HomeMy WebLinkAboutChuisano, Michael
Town of South old
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LWRP CONSISTENCY ASSESSMENT FORM
A. INSTRUCTIONS
1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for
proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This
assessment is intended to supplement other information used by a Town of Southold agency in
making a determination of consistency. * Except minor exempt actions including Building Permits
and other ministerial permits not located within the Coastal Erosion Hazard Area.
2. Before answering the questions in Section C, the preparer of this form should review the exempt
minor action list, policies and explanations of each policy contained in the Town of Southold Local
Waterfront Revitalization Program. A proposed action will be evaluated as to its significant
beneficial and adverse effects upon the coastal area (which includes all of South old Town).
3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will
affect the achievement of the L WRP policy standards and conditions contained in the consistency
review law. Thus. each answer must be explained in detail. listinl!: both supportinl!: and non-
supportinl!: facts. If an action cannot be certified as consistent with the L WRP policy standards and
conditions, it shall not be undertaken.
A copy of the L WRP is available in the following places: online at the Town of Southold ' s
website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all
local libraries and the Town Clerk's office.
DESCRIPTION OF SITE AND PROPOSED ACTION
B.
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PROJECT NAME --.C.1..JtltS4";' ~ ~ \:;..~ I ~<.;:v<' 'L - /Sc=f1-C t./- # ('Ci?j S
The Application has been submitted to (check appropriate response):
Town Board 0 Planning Board 0 Building Dept. 0 Board of Trustees ~.
I. Category of Town of Southold agency action (check appropriate response):
(a)
Action undertaken directly by Town agency (e.g. capital
construction, planning activity, agency regulation, land transaction)
o
o
(b) Financial assistance (e.g. grant, loan, subsidy)
(c)
Permit, approval, license, certification:
o
Nature and extent of action:
\dvuu <;'Thlll\& .-/J I~ ewe~ 1=01'-" ~('j).. 11{J~
Location of action:
j)1-Al)l\V'~ ~
dRle.-l~ 'ft.
Site acreage: 2 ~, (,'7~
Present land use: i ,,() /.
Present zoning classification:
y-*
2. If an application for the proposed action has been filed with the Town of Southold agency, the following
information shall be provided: \
(a) Name of applicant: !1/CH1}ec l (JlJvi~{) ~ Deiv,i 11/, (lqUIYJII,1f
(b) Mailing address: /OO~ g~l~ Ar W#9N7j11- ;/'Ill7f3
(c) Telephone number: Area Code (1~ 1r 3 7{rf
(d) Application number, if any:
.---.
Will the action be ~ undertaken, require funding, or approval by a state or federal agency?
Yes D No rr If yes, which state orfederal agency?
C, Evaluate the project to the following policies by analyzing how the project will further support or
not support the policies. Provide all proposed Best Management Practices that will further each policy.
Incomplete answers will require that the form be returned for completion.
DEVELOPED COAST POLICY
Policy 1. Foster a pattern of development in the Town of Southold that enhances community character,
preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location, and
minimizes adverse effects of development. See L WRP Section III - Policies; Page 2 for evaluation
criteria.
DYes D No ~tAPPlicable
Attach additional sheets if necessary
Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See
L WRP Section III - P~ies Pages 3 through 6 for evaluation criteria
DYes D No [ZJ Not Applicable
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Attach additional sheets if necessary
Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See
L WRP Section III - Policies Pages 6 through 7 for evaluation criteria
DYes D No o;otAPPlicable
Attach additional sheets if necessary
NATURAL COAST POLICIES
Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP
Section III - Policies Pages 8 through 16 for evaluation criteria
DYes D No ~otAPplicable
Attach additional sheets if necessary
Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III
- Policies Pages 16 througV1 for evaluation criteria
DYes D No .o;;:t Applicable
Attach additional sheets if necessary
Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including
Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III - Policies; Pages 22
th~gh 32 ~ evaifteriao
Yes
No
Not APPI_Ie
.
Attach additional sheets if necessary
Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III - Policies
Pages 32 through 34 for evaluation criteria.
DYes D NoGNotApplicable
Attach additional sheets if necessary
Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous
substances and wastes. See L WRP Section III - Policies; Pages 34 through 38 for evaluation criteria.
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DYes D No ~ Applicable
PUBLIC COAST POLICIES
Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public
resources of the Town of ~thold. See LWRP Section III - Policies; Pages 38 through 46 for evaluation
criteria. _ /
DYeD No lJ'Not Applicable
Attach additional sheets if necessary
WORKING COAST POLICIES.
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Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in
suitable locations. See LWRP Section 111- Policies; Pages 47 through 56 for evaluation criteria.
DYes D No ~t Applicable
Attach additional sheets if necessary
Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic
Estuary and Town waters".See L WRP Section III - Policies; Pages 57 through 62 for evaluation criteria.
DYes D NO~APPlicable
Attach additional sheets if necessary
Policy 12. Protect agricultural lands in the Town of Southold. See L WRP Section III - Policies; Pages
62 through 65 for evalu;&tion criteria.
DYes D No c:r:ot Applicable
Attach additional sheets if necessary
Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP
Section III - Policies; Pages 65 through 68 for evaluation criteria.
DYes D No 8'Not Applicable
PREPARED BY
TITLE
DATE
~ard of Trustees APPlicati~
County of Suffolk
State of New York
}A. (eH-~t.=L A. J belJtse. M. C ~lJt~/Y4./D BEING 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 HISIHER 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 P ,ERTY TO INSPECT THE
PREMISES IN CONJUNCTION WI REVIE l,'BIS APPLICATION.
/~ ~.M,~)~
1/6 Signature
SWORN TO BEFORE ME THIS
# DAY OF ap.w ,20Q:}
~~cR~
J Not blic
SUZANNE L. MANSO
Notary Public, State of New York
No. 5002673
Qualified In Nassau County
Qualified in Suffc:k CountY ")/\ 1tT'\
Commission Expires October 5.-r:2::!.L1-U
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APPLICANT/AGENTIREPRESENT ATIVE
TRANSACTIONAL DISCLOSURE FORM
The Town ofSouthold's Code of Ethics orohibits conflicts of interest on the Dart aflow" officers and eroo.avees. The ouroose of
this form is to orovide information which can alert the town of DOssible conflicts of interest and allow it to take whatever action is
necessary to avoid same. 't .
YOUR NAME: l1/ClrftELA. /1>ev1Y..fI...' (! f.lvI1~'Il()
(Last name, first name, J,lliddle initial, unless you are applying in the name of
someone else or other entity, such as a company. Ifso. indicate the other
person's or company's name.)
NAME OF APPLICA nON: (Check all that apply.)
Tax grievance
Variance
Change of Zone
Approval of plat
Exemption from plat or official map
Other ~ r
(If "Other", name the activity.) n /1'--\
Building
Trustee
Coastal Erosion
Mooring
Planning
0,- f3e.,.c,... <('c~jj'
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 bus'iness ihterest. "Business interest" means a business,
including a partnership, in which the town officer or employee has eve 'partial ownership of (or employment by) a corporation
in which the town officer or employee owns more than 5% of the s.
YES
NO
If you ansv..'ered "YES", complete the balance of this form and date and sign where indicated.
Name of person employed by the Town of South old
Title or position of that person
Describe the relationship between yourself (the applicant/agent/representative) and the town officer or employee. Either check
the appropriate 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% ofthe shares of the corporate stock of the applic~nt
(when the applicant is a corporation);
_8) the legal or beneficial own~r of any interest in a non-corporate entity (when the
applicant is not a corporation);
_C) an officer, director, partner, or employee of the applicant; or
_D) the actual applicant.
DESCRIPTION OF RELA TlONSHIP
Submitted this _day of
Signature
Print Name
200
Form TS I
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NEW YORK STATE DEPARlMENT OF STATE
COASTAL MANAGEMENT PROGRAM
Federal Consistency Assessment Fonn
An applicant, seeking a pennit, license, waiver, certification or similar type of approval from a federal agency which is
subject to the New York State Coastal Management Program (CMP), shall complete this assessment fonn for any
proposed activity that will occur within and/or directly affect the State's Coastal Area. This fonn is intended to assist
an applicant in certifYing that the proposed activity is consistent with New York State's CMP as required by U.S.
Department of Commerce regulations (I 5 CFR 930.57). It should be completed at the time when the federal application
is prepared. The Department of State will use the completed fonn and accompanying information in its review of the
applicant's certification of consistency.
A. APPLICANT (please print)
I. Name:l1ll:.UA,.-L A .L:[ 0 l::"Nlit..M. C !JVl S4-,.)/J
2. Address: I r.JO C, /-)A-lLtV i.; Ave. W t4-A/ TIt-C4 AI- 'f Il7f l
3. Telephone: AreaCode(17~ 7f'S-7<iS"'f
B. PROPOSED ACTIVITY
I.
Brief description of activity:
t!otJs.~ve-r C. l).:>r/~' W<lfl~ 'bel! 1<-
J~L.v FJ: tN vro- 1J/(jIlJ ST1h~S
I ~
A-T"r ~ {Z; 1-116:(+
+" q(' ~...r J h&. (' 1.1- .
2. Purpose of activity:
[>Ml/ ge4et4 Q:<>cess {lIJ-Tlfe/l.. "fht1-,J WI}L-l"';"':j d, /2.UcNJ
eml BLVFF
3. Location of activity:
SUProL-1L :>OOTlfo\..-~ T;,t.hJ. Oe'e~rrr. /52rSc)v...llVI~ R,t:J
County City, Tor' or ~iIIage Street or Site Description
4. Type of federal pennit/license required: flu w-t,.
5. Federal application number, if known:
6. If a state permit/license was issued or is required for the proposed activity, identify the state agency and
provide the application or permit number, if known:
1) EC-
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C. COAST ALASSESSMENT Check either "YES" or "NO" for each of these questions. The numbers following each
question refer to the policies described in the CMP document (see foolnote on page 2) which may be affected by
the proposed activity.
I. Will the proposed activity resnlt in any of the following:
a. Large physical change to a site within the coastal area which will require the preparation
of an enviromnental impact statement? (11,22,25,32,37,38,41,43) . . . . . .. . ... . . . . . . .
b. Physical alteration of more than two acres ofland along the shoreline, land
under water or coastal waters? (2, 11, ] 2, 20, 28, 35, 44) ............................
c. Revitalization/redevelopment of a deteriorated or underutilized waterfront site? (I) . . . . . . . .
d. Reduction of existing or potential public access to or along coasta I waters? (19,20) .......
e. Adverse effect upon the commercia] or recreational use of coastal fish resources? (9,] 0) . . . .
f. Siting of a facility essential to the exploration, development and production of energy
resources in coastal-waters-or on the Outer Continental Shelf! (29J....... . . . . . . . . . . . . . .
g. Siting of a facility essential to the generation or transmission of energy? (27) . . . . . . . . . . . . .
h. Mining, excavation, or dredging activities, or the placement of dredged or fill material in
coastal waters? (15, 35) ......................................................
I. Discharge oftoxics, hazardous substances or other pollutants into coastal waters? (8,15,35)
j. Draining of storm water runoff or sewer overflows into coastal waters? (33) ... . . . . . . . . . . .
k. Transport, storage, treatment, or disposal of solid wastes or hazardous materials? (36, 39) ..
I. Adverse effect upon land or water uses within the State's small harbors? (4) . . . . . . . . . . . . . .
2. Will the proposed activity affect or be located in, on, or adjacent to any of the following:
a. State designated freshwater or tidal wetland? (44) ...... . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b. Federally designated flood and/or state designated erosion hazard area? (I], ]2, 17) .... . . .
c. State designated siguificant fish and/or wildlife habitat? (7) ..........................
d. State designated significant scenic resource or area? (24) ............................
e. State designated important agriculturallands? (26) .................................
f. Beach, dune or barrier island? (12)..............................................
g. Major ports of Albany, Buffalo, Ogdensburg, Oswego or New York? (3) . . . . . . . . . . . . . . . .
h. State, county, orlocal park? (19,20) ............................................
i. Historic resource listed on the National or State Register of Historic Places? (23) .........
3. Will the proposed activity reauire any of the following:
a. Waterfront site? (2,21,22) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . ...
b. Provision of new public services or infrastructure in undeveloped or sparsely populated
sections of the coastal area? (5) ................................................
c. Construction or reconstruction of a flood or erosion control structure? (13, 14, 16, 17) .....
d. State water quality permit or certification? (30,38,40) ..............................
e. State air quality permit or certification? (41,43) ...................................
YES NO
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YES NO
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4. Will the proposed activity occur within and/or affect an area covered..by a State-approved local
waterfront revitalization program, or State-approved regional coastal management program? (see policies./'
in program document) ........................................................... _ _
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D. ADDITIONAL STEPS
I. If all of the questions in Section C are answered "NO", then the applicant or agency shall complete Section E
and submit the documentation required by Section F.
2. If any of the questions in Section C are answered "YES", then the applicant or agent is advised to consult the
CMP, or where appropriate, the local waterfronlrevitalization program document". The propnsed activity must
be analyzed in more detail with respect to the applicable state or local coastal policies. On a separate page(s),
the applicant or agent shall: (a) identifY, by their policy numbers, which coastal policies are affected by the
activity, (b) briefly assess the effects of the activity upon the policy; and, (c) state how the activity is consistent
with each policy. Following the completion of this written assessment, the applicant or agency shall complete
Section E and submit the documentation required by Section F.
E. CERTIFICATION
The applicant or agent must certifY that the proposed activity is consistenlwiththe State's CMP ortheapproved local
waterfront revitalization program, as appropriate. If this certification cannot be made, the proposed activity shall
not be undertaken. If this certification can be made, complete this Section.
"The propnsed activity complies with New York Slate's approved Coastal Management Program, or with the
applicable approved local waterfront revitalization program, and will be conducted in a manner consistent with such
program. "
Applicant/Agent's Name:-BI c(,tI}~""L A. e; D~l)L~ M. ,C LJuI~It"'iJ
Address: /004 ~~I~ A..,^, cJ~~U- Aiy tt7c,s
Telephone: AreaCode(\!t. ) 7r-~ -7iP-(
Applicant/Agent's Signaturel/llJJ b t?2 -t. . -'~ fYI. ~e: 7 -I? -0 7
F. SUBMISSION REOUIREMENTS
I. The applicant or agent shall submit the following documents to the New York State Department of State,
Division of Coastal Resources, 41 State Street - 8th Floor, Albany, New York 12231.
a. Copy of original signed form.
b. Copy of the completed federal agency application.
c. Other available information which would support the certification of consistency.
2. The applicant or agent shall also submit a copy of this completed form along with hislher application to the
federal agency.
3. If there are any questions regarding the submission of this form, contact the Department of Slate at
(518) 474-6000.
*ThP<:P <:t~tp ~nrlln{,AI rtnr>nmPnf<;: ~TP AV!:lilable for inspection at the offices of many federal agencies, Department of environmental
Conservation and Department of State regional offices, and the appropriate regional and county planning agencies. Local program
documents are also available for inspection at the offices of the appropriate local government.
G:\COAST AL\WORKING\SMcNeiI\FCAF. wpd
(0212004)
JOINT APPLICATION
FOR PERMIT
New
Unil
Slale
ales Ann Cor s of En i~eers
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1. Check permits applied for:
Applicable to agencies and permltcalegofies listed in Item 1. P..... read all instructions on back. Attach addilionallnformation as needed. Please prinllegibly or type.
NYS DepL of Environmental ConservaUon
o Stream Disturbance (Bed and Banks)
o Navigable Waters (excavation and Fill)
o Docks. Moorings or Platfonns
(Construct or Place)
o Dams and Impoundment Structures
(Construct, Reconstruct or Repair)
o Freshwater Wetlands
o Tidal Wetlands
o Coastal Erosioo Control
o Wild, Scenic and Recreational Rivers
o 401 Water Quality CertifICation
o Potable Water Supply
o Long Island Wells
o Aquatic Vegetation Control
o Aquatic Insect Control
o Fish Control
NYS Office of General Servic;es
(State Owned Lands Under Water)
o Lease, License, Easement Of
other Real property Interest
Utility Easement (pipeJines. conduits,
cables. etc.)
o Docks, Moorings or PlatfOfms
(Construct or Place)
Adirondack Park Agency
D Freshwater Wetlands Permit
o Wild, Scenic and Recreational Rivers
Lake George Park Commission
o Docks (Construct or Pmoo)
o Moorings (Establish)
US Army Corps of Engineers
o Section 404 (Waters of the United States)
o Section 10 (Rivers and Harbors Act)
o Nationwide Permit (s)
Identify Number(s}
For Agency Use Only:
DEe APPLICATION NUMBER
us ARMY CORPS OF ENGINEERS
14. Has Work Segun on Project? (If yes, attach
explanation of why work waS started without a permit
and ident" work accom IIshed.
16. Will this Project Require Additional 0
Federal, State, or Local Permits?
3. Taxpayer 10 (If applicant is not an individual)
4. Ap nt Is &fan: (check as many as apply)
Owner 0 Operator 0 Lessee 0 Municipality I Governmental Agency
5. If appUcant is not the owner, Identify owner here - otherwise, you may provide Agent/Contact Person information.
Owner or Agent/Contact Person 0 Owner 0 Agent IContact Person Telephone Number (daytime)
Mailing Address
poat Office
Stat. Zip Code
7. Nam. of Stream or Waterbody (on or near pro;ect site)
L.X- &ovwb .
8. Name of USGS Quad Map:
location Coordinate.:
NYTM-E
NYTM-N 4
9. Complete Narrative of Project Description and Purpose: (Category of Activity; e.g., new constructionl
Installation, maintenance or replacement; Type of Structure or Activity; ..g., bulkhead, dredging, filling, dam,
dock, taking of water, Type of Materials and Quantities; Work Methods; e.g., area Isolation, equipment type,
phasing; Need or Purpose Served) Continue on Separate Page as Necessary
tJe.,J Co.w&t'tllc..TltArJ ; It> aw~./lC-r ~
1J.'Jrf/V \l6ft9'j) bg~;f.-r ~ ()f- /S-'8L.ClFF
W,-fH- Wg~) S'Ot~ ~J,,~ TWI t.-';f.
~wlft ~", l>~
se 88:
13. estimated Completion
Da'" ~ ~(n
17. If applicant Is not the owner, both must sign the application
t hereby affirm that Information provided on this form and all attachments submitted herewith are true to the best of my knowledge and belief. False statements made herein
are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Law. Further, the applicant accepts full responsibility for all damage, direct or indirect,
of whatever nature, and by whomever suffered, arising out of the project desctibed herein. The applicant, exceptillQ state Of federal aQencies, also agrees to
indemnify and save harmless the State from suits, actions, damages and costs of every nature and description resulting from said project. In addition, Federal law
18 U.S.C., Section 1001 provides for a fine of not more than $10,000 or imprisonment for not more than 5 years, or both where an applicant knowingly and willingly falsifies,
conceals, or covers up a material fact; or knowingly makes or uses a false, fictitious or fraud I statement.
Date __ __________ Signature
Date ~~,.., Signature
of Applicant
of Owner
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LOT NUMBERS ARE REFERENCED TO "MAP OF
ORIENT BY THE SEA, SECTION ONE" FILED IN 'rHE
OFFICE OF THE SUFFOLK COUNTY CLERK ON
NOV. 21, 1957 AS MAP NO. 2777.
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JUL 20 2007
Southhold Town
Board of Trustees
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SURVEY OF PROPERTY
A T ORIENT POINT
TOWN OF SOUTHOLD
SUFFOLK COUNTY, NEW YORK
/000 /5 - 03 - /"7
SCALE /" = 30'
May /1, 2004
July 14, 2005 ( linal )
Moy II, 2007 (prop. plolfo oirs)
~~ OF NEW y.
~t' 0
":> ~:~ 1. MEr~ ~
o G'~
.., 13
NO ~
ANY AL TERA TION OR ADDITION TO THIS SURVEY IS A VIOLA TlON
OF SECTION 7209 OF THE NEW YORK STA TE EDUCA TION LAW.
EXCEPT AS PE'R SECTfON 7209 - SUBDfVlSION 2. . ALL CE'RTfFICA TIONS
HEREON ARE VALID FOR THIS MAP AND COPfES THE'REOF ONL Y fF
SAID MAP OR COPfES BEAR THE IMPRESSED SEAL OF' THE SURVEYOR
WHOSE SIGNA TURE APPEARS HEREON.
ADDfTIONALL Y TO COWL Y WfTH SAID LAW TERM' AL TE'RED BY "
MUST BE USED BY ANY AND ALL SURVEYORS UTIUZlNG A COPY
OF' ANOTHE'R SURVEYOR'S MAP. TERMS SUCH "fNSPECTED . AND
"BROUGHT - TO - DATE' ARE NOT IN COMPLIANCE WITH THE LAW.
AREA = 24,513 sq. ft. to tie line
I am familiar wllh fhe STANDARDS FOR APPROVAL
AND CONSTRUCTION OF SUBSURFACE SEWAGE
DISPOSAL SYSTEMS FOR SINGLE FAMILY RESIDENCES
,and will abide by the candlllans sel forlh Ihereln and on Ihe
'permll 10 conslrucl.
The localions of we/Is and cesspools
sho wn hereon are from field observa/ions
and or from dolo abtolned from others.
ELEVA TlONS AND CONTOURS ARE REFERENCED TO NGVD,
ECONlC
(53/J 765 - 50
P. O. BOX 909
1230 TRAVELER
SOUTHOLD, N. Y.
04-172
LONG ISLAND
.
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SOUND
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OC!.A.WI~ NUMBiiIOl!,
CHUI-07-03