..... ~ .
C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly:
L . ... ... ... ........ ... I
C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly:
I I
C4. A community's existing plans or goals as officially adopted. or a change in use or Intensity of use of land or other natural resources? Explain briefly:
I I
C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly:
I - : . . I
C6. Long term, short term, cumulative, or other effects not identified in C1.C5? Explain briefly:
I I
C7. Other impacts (incJudin changes in use of either auantitv or type of energy? Explain brieflv:
I I
D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL
ENVIRONMENTAL AREA (CEAF (If yes, explainbriefly I
DYes 0 Na t
E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes explain i
DYes DNa I
J
PART 11I- DETERMINATION OF SIGNIFICANCE (To be completed by Agency)
INSTRUCTIONS: For each adverse effect Identified above, determine whether it is substantial, large, important or otherwise significant. Each
effect should be assessed in connection with its (a) setting (Le. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e)
geographic scope; and (f) 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 H 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 if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly 10 the FULL
EAF and/or prepare a positive declaration.
Check ihisl,ox" ff you"'lave--delerm-ineif, baseir6idhe -Information andallalysisabove anct" any sUpportillg documentatlon,- thaiiheproposed ~ictio.
WILL NOT result in any significant adverse environmentallmpacts AND provide. on attachments as necessary, the reasons supporting thl
determinalion.
Name of lead Agency
Date
Print or rype Name of Responsible Officer In lead Agency
Title of Responsible Officer
SIgnature of Responsible Officer in lead Agency
Signature of Pre parer (If different from responsible officer)
..
..
Board of Trustees Application
County of Suffolk
State of New York
~r,,, (c( Je 51-(' U E'\r~BEING DULY SWORN
DEPOSES AND AFFIRMS THAT HE/SHE IS TI-IE APPLICANT FOR THE ABOVE
DESCRIBEDPERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE
TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELlEF, AND THAT ALL WORK
WILL BE DONE IN TIm MANNER SET FORTH IN THIS APPLICATION AND AS MAY
BE APPROVED BY TIm SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT
AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES
I-IARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING
tJNDER OR BY VIRTUE OF SAID PERMlT(S), IF GRANTED. IN COMPLETING TI-ns
APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR
REPRESENT ATIVES(S), TO ENTER ONTO MY PROPERTY '1'0 INSPECT THE
PREMISES IN CONJUNCTION WITHR 7 F ,[-I1S APPLICATION
Signature
SWORN TO BEFORE ME THIS _/1-!7t~DA Y OF_~1____,20M
~~ lid'
Notary Public
.IanlC'~ Nist
Notary Pttbh' \,fNew Jersey
No. 2,;:,..<,).')'"'
>~~!,:,1~on County
Commiss.... ""e"-C3 October 7, 2008
.
.
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APPLICANT/AGENT/REPRESENtATIVE
TRANSACTIONAL DISCLOSURE FORM
YOUR NAME:
The Town of SOUl hold's Code of Elhics nrohibits conflicts of interest on the Dart of town officers and emnlovces. The Dumase of
this form is to nrovide information which can alert the town of ODS sible conflicts of interest and allow it to take wl1utever action is
nee ssa to avoid same. '
} 0'1'\ 0\ I cI K. 6re (AI!. \r
(Last name, first name, _Q1iddle initial. upless you arc applying in the name of
someone else or other entity, such as a company. Ifso, indicatctheothcr
person's or company's name.) ,
NAME OF APPLICATION: (Check all that apply.)
Tax grievance
Vuriance
Change of Zone
Approvalorplat
Exemption from plat or official map
Other
(If "Other", name the activity.) __~
Building
Trustee
Coastal Erosion
Mooring
. Planning
Do YOIl personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee
ofllle Town of South old? "Relationship" includes by blood, ITjarriage, or bus.iness iilterest. "Business interest'! means a business,
including a partnership, in which the lawn 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% ofthe shures.
YES
NO
,/"
Ifyoll answered "YES", complete the balance of this form and date and sign where indicated.
Name of person employed by the TaWil of Southold __.
Title or position oftllat person ~_~__~_
Describe the relationship between yourself (the applicant/agent/representative) and Ule town officer or employee. Either check
the appropriate line A) through D) and/or describe in the space provided.
The lown officer or employee or his or her spouse, sibling, pnrent, o'r child is (check all that apply):
A) tllO owner of greater than 5% of the shares of the corporate stock oflhe aPl)lic~l1t
-- (wheil the applicant is Il corporation);
~_ll) the legal 01' 'beneficial own~r OfllllY interest in a non-corporate entity (when the
applicant is nol a corporation); -
__ C) an officer, director, partner, or employee of the applicant; or
__D) the actual applicant.
DESCRIPTION OF RELATIONSHIP
Submitted this ___day of
Signature
Print Name
200
Form TS I