HomeMy WebLinkAboutRoute 25 & Champlin Pl
,
. Permit No. /2/
File No. /...<:-
.
.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(516) 765- 3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town
of Southold for the issuance of an Excavation Permit pursuant to Chapter 83 of the
Code of the Town of Southold, Suffolk County, New York, and other applicable laws,
ordinances or regulations for the excavation herein described. The applicant agrees
to comply with all applicable laws, ordinances, codes and regulations, and to permit
authorized inspectors to ma,ke necessary inspections of the job site.
Print or Type
1)
fl'-cO fnv..ro....m<!~f."( ).'lc.
Name of Applicant
co",...ad... M II
Address
2) Ell.)fc., Co. US II P;ui....?y f/~ la, ILtoo 0 I,,) c""",-(... 1<&. lv~,t~"f ,.A/f I' )<10
Name of Owner of Premises Address
3) ~b<< '-1 me.......,.,.,,, tv<tf.i <.\k..,o; ft,., I",-I"r'i.~"'~-' 0-( !hi,~' c'~_pJ.'.,., ,'.., 0",~"",p,,-i
Work Description and Location (Street Number, Hamlet, Cross Street) "oo""....;'~
G,. r__ 1'.".1.. IV" 1
(a) Is construction located within 75 feet of tidal wetlands? *Yes No X--
*If yes, other Town permits may be required.
4) Builder's License No.
Plumber's License No.
Other Trade's License No. AI;1
Electrician's License No.
~~fA r
Ignature 0 pp Icant
3/5) /9r-
. Date
5) a) Attach plot plan showing location of proposed excavation and relationship to
adjoining premises or public streets or areas, and giving a detailed descrip-
tion of layout of excavation.
b) Attach all other necessary permits and licenses for this project.
c) Work covered by this application may not commence before issuance of a
Highway Excavation Permit by the Town Clerk.
6)
7)
Tax Map: Section Block , Lot
Starting Date: S-/;}/:J h r Completion Date ~ /:2.1. /'7 ~
8) Work Schedule:
Phase
Excavation........................................ .
Facility Installation.................................
Backfill & Compaction..............................
Pavement Replacement..............................
Completion
/1/'+
;VA
~
Date
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $lt,.6ot>
11)
Remarks:
D-39
Page 1 of 3
"
'-.'
.
.
" ,
12)
Insurance Coverage: (Attach copy)
a) Insurance company:--B-c.<::crJ
b) Policy # f'A~ Mf .acAed
c) State whether policy of c,ertification on file with the Highway Depart-
ment: E/lc (oseo/
d) Coverage required extended to the Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury,
and $50,000 property damage.
13) Security:
a) ~urety Bond or Certifi~d C:leck p~:>vid::::d i:1 trc
total amount of $ ,A~4
b) Maintenance Bond provided: 2 yea rs or 3 yea rs
14) Fees for applications and permits:
Basic Application Fee........ $25. 00
A 1. /Service Connections excavations @ $20.00 = $
~
A2. /Additional Excavations same service @ $10.00 = $
B. Ex vations 18" in depth or less:
0-100 .f. = $10.00
I.f. @ $0. 10 - $
C. Excavations " in depth to 5'
0-100 I. f. = $ .00
J.f.
Additional
D. Excavations 5' in deptH
0-1001.f. = $50.00
I'ZO'50 = . "
Additional
E. U ility Repair = $
No.
Repairs same service
Additional
F. Notice to public utilities proof must be provided and attached to
this application prior to issuance of permit.
* * *
Authorization is hereby granted to the Tow!) Clerk ?f the TO~~ of Southold to
issue a Highway Excavation Permit to: ~~~~ .
in accordance with this application.
SUPER INTENDENT OF H IGHWA YS
TOWN 0 OUTHOLD, NEW YORK
y- r; - 9:r-
Date
Received by the Town Clerk
4~/~
Date
Permit Issued
-fL/~ / fS
/Oate
Permit No.
/,L
Note:
Permit expires one ( 1) year from Date of Issuance.
No work to start without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39
Page 2 of 3
.
.
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S
RECORD
I nspection Date
Findings (use code)
Applicant Notified
1st
2nd
3rd
4th
(To Permit Clerk)
REMARKS
CODE
IB - Improper barricades
IL - Improper lights
ST - Sunken trench or excavation
UTM - Unable to measure (due to backfilling)
BUC - Building under Construction
WIP - Work in progress
DB - Improper backfill (too high) (not sufficient)
HFS - Inspector holding for final settlement of excavation
RFR - Ready to repair
D-39
Page 3 of 3
.
.
~ U.
DlCO
Environmental,
Inc.
57 MALL DRIVE, COM MACK, N.Y. 11725
TEL: 516-864-1772 FAX: 516-864-1764
388 MAIN STREET, MONROE; CT 06468
TEL: 203-459-8300 FAX: 203-459-8351
'-
April 3, 1995
REa/YED
'APR 6 1995
Sat4,w ,,_ ~
Mr. Raymond Jacobs
Superintendent of Highways
Town of Southhold
Peconic Lane
Peconic, NY 11958
Subject:
Application for a permit for highway excavations,
Dear Mr. Jacobs:
Please find enclosed an application for a permit to install four monitoring wells in the right
of ways of Champlin Place and Main Street in Greenport, New York. Note that the
proposed wells are to be installed in the area between the sidewalk and the street curb.
The monitoring wells are intended to provide data related to the delineation of a
petroleum release at Exxon Station No. 3-6015, located at 1100 Main Street in Greenport.
After installation, the wells will be monitored on a bi-annual basis, until otherwise notified
by the New York State Department of Environmental Conservation.
Please call me if you have any questions, comments, or wish to meet to review the
application. Thank-you for your attention to this matter.
Sincerely,
/~~
Nevin Murtha
Project Manager
.
.
Highway Department
Town of Southold
Peconic Lane
Peconic, N.Y. 11958
RAYMOND L. JACOBS
Superintendent
DATE:
TO:
CASE NUMBER:
This is to notify you that New York Telephone Company
and Long Island Lighting Company have been notified in
respect to the application for an Excavation Permit in
the Town of Southold.
Signature of the applicant
Tel. 765-3140
.734-5211
APR-04-1S'35 12: 04 FROM.HE TREIBER GROUP
TO
8641764
P.02
JOHN TRI!:IBER AGESCY INC
.0. BOX 7975
ARDEN CITY NY 11530-7975
04
tJS I MA'I1ClIt D
00NFEIlS NO IIIGIIITS UPOft'l1lli CEII'IlFlCATI! HOUlI!R. THI!I..........cATE
DOES *'" --. m;Nl)OR AlTERl1ll! COVERAGEAI'l'OIIDEO BY l1lE
POUCIEIS Baow.
COMPAlHS AFF()JIDING COVERAGE
& INDUSTRY INS
~~...,~~.......,.~:....::~:^.,..."..,~.,,:::....
1:-W\"'~
;
~ AMIII..
~:':-:-:'~:~:'.l-:-;<>:>:'<<'~~ ..
leo SERVICE CORP.
leo ENVIRONMENTAL
NC.
7 MALI. DRIVE
OMMACK, NY 11725
QOMPAH't A CoMMERCE
ll!I'IIlI
-
L&rn!Il
COII/IWN
LET1lII
COMPANY D
LET1lII
--
LET1lII
8 HARTFORD IRS CO
C A!IIBRICAlf lm."I. SURPLUS
--
u"...
3405188
BE6060674
5/05/94
wo~. cotN'IIIM11OI
-
~I"" UMlUTV
12WECW8450
O/Ol/lIt
ontE(>OLLUTION
LIABILITY
E07733256
.......1'1lllII...__~-
ERTIFICATE HOLDBR ADDED AS AN ADDITIONAL lOURED
: PERMIT H'WAY EXCAVATION
.......\., -"'......
.... ...N"....~._ "... ....~~.....~........ ,',
f...... '''l.r.itjll;~''''''' #
.. .. ......, ' .....w:,:..,....,':':,.... ,'v
S/lOULDAllVQFlHE- DlIClAEEllI'OlX"P 1IE0NlCI!LI.IO 8iFOAE TMI!
ea'llATIOIl~'l1I1H8lEOF. ___Nfi~_VOII'R>
"""..3.0.- DA-v.WllITlEIt_TOTHE_1liIlCllDm_TOl11E
\.EFT. BUTrM.IIlI!TO IlAA.SUCH _~'::.!R<:!!" ~OA
UAlllIJTYOfAIIVl\INII_11tECOM_ <!.R~_ATNEC.
-
1:1:
SUPERINTENDENT OF HWYS
TOWN OF SOU'l'H HOLD
PBCONlC LAN2
PBCONlC NY 11958
lIII
I
I
TOTAL P.02
.
.
PROPERTY LINE
," _.. _.. _.. -.. -.. -.. -.. -.. _.. -.. -..-
~CATCH
BASIN
I TRAILER
IJ IEXTENSlDN ~7
I i
I DIRT IGRAVEL
I I DRIVEIJ A Y RESIDENCE
I L_____...J CONCRETE I
I I -'-'-'-'-'-'-'-
I GRASSY I
AREA
-+ I
I MIJ-6 -+
4-
BUTANE
TANK I
I CJ 0
0 '" ~
-
'"
M
I <:
]>
r
2 BAY GRASSY ^ t:
GARAGE AREA Z
I '"tl VA ANT LOT
r.... MIJ-l OFFICE ~
,/ ", 4- I 0
./ \" AIR t<j
,.' . COM!,RESSOR
..' '.. ....... ';{
'. ~ I
>- CONCRETE ......
ASPHALT ~I I (lJ
~I I )
<.II I I
I I QJ
I I MIJ-S ~
4- .....
I I I -+(1)
I I
MIJ-2 L______..J: w
4- <.I
Z
I ASPHALT I '"
'"
>--
z
MIJ-3 w
PATCHY CONCRETEI 4-
Q.PHO~.. _.. _.. ASPHALT I
-"-"- '-..-..-..-..-
SIDEIJ ALK ~ _ POLE
ENTRANCE ENTRANCE \.!:)
CATCH
BASIN
MAIN STREET (ROUTE 25)
~
... : MDNITDRING WELL
~ : PROPOSED MONITORING ~ELLS
,
"""" II< .....
o 10 20
I I I
-+
-+
I
5 ; Je Cva /1<
r-
e UNleD ENVIRONMENTAL
INCORPORATED
\. 57 MALL DRIVE · COMMACK, N.Y. 11725 . (516) 864-1772
SCALE I AS SHOWN I DRAWING NO. I 2EX6015N
SPANOS SERVICE STATION
1100 MAIN STREET
GREENPORT, NEW YORK
DATE I APR I L 3, 95 I DRAWN BY I RON PULEO