The URL can be used to link to this page

Home My WebLink AboutTR-7192A James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. Town Hall Annex 54375 Main Road 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.: 7192A Date of Receipt of Application: October 19, 2009 Applicant: Douglas Gerowski SCTM#: 137-4-4 Project Location: 5705 Stillwater Ave., Cutchogue Date of Resolution/Issuance: October 21, 2009 Date of Expiration: October 21, 2011 Reviewed by: Trustee James King Project Description: To replace the existing cesspool. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the $outhold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the application received on October 19, 2009. Conditions: None If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code, a Wetland Permit will be required. This is not a determination from any other agency. Jame .~King, Presl'd~ Board of Trustees MAY-07-2009 18:04 P.03 TOTAL 'P i 0:? James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob ~nosio, Jr. Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application Wetland Permit Application ~_/Administrative Permit Amendment/Transfer/Extension ~ece~vved Application: .~l~eceived Fee:$ ~ · ~°~6mplete d Application Inconrplete SEQRA Classification: Type I Type II Unlisted Coordination:(date sent) LWRP Consistency Assessment Form · CAC Referral Sent: · Date of Inspection: Receipt of CAC Report: Lead Agency Determination: Technical Review: ~lSublic Hearing Held: lO Resolution: Name of Applicant Address AGENT: (If applicable) Address: Phone: ,ard of Trustees ApplicatJ GENERAL DATA Land Area (in square feet): Area Zoning: ~ { ~-'iX--(I Previous use of property: Intended use of property: Covenants and Restrictions: If "Yes", please provide copy. Yes ~No Prior permits/approvals for site improvements: Agency Date __ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspende~Cby a governmental agency? 1/ No Yes If yes, provide explanation: Project Description (use attachments if necessary):. Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: ~EVt~C~ ~t 5~ ~ ~ C~$ ~ C- Area of wetlands on lot: ~/~ .square feet Percent coverage of lot: /'J//~ % Closest distance between nearest existing structure and upland edge of wetlands: td / ~ feet Closest distance between ne, arest proposed structure and upland edge of wetlands: tO//~ feet Does the project involve excavation or filling? / No Yes If yes, how much material will be excavated? ~[g cubic yards How much material will be filled? ~/~ cubic yards Depth of which material will be removed or deposited: Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: feet ...S}atement of the effect, if any? ?_n [he wetlapds and tidal wa_ters_ 9f~e. t?wn that ma_y reason of such proposed operations (use attachments if appropriate): 'PROJECT ID NUMBER PART 1 - PROJECT INFORMATION 1. APPLICANT / SPONSOR 3.PROJECT LOCATION: 617.20 APPENDIX STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only ( To be completed by Applicant or Project Sponsor) 2. PROJECT NAME 4. PRECISE LOCATION: Street Addess and Road Intersections, Prominent landmarks etc -or orovide mad 5. IS PROPOSED ACTION: ~ New ~ ~pansion ~ Modifica,on / alteration SEQR 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? [~Yes [] No If no, describe briefly: 9 WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) E~R~sidential [---~[ndustflal [~Commercial ~]Agricuflure r~ Park / Forest / Open Space [~Other (describe) 10.' DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) ~Yes [~ No If yes, list agency name and permit / approval: 11. DUe5 ANY A~SF~:(Jt ~Jh IHE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? [~Yes ~ If yes, list agency name and permit I approval: 12. AS A RESUJ.~ OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? [~Yes t CER..~THAT ~IE INFORMA~N PROVI/DED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Signature ] O l ~ 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 - IMPACT ASSESSMENT (To be completed b~/Lead A~lency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 6t 7.4? If yes. coordinate the review prccess and use the FULL EAF, B. WILL ACTION RECEIVE COORDINATED REVIE~V AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR. PART 617.67 if 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 han~Jwdtten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic pattern, solid waste producUon or disposal. potential for erosion, drainage or flooding problems? Explain bdefly: C2. Aesthetic. agricultural, amhaeological, historic, or other natural or cultural msoumes; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain bdefly: C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use et land or other natural resources? Explain briefly: C5. Growth, subsequent development, or related activifies 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: C7. Other impacts (including changes in use of either quantity or type of energy? Explain briefly: WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL E. IS THERE, OR IS~TJ~IERE LIKELY TO BE, CONT~0v. ~' ~LAZ~? ? ~0TENTtAL ADVERSE I~NVIRONMENT,~,_I~.IMPACTS? If yes explain: I N°Ii PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: F~reachadversee~ectidenti~edab~ve~determinewhetheritissubstan~a~~~arge~imp~rtant~r~therwisesigni~c~nt~ 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 detsii to show that all relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked ye-", the de!erin!net!eh ef e!gn!ficonce mutt cv =!'Ja~.c Lh c pctcnt!a~imf)ac-tc f thc prcpc~.cd ~. ct[c. n on '.~.c cnv~ranm~ntc~: ch&Fac~'.~c,~ of~ha C ~,. Check this box if 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. C-;~e~ ~h~ box i(~ I~v~ ~ei~'rr~¥ned, b~sed on the information and ~naly~is ~bove and any supportin~ documeni~ti~nl t~hat {l~rop~s~ ~ c~(~' WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the masons supporting thi., determination. Name of Lead Agency Titts of Responsible Officer Pdnt or Type Name of Responsible Officer in Lead Agency Signature of Responsible Officer in Lead Agency Signature of Preparer (If different from responsible officer) Board of Trustees AppliCon County of Suffolk State of New York "~x~t.a5 ;4. ~6~co5~ / BEIN~ DUtY SWOR~ 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 BELmF, ~ THAT ALL WORK WILL BE DONE 1N 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 0F 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 PRESSES IN CON'~CTION ~Z~Cfi~WW OF T~S 7ICAT~ON. ' Signature SWORN TO BEFORE ~ ~HI~ '~4-~' ~AYO~Od~/ ,~0Oq ~ PUBLIC-ETAI'E OF NE~ YORK No. 01RU6190178 ~laHfl~ci in Nassau ¢ountv My Gomrnls~an lx~&'es July 21. 201'J Board of Trustees Application AUTHOP. IZATION (where the applicant is not the owner) (print owner of property) (mailing address) ~-vo ~QhZK, ~ (~0~0 do hereby a~thorize ~66A31C (Agent) ~-~5?CO~-/t~5I~ ~CI0~0p05~to apply for pe~it(s) from the Sou~~~d Board of wn rustees on ~ behalf. (~ner s signat~e~ APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics omhibits conflicts of interest on the hart of town officers and emalovecs. The ouroo~c of this foroa is to nrovide information which can alert the town of oossible conflicts of interest and allow it to take whatever action is nec~sseffv to avoid saree. (Last name, first naree, J,niddle initial, unless you am applying in the naree of someone else or other entity, such as a company. If so, indicate thc 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 (If "Other", name the activity.) 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 buginess 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 lfyou answered "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 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) tho owner of greater than 5% oftbe shams of the corporate stock of the applic0nt (when the applicant is a corporation); B) the legal or beneficial ownqr of any interest in a non-corporate entity (when the applicant is not a corporation); __.C) an officer, director, parlner, or employee of the applicant; or __J)) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS 1