Loading...
HomeMy WebLinkAboutTR-6610E Jamee F. King, President ~QF SDUIy Town Hall Jill M. Doherty, Vice-President ~O~ 53095 Route 25 Peggy A. Dickerson P.O. Box 1179 Southold, New York 11971-0959 Dave Bergen Bob Ghosio, Jr. ~ ~ Telephone (631) 765-1892 lyCOUli~ ~ Fax (63ll 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD EMERGENCY WETLANDS PERMIT Permit No.: 8610E Date of Receipt of Application: May 21, 2007 Applicant: Paul & Loretta Dombrowski SCTM#: 31-18-2 Project Location: 50 Rabbit Lane, East Marion Date of Issuance: May 21, 2007 Date of Expiration: N/A Reviewed by: Trustee Bob Ghosio Project Description: A temporary repair of the existing bulkhead using non- treated lumber and to fill the area between the bulkhead and the existing concrete wall. Findings: The project meets all the requirements for issuance of an Emergency Wetlands Permit as determined by the Board of Trustees. The issuance of the Emergency Wetlands Permit allows for the operations as indicated on the application received on May 21, 2007. Special Conditions: A full Wetland Permit must be obtained in order to conduct any further activity on the bulkhead. This is not a determination from any other agency. o~ Jam s F. King, President Board of Trustees _ - ' i ...,-~..n ~ ~~~Z~ SURVEY ~,+i ~A ~ ~•3° - EAST Mx~ - ~ 6929 U~~~:+j°"~ ~ Y''° ` T@V~1 OF S i - ~ 'F~ ~ s SUFFOLK C9UtJTY, ! ~ `}>r• ~ S•C. 7AX Nf:- 1a00~3#L~ M 6K~p}e ~ ' ~ .1 ~ •.303.68 ~4- 1f' e~. ~4~~r (ro bauNtM! 9 099 a^.. ~ ~ t a ' ` ~ ~w~ ~ I. 4 y ~l ~ xdY O,t '`S~`n 1 ~ Iy4„ 1 ,any ~n~` ~ q - 's~, i , ~ r.- .I „s ~ - ,X s~ 'a, ~o g ti0 . g ~,I i ~ ~ ' i+RY f j, r i i~.! d 5 i. .d ~ 11 r ry ~ebi~ SG.~LT1 l i~ ~ ~7 ~ q 'D'Ts ~r. r.. rslMww a nma+ g, px~, r 4' 7 r I i ~ alf~ y~MMf'~'c~PM~vw~~t d' y ~ PI ~i ~ j ~ r w ; r~€ R r. d ~ 1 • n rq~.q~ R..q~~a rlip ~a..o ~e.~ L+M~n - 7k tin - !--~rw•w rw..:w u.~wwaM,^~f/ro,Y~{~~M~.La.ea.. r~ Merl' I M K 6:xti0 , Yq. fw~!75f- 1C4] •rl+l. ;F•/4eIrN rC •9. "S f a 31 yy~ ~ - +a•L'p(~. ref r.9 I ~,{i °,S`$7 } s nJ' .~iyai I~siW.'a ai Rmn. V 1 S ~ r.. T-+t1~ `I~ M.,.q,. n}pI AM, xeT S•E+r+ ~K K' eMIRY1RT - Wst -~F~~ a H7~/Id9 6Z4T Z9i ~fL'[ ZYd. GL~#fii'.~d~Itl~JT[ j 4+.Siei1. ..w. .S~YkJkux.6..[a_.~ --n. i i r ~..~~~--.-r.,~ ~ . X ' t -FkY-7. ~ ~ C ,~t f 3-~ ~y ~ S i n. ~ ~ i ~ F. ! J S ^1.~ `'yea ~ ~ ~y & F~~t ~ ~ a~ F z x _ , ,f r 4 wt F + ~ ~ s' ~ ~ ~ ~ ~~°r ~ Vii; .~1. ~`.y ~ ~ ~N C ti7M°~~ '~y i~"~ a , ~ ibis e e~ i ~ t ..w f ~ ~ + ~ 1 . ~ ~ 5 ~y.Z`1 ~ d ~ d~~. ~ ~ ~ ~ ~ t sr,a„. ~ qtr ~ ~i' k ~T 77 g1[yil~¢1 u ,j N6. ~ ' ~T 4~ 4 •f i. i s ~ s , ~ r ~ a ~ w, ~~p73 ~ 6'~ 4° ~ .,F ~ ~ Birk Y~~ ~t#~, 1 "`A ' ; of /h ' ~ ~'c~^`w~ r~°' t~~y F' e , ' A 1 ~ , e a\ ~ 3 6 ~'Y u~~-~ . , y..e ail. ._'+....,_i K. S~ ~i ~ '~~i?. tti n it '~I~ ~ 3E ~~i~~~~ I ~ v # ~ ~ i ~ 1 ~In~~ + ~ i ~ 1'~ , F ~ .',.',u~ ty iP ^ ~P',i w A ~ ~1 c^.3 3 !~y, 3 c~ 'S~ i fat f~, F. € eye, ~ ~ t R~~ ~ 6 ayi, ~f. ~ ~ 2' ~ 1 i r ~ t F 4~ t r a i 1~ ~ I t ~ ' ib i Y ~ ~ y $ ~ ra.~ ~ ' t ~ . cy. a . /'w ~ ~ ~SF q ~ ~ ~ ~ ~ i ' 1~ ~ to F~~'~~ f ~ r f`''"t fl ~ ,a s a~ ~ ~;~~sa ~~o ~ '~t r°'44 ( _ ~'~i~'yg yq a~5'~`~, S ib~( J ~µi h ~ G Mf y~ 1 v~ i~ ti 7yy,"(~~~ p~ 1. ' ~ x1 `,}~i .B i'F ~'F ~~rir ~t ~ llXg~+y~~ ` ~ i r ~ ~ F t In r a ~ ~ .,i~ i d d 4 GSM. ~ ,~b i ~ ~ k ~,t~, I ~f ti ~i'ili~i,,.: 11 l ~ 1 l: ~ ~ f v. ~+r.+r~ ~ 1~ ~ ~ F~_ ~ . Y ~ ~ { J Y V -i r ~ ~ ~ `aA' - - - }~r1ii _ T - _ „,,.,y,-.._, r ' ,i i >Q: @i.""pp: ary~x a,; : i t D ~i It s. ~ ' ' ~,w M1 t «~1 ~ ~ :~1• s + p`w' ~ '•1 ~ - z @_ Aj~ ,~b q;{, p ~ ~ Y x j~~~,,, r ~ a= x ~~~44F ~f, S_. ;f ~ f ' 3 a Y ' s,_,7p ~ '7 F~ ~ ~ c t1i 1 g p ~ s. ~ - ~N A~ ~ ~ s rn_ ~ i° t ~r~'.. 1 ~i F e t t M1 - • 1~ . - vim-. y w y~~ la_ ~ , ~ fir- .s r. ~ ,.I .e y,i• f r3~ _ er 4f pis ~~ji 1' . ':fit; • ~ ~ ~~a • \ ~ ~ - ~ ~ ~ ~ti` . . 1 ~ r~ 1! ~ I / • ~1 11 1 1 1, ,I / 4 ~ F _ a E. ~ j t ' _ r `fr ~If~~ 'H _ • it MR; 4~ ~ - ~T~~ _ .err .w,4 C. a .r... ,rN i~ _ } } i ~ 1! 1 ~ ~1 1 1; 1 1 T J ` ' ` ` 1 ~ ,i ~ p c 1 ~ • 1~~, ~ ! : ~~Y-,'- `s^~ - Yom' 1 i' ~ {=,Y~ ~ _ _ _^.;r` ~ ~ Tom. f .',l , I _ ~ ~ ' ._I ~l , 1! ~ k ~1 •~§y - - 1~. ~ 4 ~ - i ~ ' 1 r ~ ' r ' . n j 7y 4 P 4 .J ' 'r. 'r ~o ~¢ac. xa.~ m as TE wn°~u p¢~.rn® - ~E ~.~K~~ ~ ~Fp O ~q y ..a .o..e~.w.oa J' ~ a g < s awn u~ ~,~p ql ti. ~~i W ~ ~.(4d ~ as 8 n r•~ 'MU" J ' ~Y(4 a~ n m .M qq9 , yWd© zap `WA ~Jq/ w.iawmsm qV~ mm q Me~ nY y~j ¢uxrv a~ iY~x © 'd / I ;q j Ta s 9y9~ P , q a e J ~s&INWn ® d 9Y ' a ILIFKW W(E ~ A ~ 9~ ``y° a e F ~ ~9 V I u 9 p ` • ivWtl j. i 'W Y q' q M1 1 * q ~q a n l u O q e O, 'z~x.~ as Ba 0 e • < 9, q Axa .P . a II o aq I s q ~ ,C q y. ANIt10N1ANE 9~t q _ ,a~ d Oq'LB ,eJ a a .a4 ~i ~ ~ aw~..s.,,. ..xxa. _ ~ ~ r JV u F~ ~ O w*pe COUMYOF SUFFOLK © s aemrox xo ~ Real P~oppb Tav Ber eApp4y uD_ _ - e..~x~..rx.nw ~ 31 r I James F. ~ Preeident ~0~ ~Oflj~ Town Ife? Auna~ Bob 6hatio, Jr., VSaa-Peaodeat w,~~ P O. B~ L1Bosd ~ Dave Her9au 1~r ~r 8outlaold, Neer York 11971.0969 ~ ~ John ]3redemeyer ~ , Mfd+eet J. Domino TeLpbome (881) 766.1894 ~ ZZZ~~~" t~ Fez (8317 786E641 BOABU OF TOWN TRLJSPESB mown of sovmxor~o ZIOZ 6 - AON HURRICANE SANDY EMERGENCY APPLICATION Valid ttinr June 1,2013 ~ i, Property Owner Name: =awl. v a.• e t~~. ~o.N brr..+6l~c!' 4 I ~y D N `1 PernanernMaiNngAddress: Cuu„wAIG/FI.n Avd F/oe.rl 1~a~ iiei/ I. Phone Number(s): Q l Z Q R ~ 7 i 3 / ~G/ ~~'i ~ - ~ 5"- 3 y~V {N~ Property Address: SD /~x.~Eft f lieu= Eaef INp~~o~v ?icah ~ Suffolk CourrlyTax AAep Number. 1000 - Od /3/oc~c /d ~ poZ ®a v Agent (if applicable) Address: Phone Number(s): j i • Board of Trustee PermR Number(s): ~ WTI arty part of this project require a Building Permit? d/v Flow much fill will be required? ~ C ? S Project Description: Brc~i~c~l~'MO I.7AwrAFGa ~v I. i 800/S00(pj 3.L0/Id9 BSCT Z5S 9TL T 7:Vd CT:9T STOS/BO Hoard e! Szustees a+yp11aat1on i. County of SuSolk Star of New York I r,. l ('pw,Z ~,.,ig,~~s ~ BEING DULY SWORN I ~ DSPOSBS AND AFFIItMS THAT HE/SI3E IS THS APPLICANT FOR TIDE ABOVE j DESCRIBED PIT(S) AND THAT AIJ. STATEMENTS CONTAINED HEREZDi ARB 'TRUE TO'I4TB BEST OF HIS/Y~R KNOWLEDOFi ANA BELIEF. AND THAT AI.L WORK WII.L BE DON& IIQ TIII+ MANNER 3ET FORTIi ID1.THis APPLICATION AND AS MAY ~ BB APlROV~ BY T~ SOU'I'HpLD TOWN BOARD OF TRUSTBBS. TIIa APPLICANT ACB~8ZS3 TO SOLD THB TOWN OF 3OUTHOLD AND THE TOWN TRUSTBE3 . AND Fii$B FRCBd ANY AND ALL DAMAGES AND CLAIIvIS ARLSINIG { llNDI'?!t OR BY V t)F SAID PERMIT(S), ~ GRANfBD. IN COMPLETIIdO THIS APPLICATION, I Y AjTLIiORIZE THE TRUSTEES, THEIIL AGENT(S) OR REPRffiENTATXVF.S(S~ TO ENTER ONTO MY PROPERTY TO II3SPECT THE PRIES IN OONJUNCTION WITH REVIEW OF THIS APPLICATION. i 3i~nture of Property Owner { f~ ~ ~~~~~Z SWORN TO BEFORE MH THIS C/ DAY OF i ~ ~y4bd~:8Mte otNw+Yak Ne. 4ar1675? ~ie~tesirb~j,~l'S . i 600/C00~ 3.L~/Id9 BrCT ZSr 8TL T %Vd CT~OT STOZ/80/Ti Re: NOI • ~ . Page 1 of 1 ' NOS j SandyRl [SandyRl~gw.det.stabe.rty.us] tlwit 7tsas~Y, NoNmber ae, m>Z ioa3 as 7a pomOrewald,t~aul(NwYoAc) i atlndoames:Odteral ietmit (~I2-0O6•i.pdF(5210~ ~1"'*° re.~~l Peres GP-0-12-006 - Huer4xne Sanalx General Perms i i kris corms out nx;eipt of yortr Notice of Dent for (3P-a12-006 which iB the fieDecal Pd711R ~mhoriti~g recovery and repent wo& aaoairtd vvitlt sboees damage from Hutrioaoe Sandy. A Dopy cf the (lsesrd Permit is atdched and it is also available ao DFC's wrobpage, Please eirwe that Baas i~aYaattrtl vunrk nndertttod and comply wish aR tams grad ooaditioras of the IMM~RaarsiRMyPilMgrwoa~ls~v~llutltenoopo~efuctiiaitieaaa8oondiic~eft»t~airciailbetnerloi ~rpariolr~tiort ofll+e Favaa~aahf~Savr~n T.a~v ~ lEyoe Mare grertioaa ar eocoantx ue4orereea pmbh3ma during the co~aae of the work, aoaract the Regicoal lWnisitAdoasistra+ar~ Roryoar ao~ry: ~~Naws?.>.i ~aCMrrMam ' bLIC'A1oGI0bT'i ~a Adu~abor 'I 50 Circk Road Stonyi3rook,NY 1]790.3409 1i (63])444-0365 fiat: (631)444-0360 email: Or Ceralaet» NYS DBC Division ofBovunamennl Pemaits 625 H~arr~aapr ';a~'14'ft . _ (S!8) 4t)Q-9167 fcc: (516)402=9161 ~ ~ .oom> 11/g/20127e3>so~>•» ~p+ , °1t r!s - ~ ~ 911-'249-TI3f .e[.°ItemBL>=81~.N0't08Li~RgAAAAA~r.~+•. ]ll~ll~12 a R;~ „ S,i~/Id9 aiCi Z9~G ~7-jJ,i ZYd YTKlT .J, • ~ ~PL~A~~TE A Joint Venture FACSIMILE TRANSMITTAL SHEET ' FROM: ~owFv ~ f ~u ~1~aL~ COMPANY: DATE: FAR NUMBER: TOTAL NO. OF PAGES, MCLUDING COVER: ~ PMONF NUMBER- SENDE'MS•PXON/VF ~NUCMAF~E/R~ JY7-702-6430 RE: SENOEMS FAR pu MBE0.: 778-252-1329 I ? URGENT ? FpR REVIEW ? PLEASE COMMENT ? PLEASE REPLY ? PLEASE RECYCLE pDTFS/CAMMENfS: u rrr ~CA ~ t~ Al ~ ? ~]OS AVENUE V, LOWER LEVEL, BROORLY N, NY 312Ba 800/T00@J B.L~/Id9 BZCT Z5Z 8TL T YV3 ZT~9T ZTOZ/80/TT James F. King, President ~QF SDUry Town Hall Jill M. Doherty, Vice-President ,~0~ ~lO 53095 Route 25 P.O. Box 1179 Peggy A. Dickerson Southold, New York 11971-0959 Dave Bergen G C Bob Ghosio, Jr. ~ ~O Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD EMERGENCY WETLANDS PERMIT Permit No.: 6610E Date of Receipt of Application: May 21, 2007 Applicant: Paul & Loretta Dombrowski SCTM#: 31-18-2 Project Location: 50 Rabbit Lane, East Marion Date of Issuance: May 21, 2007 Date of Expiration: N/A Reviewed by: Trustee Bob Ghosio Project Description: A temporary repair of the existing bulkhead using non- treated lumber and to fill the area between the bulkhead and the existing concrete wall. Findings: The project meets all the requirements for issuance of an Emergency Wetlands Permit as determined by the Board of Trustees. The issuance of the Emergency Wetlands Permit allows for the operations as indicated on the application received on May 21, 2007. Special Conditions: A full Wetland Permit must be obtained in order to conduct any further activity on the bulkhead. This is not a determination from any other agency. o'er ' Jam s F. King, Presi ' nt Board of Trustees J'2w:~ ~ i~1111 ~ 4 w= ~a f~~ Y ~ 4 4 s`~~~ M~~~~ene2~4 "J qty d1rv 4 ~ t ~ .~.f ~t ~ k M ~ ' M t ~ r r ~ ~ . ~ s . a 1 ~ I 4+x.'3 Ml+m!wwaR.tt N .~H ~ ~~,R~~ti,eT ~ , h+.~C : 1, „~ar~urs F~~ "`~w*~' ~ ; G ~ ~ , ' ~ w,t i!' , ~ a+~ ~ ^ - ~ Po . ~~i~ n a : v r~~% tt'ilf~~~~lS~ 4.~ .s3 ~ tl~~ S ~ ~ 7 p ,i~ N - - - ~g,. ~ { S ' 7 4 k x " ~II~ Y ~ r.ry .rte-...~.~ ~ 1n ~ J f m ii ne+e~r+ ~i°*s~a~:" ht rem _ ~ { a I . t ~ o, r~' i ' k, i . . + r ` z ~ ~ ~ a y 'R a,~ ~ ~fi ~ ,1 a~ ~ ~ ~ ~ f~~•r F _4 ~ ~ ~ ~ ~ a' _ ~y x~ ' ¢ H ' ` ~1 ~ t ~ 1 4 ~ - ~ ~ .t ' ~ ~ ~ ~ ,at ~ a ~r~ ~ ~ ~T x ~ , ~ °a~li w. - ~ i ~ k'~€ ~ »~7 I N ~ ~ T i~ ~ ~ ~ ~ ~ ~ ' t L c vC, H e i " a :3 ! ~ ~ ' ,red ~ ~ t ~ { t ~ t ~ ~ ~ 6 f, ~ r~ ~ ~ 1 ~p ~ ~ a~~'~" ~ ~ - ~3raa ea .~"z~'=~'~,":~.'r e ~..F~W. r , , a t. y.~ ~h, ~I t . Y~G ,a Board of Trustees Town of Southold Town Hall 53095 Route 25 Southold NY 11971-0959 Re: Emergency Temporary Permit SO Rabbit Lane ` East Marion NY 11939 I have attached the request for an Emergency Temporary Permit to allow for the maintenance of my bulkhead that was damaged in the April 15, 2007 storm. As noted in the application, the fascia boazds will be replaced and the area between the timber bulkhead and the existing concrete wall behind will be filled. It is my understanding that Mr. Ghosio had recently inspected the azea. Thank you in advance for your response 1 a and a Dombrowski 44 Cunningham Ave. Floral Park NY 11001 (r'-S )fr' i ~.w. F, .s ,r T a. Jamey F, King, President ~~OF SOUtyO Town Hall Jill M. Doherty, Vico-President ,`O j l;3oB6 Route 28 ,If, ~ P.O. Box 17.79 Peggy A. Dickerson 7' 6outhold, Naw York 11971-0889 Dave Bergen Bob lihusio, Jr. Telephone (631) 788.1892 ~COU ~ Fax (631)988.8641 I BO,AR'D OF TO T~i.L19TE)t$8 ''OWN OF $ UTHO1rD Office U9 Only -Coastal Erosion Pe I it Application -Wetland Permit Ap lication Administrative Permit AmendmentlTransf r/Extension' -Received Application: -Received Fee:$ -Completed Application , Inwmplete i, _SEQRA Classification ~ ~ ~ ~ ; i Type I_Type II_Onlist~d_ r _Coordination:(datecent) I ~ ~ ~ ~ , -CAC Referral Sen[: + i I ' i ~ ~ ! -Date of Inspection: ~ -Receipt of CAC Report: -Lead Agency Detertninatio Sai I;old to s Teohnical Review: ! F_ ~ of Tres =Fs -Public Hearing Held: Resolution: Name of A('pp~l/icant~wl~ _~~,Q/ZpUlb~~~ ~J Addresss_ 7 ( ~ufW U/.f/ ~N~1 m ~ ~ld2A c. /"dl ~ //d B 11 Phone Number: Qi j+ 'Z,'Q ~j - 7/ / Suffol County Tax Iv~ap Number: 1000 - ~eLZ/ 3 / ~~e c~c ~ ~ ~ y f Z Prope y Location: SD ~p,gg, f ~~ys f /~A2ro.v (provi e LILCO Pole. distance to cross streets, and location) AGE T: (If applicable) Address: Phone: I, i i i ~ ' ~ I Board of Trustees Application GENERAL DATA • Land Area (in square feet):_ 3'~ 227 Area Zoning: Previous use of property: Intended use of property: ~~5 ~ 7r ni c-( Prior permits/approvals for site improvements: Agency Date tiv pv-P 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): ~a Grn ~t/ SL4oa,y+ lF y~s`~0~ _ANa >r.Gl 6~.ti,Nn 3u~~~ttA~ Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations:~s/ Ai Area of wetlands on lot: 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 ? Yes If yes, how much material will be excavated? cubic yards How much material will be filled? Z cubic yards Depth of which material will be removed or deposited: Z feet Proposed slope throughout the area of operations: A/ rMl~anner in which materlIial will be removedd or deposited:Qe ~/~g /CIA ~Yr/A ~ hi it ri fT,iNG 47u hC/A 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): No N Board of Trustees Application COASTAL EROSION APPLICATION DATA Purposes of proposed activity: I~{p~q,2 / T'trr~psre its) [7u ~ , Are wetlands present within 100 feet of the proposed activity? No y Yes Does the project involve excavation or filling? No ? Yes If Yes, how much material will be excavated? (cubic yards) How much material will be filled? Z (cubic yards) Manner in which material will be removed or deposited: Fi~! Arz.a A.O~o~OY 2 ~ (Jee.o loe it mow/ ~ J ~f wL~sAat Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) NO ~v~ - . , • L/ fD /.~e .~n,.,, '~Cis,,.w ~d Rte/ ~/JAi 2 ear/ Exi i.v ~ ~u LlclteAo Board of Trustees Application County of Suffolk State of New York ~ ~ ~om f32a w5~/ 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 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. S nature SWORN TO BEFORE ME THIS_~~~ DAY OF r~(~`( Zp_U_] Notal ublic JAMES F. WERER Notary Public. State of New Vork No. 4Ff15252 qualified in Suffolk County Commission Expires Feb. 17, Z U 1 PROJECT ID NUMBER 617.20 SEAR APPENDIX C STATE ENVIRONMENTAL OUALrrY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM PART 1 • PROJECT INFORMATION p y ppr UNLISTED ACTIONS Only (To be com leted b A Iicant or Project Sponsor) 1. APPLICANT/SPONSOR ~ 2. PROJECT NAME a rtiL A s /e 3.PROJECT LOCATION: Munklpality S L County S((~ d ` ~ , 4. PRECISE LOCATION; Street Addasc and Road Interseclbne, Prdminent lantlmetlca etd - or provide map S17 fL~~B, fi L„a•P 5.15 PROPOSED ACTION: ~ New ~Expanslon ?Modigcatlal)aNerelibn 6. DESCRIBE .PROJECT BRIEFLY: / en,~o~tn.,~ r?e®on~2s ~ /?ey/q~.e ~py~,o r3vnaps Aa0 ~~~~r~ii ~~a,.,,, 7. AMOU NT OF LAND AFFECTED: Initially ecrgs Ultlmalaly acres B.fWI~LL/PROPOSED ACTION COMPLY WITH EXISTING 20NING OR OTHER RESTRIGTIONS7 t ~I Yes ~ No It no, tleacriba bde}ly: g. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose ae many as apply.) Reslden0al ~ IntluaMal ~ Commercial ?Agtlculture ~ Park / Forect / O en S aGe. p pOther (tleacribe) 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNtiING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Loral) Yes f ~71M Ir ygs, Ilsl. agency name and pennll /approval: 11. DOES ANY ASPECT OF THE .ACTION HAVE A CURRENTiY VALID PERMIT OR APPROVAL Yes I-INer- If yes, Ilat egan name and L~_f pY permit /approval: t AS A RE U F PROPOSED ACTION WILL EXISTING PERMIT:/ APPROVAL REnVIRE MODIFICATIONS ea Nd 1 CERTIFY THAT THE INFORMATION PROVIDED ABOVE' IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant /Sponsor e Dela: SI nature s~y~~ if the actibn le a Costal Araa, and you are estate agency, complete tfie Coastal AssessmentFOrm tlefoye proceedlnp with this assessment PART II - IMPACT gSSESSMENT o ba coin leted b Lead A enc A. DOES ACTION F~(CEED ANY TYPE I THRESHOLD IN 8 NYCRR, PART 617.47 If yes, coorolnate the review process antl use the FULL FAF. Yes ~ No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.67 II No, a negative declaration may be superseded by another Involvetl agency. Yea ~ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE. FOLLOWING: (Answers maybe handwritten, U legible) C1. Exis6ng air quality, audaW or groundwater quality or quantity, notes levels, exlstlng VaRrc pattam, solid waste protluctlon or disposal, potential foreroslon., drainage wilooding problems4 ExplaXi briefy: C2. Aeafhelic, egricullurel, archeedoglcel, historic, or Ober naWrel or cutturel resa,mes; orcommunlty or nelghoorhoodcharecler! Explain briefly; C3. Vegetation or fauna, fish, ahallfleh a Wlld Ifs apache, algal cant abitals, or threatened or endahgeretl apeclea7 Ezplein briefly: C4. A community's exlatlng plena or goals as oMdlatly edaptetl, ore cha f;e Inpee or Intanaily of use of and or other natural resources? Explain bde6y C5. Orovdh, aubaequent tlevekWmenf, or relatiQd adMUes likely M be imfuced py the pro used actlon?Explaln briefly: C6. Long term, short term, cumulative, or other eHecta not IdedUfled In C1-C57 Explain Srisfly: C7, Other Im acts' Includin chars s In use t><either uanU or :ofens. Ex lain bdafl D. WILL THE PROJECT HAVE AN IMPACT ON THE.ENVIRONMENTAL CFWRAC7ERISTICSTffAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA CEA7 II es ex lain bde ; Yea ~ No E. IS THERE, OR IS THERE LIKELY TO B CONTROVERSY ELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMpACTS7 If a lain: Yes ~ No PART III • DETERMINATIDN QF SIONIFICANCL (To be completed by Agency). INSTRUCTIONS:.For each adverse stied Identified above, determine whether k Is substantlal; large, Important or otherwise elgnificenl. Each effect sfiould be assessed In connection with Its (a) setting (i.e, urban ornral); (b) probability otoccurring; (c) duration; (d) Inevereiblliry; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference. supporting materials. Ehsurethet explanations contain sufficient detail to show thatall relevant atlverse impacts have bean Identified and adequately eadressed. IfquesWn d of part ii was checked yes, the determinalbn of sgniflcance must evaluate the potehGel Impact ofthe proposed eCyon on the environmental characteristics of the CEA. Check thialax it you have IdenUfletl one or more potentlally large orsignlgcant etlverea Impactawhich INAYoccur. Then proceed tliradly to the FUL F~4F antl/or prepare a posldve tlecleretbn. Check thlebox if you havedatarmlhed, based on thelnfirmaUon endanarysls above and any supporting documentatlan, Thal the proposed aWo WILL NOT result In any significant adverse environmenyl impects.AND~provide, on ahachments as necessary, the reasons supporiing thi tleterminatinn. Name of LeeO Agency Dale nt or ype ame o espons a car n ea gency T da of Responsible Officer gnalure o esponar e. car n ee .gency gnature o taperer. ~ i area rom recpons e c r