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Home My WebLink AboutTR-7215A James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghost. o, 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 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 1st day of construction % constructed V//'Project complete, compliance inspection. James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. Town Hall Annex 54375Main Road P.O. Box 1179 Southold, NewYork 11971-0959 Telephone(631) 765-1892 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OFSOUTHOLD Permit No.: 7215A Date of Receipt of Application: December 8, 2009 Applicant: Suffolk County Water Authority SCTM#: N/A Project Location: East Mill Road, Mattituck Date of Resolution/issuance: December 16, 2009 Date of Expiration: December 16, 2011 Reviewed by: Board of Trustees Project Description: To install a 6" water main in pavement in order to get public water to homeowners on East Mill Road, Mattituck. 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 site plan prepared by Suffolk County Water Authority, dated September 29, 2009, received on December 8, 2009. Special Conditions: The installation of hay bales at the read end of East Mill Road to contain runoff. Inspections: Final inspection. 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. I,~M~. Doherty, Vi~ Board of Trustees JMD:eac 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 December 21, 2009 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Mr. Cad Pfeifer Suffolk County Water Authority 4060 Sunrise Highway Oakdale, NY 11769-0901 RE: Installation of a Water Main East Mill Rd., Mattituck Dear Mr. Pfeifer: This is to inform you that the application dated December 8, 2009 has been reviewed by the Board of Trustees at the regular meeting of December 16, 2009 and the application has been approved pending the receipt of the application fee in the amount of $50.00. Please make check or money order payable to Town of Southold. The fee is computed according to the schedule of rates as set forth in Chapter 275 of the Southold Town Code. Please don't hesitate to contact our office at (631)765-1892 if you have any questions. Very truly yours, M. Doherty, Vice- sident f Trustees JMD:lms Steven 'E Bums, RE. Director of Disfffbution Regional Manager Bureau of Marine Habitat Protection NYS Dept of Environmental Conservation SUNY Campus Bldg. 40 Stony Brook NY 11790-2356 SUFFOLK COUNTY WATER AUTHORITY 4060 Sunrise Highway, Oakdale. NY 11769 (631) 563-0205 Fax (631) 589-5273 Dear Sir: In accordance with our general permit No. 1-4700-00010/00640'0 dated August 1, 2005, we are notifying you ora project that is within 300 feet ora tidal wetland. Project title: /~.u,3 ~dl~VC~.- Project Engineer: ~' ~;ql ~ Phone#: [_o~l- ~'(~'~.'_~(~L-I Expected Commencement Date: J 2 -2 7 - ~ § Expected Duration: 1 2-2 z -' O ~ To: fi= -'Z.Z - I c~ SCWA Authorization Number: D O~'-i D-- ,~13 - O O ~ ~ Very truly yours, SUFFOLK COUNTY WATER AUTHORITY ~C. Berg, Supe.,in~eh~ent FB/bb Enclosures: 1) Project location map 2) Photographs of site & adjacent wetlands tidal.wpd James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob t~nos~o~ Jr. Town Hall 53095 Route 25 P.O. Box 1179 Southo]d, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application~ Wetland Permit Application ~ Administrative Permit Amendment/Transfer/Extension Received Application: Received Fee:$ Completed Application Incomplete 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: ~Public Hearing Held: __Resolution: Name of Applicant Address Suffolk Co~ Tax Map Nmber: 1000 - Prop~ Location: ~/~ ~Xf ~IC~ Orohde L~CO Pole ~, dist~ce to goss s~eets, ~d location) AGENT: (If applicable) Address: Phone: Board of Trustees Application Land Area (in square feet): Area Zoning:. GENERAL DATA Previous use of property: Intended use of property: Covenants and Restrictions: Yes No If "Yes", please provide copy. Prior permits/approvals for site improvements: Agency Date __ No prior permits/approvals for site improvements. Has,any permit/approval ever been revoked or suspende/~_by a governmental agency? t-~No Yes If yes, provide explanation: Project Description (use attachments if necessary):_ '/l,d~T~t t ~" ~J~-~_ Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Area of wetlands on lot: _squaxe 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 If yes, how much material will be excavated? How much material will be filled? 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: ~/'~. cubic yards cubic yards feet Statement of the effect, if any, on the wetlands and tidal waters of the town that m.aj_result by_ PROJECT ED NUMBER PART 1 - PROJECT INFORMATION 1. APPLICANT / SPONSOR 3.PROJECT LOCATION: Municipality ~d 5 "~ 617.20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only ( To be completed by A ~licant or Project Sponsor) 2. PROJECT NAME SEQR 4. PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks etc -or orovide map 5. IS PROPOSED ACTION: E~ New [] Expansion [] Modification / alteration 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY W1TH EXISTING ZONING OR OTHER RESTRICTIONS? r~Yes [] No if no, descdbe briefly: 9. WHAT ~S PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) E~]Resider~tial E]I"dustdal E~COmr~ercia' E~Agriculture []Park/Forest/Ope. 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 yes. agency name and permit I approval: If list 11. uuE3 ANY ^3FI:CI OF I HI: A~JIION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? Yes []No If yes, list agency name and permit / approval: AS ^ *ES..T O. PROPOSE. ACT,OM WI.L EX ST,NO PERM T APPROVA. REnU,RE MOD,FICATION? I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant I Sponsor Name ,/~ .... ,~ Date: If the action is a Costal Ama, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment PART II - IMPACT ASSESSMENT (To be completed by Lead A~lenc¥) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the review process and use the FULL FAF. []Yes r~No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be supemeded by another involved agency. [] Yes [] No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WiTH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic pattern, sol~d waste production or disposal, )otendal for erosion, drainage or flesding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cutiuml resources; or community or neighborhood character? Explain briefly: C3. Vegetatlan or fauna fish shellfish or wildlife species signiticant habitats, or threatened or endaegemd species? Explain briefly: ! C4. A community's existing plans or goads as officially adopted, or a change in use Or intensity el~ use of land or other natural resources? Explain briefly; C5. Growth, subs~quent development, or related activities likely to be induced by the proposed ac§on? Explain briefly: C6. Long term, short term, cumulative, or other effects not identlfiod in C1-C57 Explain briefly: C7. Other impact~ {including chart§es in usa of either quantit~ or t~pe of energ~t? Explain brlafly: D~ WiLL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA tCEAI? [] Yes [] No I {~f ;/es, explain bdel~: I E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes explain: PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adveme effect identified above, determine whether it is substantial, large, important or otherwise significant. Each effect should be assessed in connection with its (al setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (el geographic scope; and (~ 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 ii was checked ye~, thc dctcrm!~=~cn cf--.!?=n!fi~ncc mu:.' cvc!uc:c t~.c pc. tcnt!:~ !,.mpc=t cf L",: ~r=~::=~ c=tlc, ncn thc~ ~nv~rc, nmant~', c~-,~ract~r',~[c~ c,~ hh~ C ~-~.. Check this box if you have identified one o~ mom potendalty large or sJgniticant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepom a positive declaration. WILL NOT result in any significant adveme environmental impacts AND provide, on attachments as necessary, the masons supporting thi~ determination. Name of Lead Agency Date Title of Responsible Officer Print or Type Name of Responsible Offosr in Lead Agency Signature of Responsible Officer in Lead Agency Signature of Preparer (If different from responsible officer) Board of Trustees Application County of Suffolk State of New York DEPOS".S ~W ~FnmS THAT m/sm ~s Tm ~Pucmr vo~ ~ ~o~ ~scm~ P~m~(s) ~ ~ ~ s~~s co~ ~ ~ ~m zo zm ~sz o~ ms~ ~o~ ~ ~, ~ ~ ~ wo~ BE ~PRO~D BY Tm SOUmOLD TO~ BO~ OF ~US~ES. T~ ~PLIC~ AG~ES TO HOLD T~ TO~ OF SO.HOLD ~ ~ TO~ ~UST~S ~ESS ~ F~E ~OM ~Y ~ ~L D~GES ~ CL~S ~S~G ~ER OR BY ~T~ OF S~ PE~T(S), ~ G~D. ~ CO~LET~G ~S ~PLICATION, I ~BY A~HO~E T~ ~US~ES, T~ AGENT(S) OR ~P~SE~ATI~S(S), TO E~R ONTO ~ PROPERTY TO ~SPECT ~ P~SES ~ CON~CTION ~ ~W OF ~S ~PLICATION. S~gnature SWORN TO BEFORE ME THIS ~-/'~ DAY OF ~ C.¢t~J::~a~ ,200~ Notary Public CONNIE D. RUNCH Notary Public. State of New York No. 01BU$185050 Qualified in Suffo/k Coun ~ Commission EX~ires April 14, ~0/~ Board of Trust~es Application AUTHORIZATION (where the applicant is not the owner) (print owner of property) residing at (mailing address) do hereby authorize (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. (Owner's signature) APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE. FORM Thc Town of Southald's Code of Ethias omhibits conflicts of inter'at on the oart of town ~Jfficers and emnlovees. The our~oS~ of this form is to vrovide information which can alert the town of nosalbld conflict~ of interest and allow it to take whatever action necessacv to avoid same. ' ' (Last name, firat name, ~iddle initial, ualcss you ~ applyin~ ~n the name of ~omeone else or other entity, such as a company. If~o, indicet~t~ other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Tm~tee 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 reelationship with any officer or employee of the Town of.Southold? "Relationship" includes by blood, l~arriage, or business ii~terast. "Basiness interest" means a business, including a partnership, in which the town officer or employee has even a partial ownership of (or employment by) a coq~oration in which the town officer or employee owns more than 5% of the shares. YES NO /g~ ., If you 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 applicanttagenVrepresentative) 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 tl~at apply): __A) the oyvner of greater than 5% of the shares of the corporate stock of the applic0nt (when the applicant is a corporation); B) the legal or beneficial own.er of any interest in a non-corporate entity (wh~n the applicant is not a corporation); __C) an officer, director, porlnei', or employee of the applicant; or __.D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS 1 Subm{tted. this day of /~£C/ 200 Signature --~'--~_Y OFFICE LOCATION: Town Hall Annex 54375 State Route 25 (cot. Main Rd. & Youngs Ave.) Southold, NY 11971 MAILING ADDRESS: P.O. Box 1179 Southold, NY 11971 Telephone: 631 765-1938 Fax: 631 765-3136 LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Jill Doherty, Vice President Town of Southold Board of Trustees From: Mark Terry, Principal Planner LWRP Coordinato~2> Date: December 10, 2009 Re: Proposed Wetland Permit for Location: East Mill Road SUFFOLK COUNTY WATER AUTHORITY requests an Administrative Permit to install a 6" water main in pavement in order to get public water to homeowners on East Mill Rd., Mattituck The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is CONSISTENT with the Policy Standards and therefore is CONSISTENT with the LWRP. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Cc: Lori Hulse, Assistant Town Attorney 16315895273 SU FF.CNTY WATER ,6 Herman J. Miller Depu~/ Chief ~ecutive Officer for Operations SUFFOLK COUNTY T~rATEI~ AUTHORITY Administrative Offices: 4060 Sun~e Highway, Oakdale, NY 1 1769-0901 (631 ) 563-0203 Fax (631) 563-0358 Apd120,2005 Mr. Edmund Lynch Superintendent of Highways Smithtown Highway Department 758 Smithtown By-Pass Smithtown, New York 11787-5082 Dear Mr. Lynch: The Authority (SCWA) recently received an invoice from your off-me for miscellaneous road opening permit fees. As was discussed at the Highway Superintendents Meeting hosted by the SCWA last November, SCWA is exempt from highway work permit fees. The state statute that governs the activities of the SCWA was anqended to c0nfo rm to the statutes of other water authorities across the State. PublicAu(horities Law Section 1082 now provides in part: The revenues, monies and other properties and activities[0fthe SCWA] shall be exempt fTom taxes and governmental fees or charges, whether impesed bythe stateor any municipality. A copy of the law has been enclosed. The SCWA will continue to make applications for highwaywork permits and will comply with their provisions. If you should have any questions, please do not hesitate to contact me. Attachment HJM:ms cc: S. Bums T. Kilcommons Very t/uly yours, Deputy CEO for 0pera'tions 16315895273 SUFF,CNTY WATER AUTH . . ?t/ ... ~s of the autho~t~ ~[tslaUve HiM, oriel L.2001, ~ 4.M..: F? ~, ~ m' JudJe~d n~mmuHium relating ~o ~la an~ meAUmey-s ~ _P~__-_ion Laws d N~ Yin'k, p. 1~, law, § ]083. State, County and municipalities not liable on bo~ds Res,~rch References Encyelopediu N~ Jm'., ~d, Pub]re ~cm'it,~H *~ 100, Revenue*producing undert~8~L ]WY Jer., 2d. l~ie ~'m'ltle~ J 308, Lk~,flity of ntata or poHUeM ~Ed~v~sjon on obli&~tiona of pnblle 8 and ~ny o~m.: APE 21,2006 James F. King, President Jill M. Doher~y, 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 OFTOWNTRUSTEES TOWN OFSOUTHOLD Office Use Only Coastal Erosion Permit Application/ ~_Wetland Permit Application ~.,"-Administrative Permit Amendment/Transfer/Extension ~----'~ece-~vve d Applic ' ' [~(~ ~Aeceived Fee:$ t t.~_j-~ %~D ~Completed Application I~--I __Incomplete __SEQRA Classification: Type I Type II Unlisted Coordination:(date sent) --.~WRP Consistency Assessment Form __CAC Referral Sent: __Date of Inspection: __Receipt of CAC Report: __Lead Agency Determination:__ Technical Review: ~Public Hearing Held: 1041 ~ __Resolution: Name of Applicant Address Phone Number:(6a) ~'/~ ~ ~ ~& ~-- '~ Suffolk County Tax Map Number: 1000 - Property Location: ~/~ ~ ~-.~ ~ fyi It._~ 1~.9 (provide LILCO Pole #, distance to cross streets, and location) AGENT: (Ifapplicable) Address: Phone: rd of Trustees Applicatic Land Area (in square feet):. Area Zoning:. GENERAL DATA Previous use of property: Intended use of property: Covenants and Restrictions: Yes No If "Yes", please provide copy. Prior permits/approvals for site improvements: Agency Date __ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? ~ Yes If yes, provide explanation: Project Description (use attachments if necessary):_ ~ard of Trustees Applicati WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: 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 If yes, how much material will be excavated? t_//../, cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: ,~' feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: ~yatement ofm~ e~.ff_ec[~ if any, O~ the wet!~_ds and_tid~ w.a_tg?s_ pf .th_¢._tpwn_tha_t ~a_y resu!t by reason of such proposed operations (use attachments if appropriate): PROJECT ID NUMBER PART i - PROJECT INFORMATION 1. APPLICANT / SPONSOR &PROJECT LOCATION: Municipality 617.20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only ( To be completed by Applicant or Project Sponsor) 2. PROJECT NAME Ico..,, 5..,-'fo x. SEQR PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks etc -or provide mad IS PROPOSED ACTION: ~ New ~ Expansion ~ M~ification 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? [~Yes [] No If no, describe briefly: 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) F-qResidential F'-]lndustdal [---]Commercial F--]Agriculture 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 r--~No yes, agency name permit approval: list and / 11. UU~8 ANY A61"EGI DP IHE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? Yes [---]No If yes, list agency name and permit I approval: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REaUIRE MODIFICATION? I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sponsor Name~'~/~ ~. ~ Date: Signature /"~ -- ~-- 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 by Lead A~lenc¥) A. DOES ACTION EXCEED ANY TYPE t THRESHOLD IN 6 NYCRR, PART 6'i7.47 If yes, coordinate the review process and use the FULL EAF. B. WILL ACTION RECEIVE COORDINATED REVIEW 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 handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic pat[em, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain bdefly: C2. Aesthetic, agricultural, amhaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefiy: C4. A community's existing plans or goals as officially adopted, or a change in use or in[enslty of use of land or other natural resources? Explain briet~y: Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly: C6. Longterm, shortterm, cumulative, or other effects not identified in Cl-C5? Explain briefly: C7. Other impacts (including changes in use of either ({uanflt~ or type of energy? Explain bdefiy: D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA ICEAI? {If yes, explain bd~fi¥! E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes explain: PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: F~reachadverseeffectidenti~edab~ve~determinewhetheritissubstantia~~iarge~imp~rtant~r~~herwisesigni~cant~ Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probabtiity of occurring; (c) duretion; (d) irreversibility; (e) gecoraphic s~ope; and (~ magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanation~ contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question d of parf ti was checked 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(~l[ ~h~s ~)~x if yo~- i~ve determined, based o~1 the ir~ormation an~ ~iy~is ~b~ve anc~ an~ ~upporting docurnent~fion~ tha~the~ropos~d~';~)i WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessap/, the reasons supporting thi determination. Name of Lead Agency Date Tifie of Responsible Officer Print or Type Name of Responsible Officer In Lead Agency Signature of Responsible Officer in Lead Agency Signature of Preparer (If different from responsible officer) ~oard of Trustees Applioa~on County of Suffolk State of New York ~ J~-- 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. SWORN TO BEFORE ME THIS ~W/fh DAY OF ~ CCt~a~-% ,20C2 ~ Notary Public OONNIE D. BUNCH Not~q~ Public. State of New York No. 01BU018§050 Qualified in Suffolk County , Commission E~ires April 14. 20 t~ oard of Trustees Applicat~ AUTHORIZATION (where the applicant is not the owner) (print owner of property) residing at (mailing address) do hereby authorize (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. Owner's signature) 8 APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics nmhibits conflicts of interest on the oart of toWn bfficem and emvlovees. The oumoso of this form is to nrovide information which can alert the town of ~ossible conflicts ofi~temst and allow it to take whatever action necessary to avoid same. (Last name, fast name, ~alddle initial, unless you am applying-in th~name of someone else or other entity, such as a company. If so, indicate the 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 oftbe Town of Southold? "Relationship" includes by blood, marriage, or business 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 shams. YES NO X If you answered "YES", complete the balance o£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) thc owner of greater than 5% of the shams of the corporate stock oftbe applic~.nt (when the applicant is a corporation); B) the legal or 'beneficial owner 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 RELATIONSHIP Form TS 1 Submitted this.~._day of ]~£C 200 oj Signature ~ ~ .... SUFF.CNTYWATERA~ j 16315895273 14:30 12-09-2009 1/5 12/89/2889 18:53 7656 BOP~DOF PP, GE 01 Tram ~ ~lmkl A. . I~ai*&UCTIONS a~ ihe aol~ of the LWRP policy mndmds md ~ldtflom ,~*~ in th~ comtstencY A copy of ti2 LWEP is availabi~ in the following places: online at ~ae Town of ~:mthold ' s webstte (soulholdtown~rk.net), the Board of Trustees Offi~, the Planning Degartmmt, local h'bmri~s nad the Town Clerk's office. K. D~SC'RII~ONOF~[~-~ANDPROPO~DACTION The Appth:~ion has beta sulmit~d to TownBoard [] Plam~si~mlE~ Calegc~ of Town of Soulhold agency a~tion (cheek q~pmpriatc'~): (c) p~m~,, am,,,,al,~ ca. ar:~ao~: ~ 16315895273 SUFF.CNTY WATER AUdi~ 1:15:03 12-09-2009 2/5 C. lCvalute the project to the folbwing pelldes by nnalyMn[ how ~he projeet wJH fla~thm- suppofl or not suppoFt ~e pelicim. Provide all pFoposed Best Mana~nent Practices ~hat will farther eneh policy. Xneomplete ans~ers will FequlFe that the fo~m be returned for completion. DE'v'KLOI~3) COAST POLICY Policy 1. FOster · p~ttern of development in the Town of Sou*hold ~at enhanees eemmnnity eharneter, pmset%~s open simce~ maims efllden¢ use of hfraMrueture, mains bendlebd ue efa eoa~al ioeation~ and ~ sdver~e effee~ of developmenL See LWRP Section Ill- Polle~; ~ 2 for evtluafioJa eriterh. Policy 2. Frotect and ~ hatoric and archneologienl rumurces of the Town of Southold. See LWRP Seffion I~ -~gm 3 tbroush 6 fOF evuludion nriterb [] Ym [] No t t Not Applietble 1631 $89~273 SU FF.CNTY WATER AIJ~i~ 12/89/2889 10:53 76566~" j 15:25 12-09-20~9 3/5 PAGE ~3 l'ollcy 3. gnhnce ~ ~ mHi ~ scuie mmtrm tbroq:hogt &e T~wn of Soutbdd. See LWRP ~ka I11 - Peff~.~ 6 tb~t~ 7 fer ev~mbn erite~ COASt Seetion m- P~lkie~[.~ Ihroulh 16 ~or mdu~fhm efiteri~ [] Yes [] No L=J NotAppllcmbb Policy S. Proteet mtd improve wuter quli~ and supply tn the Town of J~omhoM. See LWI~ Sedion I]1 - F'ollde8 Ptsu 16 th~ for evahmttou eriterh Polk'y 6. Pndeet mtd rustou (he' quoHty iud hm~ton of the Tawu ef SoatlMM eeesystetm indudru~ 8ipbnt Co~s~l fbh m~d WOdlEe Habltm mid wethmb, b LWRP ~ m-Po~lc~ ~ ~ fhroosh $2 for e, dumlon criterh. 16315895273 SUFF.CNTY WATER AU~ j15:~ 12-09-2009 4/5 X2/eg/28e9 3.8:53 7SSSb"~F~' BOARD ~ PA~E 84 Yes N~ Not Apfdhbk Poliey 8. B*fi~ mavironm~mtal de~gntdation in T~,m of So.old Ikmm redid wsste nd ~ subtmms md wf..lams~LWRP Seetlon ~ll - Polities; Pages 34 through 38 for evduatioa er/twh. ruources of the Tewn of SouthoM. see LWI~ Seeh m - mlaes{ ],qe ~8 ~m,u~ ~6 f,,r eubmtbu 16315~95273 SUFF.CNTY WATER AUd~ 1:16:00 12-09-200~ 5/5 12/89/28~9 ].0:53 7656BI1~ BDe,RD OF PAGE 85 Policy 12. ISTOM~ ~tpteuitumi lamb. in the Town o! ~e~oM. See LWRP Section i~ - Poih:h=; Paps 62 through 65 for evfduqon eflterb. ® SEE PAINT 3' HAYBAILB SEE PAINT BEND 6" VALVE & BOX BY BCWA CREW INSTALL 2" BLOW-OFF ~ END OF NEW WATER MAIN USING: 14" PLUG(T/J) 1-2" CURB STOP & DRAIN 1-2' GALVANIZED CAP 1-2" GALVANIZED ELBOW 2-2" GALVANIZED NIPPLE 2" X 2-VALVE BOXES (COMPLETE) 5~-OF 2" GALVANIZED PIPE --NOTE5 TO CONTRACTOR -- BY $CWA CREW OF NEW WA~R MAiN USING: 14" PLUG(T/J) t-2" CURB STOP & DRAIN 1-2" GALVANIZED CAP t-2" GALVANIZED ELBOW 2-2' GALVANIZED N~PPLE 2' X 8" 2-VALVE BOXES (COMPLE-/~) 5'-OF 2" GALVANIZED PIPE ~DUCER NO VALVE SKETCH AVAILABLE t8-O -8' VALVE & BOX 8" X 6" REDUCER VALVE & BOX 'BEND ~0 INFRONT ' B~ASINS EXISTING 8" PLUG(TJJ) ~ ~L T~NCH IN ROAD TO BE SWE~ED ~D PAVED AT THE END OF THE DAY i ~ ~- '~ ~r~'~,'~'~ ~ G" X G" T~ (ANC.) "MATTITUCK NORTH 5 SURCHARGE AREA" co~.c~o~ ~o.~ ~ Suffo~ Co~ty Water Au~oHty ~, o, ~ ["~' ~' ~5-1~39-(1) ~OREKEEPER COPY WA~ ~ ~ST~LA~ON I INSTAL SEEP/