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HomeMy WebLinkAboutTR-7906A Glenn Goldsmith, President �QF SQU�y Town Hall Annex Michael J.Domino,Vice-President ,`O ��� 54375 Route 25 P.O.Box 1179 John M.Bredemeyer III #[ Southold,New York 11971 A.Nicholas Krupski G Q Telephone(631) 765-1892 Greg Williams Fax(631) 765-6641 Comm,��' BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD February 13, 2020 David Jude Jannuzzi P.O. Box 1672 Mattituck, 'NY 11952 RE: 1470 JACKSON ST., LLC 1470 JACKSON STREET, NEW SUFFOLK SCTM# 1000-117-10-11 Dear Mr. Jannuzzi: The following action was taken at the Southold Town Board of Trustees regular meeting held on Wednesday, February 12, 2020: RESOLVED, that the Southold Town Board of Trustees APPROVE the request for a Transfer of Administrative Permit #7906A from Claire Manning to 1470 Jackson St. LLC, as issued on September 19, 2012. Any other activity within 100' of the wetland boundary requires a permit,from this office. This is not a determination from any other agency. If you have any questions, please contact our office at (631) 765-1892. Si erely, GlennGold i , Board of Trustees GG/dd t Michael J. Domino,Presi $UFFQ(�-COG Town Hall Annex John M. Bredemeyer III,Vice-President �� yam, 54375 Route 25 Glenn Goldsmith C3 P.O.Box 1179 A.Nicholas Krupski �. `' Southold,NY 11:971 Greg Williams �L p! Telephone(631)765-1892 ��l �a Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in field by: N. kr'PZk',! David Jude Jannuzzi on behalf of 1470 JACKSON ST. LLC requests a Transfer of Administrative Permit #7906A from Claire Manning to 1470 Jackson St. LLC, as issued on September 19, 2012. Located: 1470 Jackson Street, New Suffolk. SCTM#: 1000-117-10-11 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=q Setback Waiver Required 1. Residence: 100 feet 2. Driveway: 50 feet 3. Sanitary Leaching Pool (cesspool): 100 feet 4. Septic Tank: 75 feet 5. Swimming Pool and related structures: 50 feet 6. Landscaping or,gardening: 50 feet 7. Placement of C&D material: 100 feet TOP OF BLUFF: 1. Residence: 100 feet 2. Driveway: 100 feet 3. Sanitary leaching pool (cesspool) 100 feet: 4. Swimming pool and related structures: 100 feet Public Notice of Hearing Card Posted: Y / N Ch. 275 V Ch. 111 SEQRA Type: 1 II Unlisted Action Type of Application: Pre-Submission Administrative Amendment Wetland Coastal Erosion Emergency Violation Non-Jurisdiction Survey <_ 5 years: Y/N Wetland Line by: C.E.H.A. Line Additional information/suggested modifications/conditions/need for outside review/consultant/application completeness/comments/standards: 2,IS All ©K. . I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: J. Bredemeyer M. Domino G. Goldsmith N. Krupski G. Williams Other Glenn Goldsmith, Pa * S Town Hall Annex res�it �� ou�y Michael J. Domino,Vice-President ,`O� ��� 54375 Route 25 P.O. Box 1179 John M. Bredemeyer III Southold, New York 11971 A. Nicholas Krupski G Telephone(631) 765-1892 Greg Williams O Fax(631) 765-6641 nn BOARD OF TOWN TRUSTEES a TOWN OF SOUTHOLD i JAN 1 3 2020 APPLICATION FOR TRANSFER OF WETLAND PiLRMIT•- - , -- DATE: PROPERTY OWNER NAME: MAILING ADDRESS: J��� a611 b lam/ l PHONE: &� / 2W- AGENT: -AGENT: PHONE : ADDRESS: PROPERTY LOCATION: `� /y � ST SMF TAX MAP NO.: DLiJOAUD"16±��Z1 - -ak- . itS 7- request a Transfer of Permit # from / S C Signed b : 9 Y C� Board of Trustees Application AUTHORIZATION (Where the applicant is not the owner) I/We, owners of the property identified as SCTM# 1000- ( � _ / o ^ r / in the town of New York hereby authorizes I' 1 U(7 U2-2-t to act as my agent and handle all necessary work involved with the application process for permit(s) from the Southold Town Board of Trustees for this property. GGc�7 h ' ;ropnertyv Owner's Signature Property Owner's Signature SWORN TO BEFORE ME THIS DAY OF 20 No blic BETSY A.PERKINS (Votary Public,State of New York No.01 PE6130636 Qualified in Suffolk Coun� Commission Expires July 18, Boara of 'Trustees aPP-L1( Au1oA AFFIDAVIT 1 Y7U � � cS 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 BOARD OF 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, INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. Signature of Property Owner ` ��� Signature of Property Owner � uZ� / SWORN TO BEFORE ME THIS /� DAY OF J47J , 20 02� vV No ublic BETSY A.PERKINS Notary Public,State of New York No.01 PE6130636 Qualified in Suffolk coun / commission Expires July 18, 1 John M. Bredemeyer III,President 'I�i�4�OF S00T/y Town Hall Annex Michael J. Domino,Vice-President 1∎1 l0 54375 Main Road P.O.Box 1179 James F.King,Trustee ! Southold,New York 11971-0959 Dave Bergen,Trustee G @ �� � Telephone(631) 765-1892 Charles J.Sanders,Trustee Fax ii•• Fax(631) 765-6641 soi BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 0962C Date: April 3, 2014 THIS CERTIFIES that the removal of the existing septic system and construction of a new septic system further landward At 1470 Jackson Street,New Suffolk,New York Suffolk County Tax Map# 117-10-11 Conforms to the application for a Trustees Permit heretofore filed in this office Dated July 18, 2012 pursuant to which Trustees Administrative.Permit#7906A Dated September 19, 2012,was issued and conforms to all of the requirements and conditions of the applicable provisions of law. The project for which this certificate is being issued is for the removal of the existing septic system and construction of a new septic system further landward. The certificate is issued to CLAIRE MANNING owner of the aforesaid property. gig"' 44""‘ 61,4412.7.4 Authorized Signature 0 0 John M. Bredemeyer III,President �,,1' FOL,, Town Hall,53095 Main Rd. Michael J. Domino,Vice-President s,+'# � 0 P.O. Box 1179 James F. King y ; Southold,NY 11971 Dave Bergen `O f%$ Telephone(631)765-1892 g -44;* `ait 11 Fax(63 I)765 6641 Charles J.Sanders 1 * , BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DAT7INSPECTION: Z 6 ( 1 If Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1st day of construction '/2 onstructed Project complete, compliance inspection. INSPECTED BY: r, I' e_�0 f COMMENTS: 4/ ( CA L S (a te-' � ',Nar CERTIFICATE OF COMPLIANCE: C) (r James F. King, President Bob Ghosio, Jr., Vice-President Dave Bergen John Btedemeyer Michael J. Domino Town Hall, 53095 Maia Rd. P.O. Box 1179 Southold, NY 11971 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 1~ constructed Project complete, compliance inspection James F. King, President Bob Ghosio, Jr., Vice-President Dave Bergen John Bredemeyer Michael J. Domino Town HallAnnex 54375MainRoad 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.: 7906A Date of Receipt of Application: July 18, 2012 Applicant: Claire Manning SCTM#: 117-10-11 Project Location: 1470 Jackson Street, New Suffolk Date of Resolution/Issuance: September 19, 2012 Date of Expiration: September 19, 2014 Reviewed by: Dave Bergen, Trustee Project Description: To remove the existing septic system and construct new septic system further landward. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the survey prepared by John C. Ehlers Land Surveyor, last dated on August 9, 2011, and stamped approved on September 19, 2012. Special Conditions: None 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. James F. King, President Board of Trustees James F. King, President Bob Ghnsio, Jr., Vice-President Dave Bergen John Bredemeyer Michael J. Domino Town Hall Annex 54375 Route 25, P.O. Box 1179 Southold, NY 11971 Telephone (631 ) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Please be advised that your application dated -/Il{ ~1 ~:: has been reviewed by this Board at the regular meeting of '' t~/l~/~¢- and your application has been approved pending the completiofi of the following items checked off below. __ Revised Plans for proposed project __ Pre-Construction Hay Bale Line Inspection Fee ($50.00) __ 1st Day of Construction ($50.00) __ ½ Constructed ($50.00) V/ Final Inspection Fee ($50.00) __ Dock Fees ($3.00 per sq. ft.) Permit fees are now due. Please make check or money order payable to Town of Southold. The fee is computed below according to the schedule of rates as set forth in Chapter 275 of the Southold Town Code, The following fee must be paid within 90 days or re-application fees will be necessary. You will receive your permit upon completion of the above. COMPUTATION OF PERMIT FEES: TOTAL FEES DUE: BY: James F. King, President Board of Trustees I WWM-042 (Rev.9/2004) SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES OFFICE OF WASTEWATER MANAGEMENT 360 YAPHANK AVENUE, SUITE 2C YAPHANK, NEW YORK 11980 (631) 852-5700 NOTICE OF INCOMPLETE APPLICATION - RESIDENTIAL TO: Claire Manning [ H.S. REFERENCE NO.: R10-10-0047 PO Box 262 I New Suffolk, NY 11956 PROPERTY LOCATION: TXM:1000-117-10-11 The plans for your proposed sewage disposal and water supply systems have been reviewed and the following will be required prior to further processing of the application for approval to construct. PLEASE RETURN A COPY OF THIS FORM WITH ANY RESUBMISSION. NOTE: CHANGES TO PLANS MUST BE MADE BY A LICENSED DESIGN PROFESSIONAL (I.E. SURVEYOR, ARCHITECT OR ENGINEER). 1. PRELIMINARY APPROVALS -- OTHER AGENCIES [] N.Y.S. Dept. of Env. Cons. [] Sewer District Approval [] Town Wetlands Permit: [] S.C.D.H.S. Vector Control ] SEQRA Determination- Town ]Other:waterline easement 2. PLAN DATA AND INFORMATION REQUIRED 3 prints of revised survey (or plot plan) required with design professional's original stamp and Application form : missing wetland and town zoning checkoffs. Application Fee: $ Submit floor plans for Pool house/or barn? Surveys must be no larger than 11"X 1T' Indicate area of lot (sq. ft.) Show existing/proposed driveway locations on plans S.C. Tax Map Number incow?c~. Public sewer stub location from sewer district shown on plans Indicate on plan the specific location(s) [with measurements] of all water supply wells and septic systems (within 150' of all property lines) or state if dwellings are connected to Minimum separation distances not maintained: sanitary system must be clear &driveway Show area for 50% expansion of sewage Show highest recorded groundwater and calculations Show proposed sewage disposal system location(s) on plan. bulletin Indicate any surface waters within 300' of plot; show wetlands limit as flagged by NYSDEC and/or Town. must be based upon NGVD (1929), USC & GS Datum Sewagedisposa] systemdesign See below: Surrounding property - vacant or improved (within 150' of all See enclosed Form WWM-043 3. OTHER/REMARKS: Show location of existing water and sanitary facilities, Must state existing sanitary to be abandoned. Submit letter from water district indicating distance to nearest public water main and availability. Show sanitary system design based upon Retaining wall must be designed by P.E. or R.A. Missing PE's stamp or seal Comer elevations and first floor elevation. Show test boring and location on plans : please note the date and by whom it was done by. Or~di2g p!~ al, owing invert elevations of sewage disposal system, foundation and final grade. Slope exceeds standards: 15% maximum within 20' of sanitary system, including See additional comments on marked-up enclosed REVIEW OF THE ADDITIONAL INFORMATION REQUESTED MAY RESULT IN THE NEED TO MODIFY THE PROPOSED WATER SUPPLY AND/OR SANITARY SYSTEM DESIGN. FURTHER INFORMATION MAY ALSO BE RE(~UIRED FOR REVIEW BY THIS DEPARTMENT. DATE PREPARED: February 2, 2012 REVIEWED BY: Nadia Tintera No. James F King, President Bob Ghosio, Jr, Vice-President Dave Bergen John Bredemeyer Michael J, Domino PO Box 1179 Southold. NY 11971 Telephone(631 765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection/VVorksession Report CLAIRE MANNING requests an Administrative Permit to remove the existing septic system and construct new septic system further landward. Located: 1470 Jackson Street, New Suffolk. SCTM# 117-10-11 Type of area to be impacted: __Saltwater Wetland Freshwater Wetland Distance of proposed work to edge of wetland Part of Town Code proposed work falls under: ~(Chapt.275 Chapt. 111 other Sound ~ Bay T~,T~e of Application: Wetland Coastal Erosion __Amendment dministrative__Emergency --Pre-Submission __Violation Info needed: Conditions: Present Were: __J. King __B. Ghosio ,"~ D. Bergen, __J. Bredemeyer.__ Michael Domino D. Dzenkowski Form filled out in the field by Mailed/Faxed to: Date: other 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: Jim King, President Town of Southold Board of Trustees From: Mark Terry, Principal Planner LWRP Coordinator AUG - 9 2012 $0ut, ,~0b !'0w~ P, eard of Trustees Date: August 9, 2012 Re: Proposed Wetland Permit for CLAIRE MANNING SCTM#1000-117-10-11 CLAIRE MANNING requests an Administrative Permit to remove the existing septic system and construct new septic system further landward. Located: 1470 Jackson Street, New Suffolk. SCTM# 117-10-11 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 INCONSISTENT with the denoted following Policy Standards and therefore is INCONSISTENT with the LWRP: Policy 6. Protect and restore the quality and function of the Town of Southold ecosystem 6.3 Protect and restore tidal and freshwater wetlands. A. Comply with statutory and regulatory requirements of the Southold Town Board of Trustees laws and regulations for all Andros Patent and other lands under their jurisdiction. The proposed relocation of the leaching pools does not comply with Town Code setbacks. The required setback is 100' from a bluff line (top of bank) to a sanitary leaching pool. Bluff line. [3] Sanitary leaching pool (cesspool): 100 feet. It is recommended that the sanitary system be relocated to meet required setbacks. 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 James F. King, President Bob Ghosio, Jr, Vice-President Dave Bergen John Bredemeyer Michael J. Domino Town Hail Annex 54375 Main Road P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEEt TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application --Wetland Permit Application .~ Administrative Permit --Amcndmen~f['rans fer/Extension ~( Received Application: ~Received Fee:$ ~O ~ ~ Completed Application __Incomplete __SEQRA Classification: Type I__Type I1 Unlisted _ __Coordination:(date sent) ?/~//1~ ~LLWRP Consistency Assessment Form _ CAC Referral Sent: ~Date of Inspection:_ ~[I ~/]~ __Receipt of CAC Repo/t: ! ' Lead Agency Determination: _ Technical Review: Public Hearing Held: Resolution: Southhdd ,rowe Board of Trustees Name of Applicant Address /ZT/YP /~/t~ ,-~/~/~ Phone Number:( ) Suffolk CountyTax MapNumber: 1000~ //'~ ~/~ Property Location: (provide LILCO Pole #, distance to cross streets, and location) (If applicable) Address: Phone: of Trustees Appllcation Land Area (in square feet): Area Zoning: Previous use of property: Intended use of property:. Covenants and Restrictions: If "Yes", please provide copy. GENERAL DATA Yes ~ No Does this project require a variance from the Zoning Board of Appeals __ If "Yes", please provide copy of decision. Yes * No Will this project require any demolition as per Town Code or as determined by the Building Dept. Yes 3/ No Does the structure (s) on property have a valid Certificate of Occupancy ;~ Yes No Prior permits/approvals for site improvements: Agency Date 2~ 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) In preparation to apply for a permit to improve an accessory building on my property at 1470 Jackson St, I made an application to the Suffolk County Department of Health for a half bath. However the county is requiring that I upgrade the septic system on the main house (a two story single family). The septic system was original to the house built in 1967 and was built using brick materials. The system was inspected by Joseph Fischetti, PE and a new replacement system has been designed by him. The county will approve the replacement design and removal of the otd structure but is requiring us to have a Town Wetlands Permit before granting approval. Therefore I am making an application to the Board of Trustees for a Town Wetlands Permit to replace the 45 year old septic block built system for a new system which will be up to code. Claire A. Manning of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: of wetlands on lot: ~/j~F/) square feet Area Percent coverage of lot: ~ / % Closest distance between nearest existing structure and upland edge of wetlands: [ ~5 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? 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: 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): Board of Trustees Application County of Suffolk State of New York DEPOSES AND ~ ~T ~S~ IS ~ ~PLIC~ FOR ~ ~O~ DESC~ED P~(S) ~ ~T ~L STA~S CO~D ~ ~ ~ TO ~ BESTOF ~R.~O~EDGE ~ BEL~F, ~ ~T ~L WO~ ~L.BE DO~ ~ T~ ~ SET FOR~.~'~S ~PLICATION ~ ~-~Y BE ~RO~D BY T~ SO.HOLD TO~ BO~ OF TRUSSES. ~ ~PLIC~ AG~ES TO HOLD T~ TO~ OF SO--OLD ~ ~ TO~ ~US~S ~ESS ~ ~E ~OM ~ ~ ~L D~AGES ~ CL~S ~S~G ~ER. OR BY ~ OF S~'PE~(S), ~ G~. ~ CO~LE~G ~S ~PLICATION, I ~BY A~O~ ~ ~US~ES, ~ AG~(S) OR ~P~S~ATI~S(S)~ TO E~R O~O ~ PROPERTY TO ~SPECT ~ '~SES ~'CON~CTION ~H ~W OF ~S ~PLICATION. SWO~ TO BEFO~ ~ TinS ; Q .20 l& Notary Public CONNIE D. BUNCH Notary Public. State of New York No. 01BU6185050 Qualified in Suffolk County ~ Commissipn Expires Apr 114.2 J APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM Thc Town of Southold's Code of Ethics prohibits conflicts of interest on thc Dart of town Officers and cmolovccs. Thc vurvo~ of Lh, i~ form is to nrovide information which can alert the town ofoossible conflicts of intcm~t and allow it to take whatever action is nec to void (Last name, first name, middle initial, unless you are applying in the 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 Of"Other", name the activity.) Do you personally (or thmagh 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 business interest "Business interest'~ means a business, in~:luding 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 ,/X~ 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 applicant/agent/representative) and the t~wn 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% oftbe shares of the corporate stock of the applic0nt (when the applicant is a corporation); ___B) the legal or 'beneficial own~ of any interest in a non-corporate entity (when the applicant is not a corporation); ___C) an officer, director, partner, or employee oftbe applicant; or ___D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS 1 617.20 PROJECT ID NUMBER APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only PART 1 - PROJECT INFORMATION ( To be completed by Applicant or Project Sponsor) 3.PROJECT LOCATION: , ,.,.~/~ I _ _~ ,, SEQR 4, PRECISE LOCATION: Sb'eet Addess and Road Intersections, Prominent landmarks etc -or provide map 5. IS PROPOSED ACTION: ~ew ~ ~pansion ~difica~on / alteration 6. DESCRIBE PROJECT BRIEFLY: Initially ~ Ultimately acres COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? ] No If no, describe briefly: IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) Residential [~lndustria, [~Commercia, E--lAgriculture E~] Park / Forest / Open Space [~] Other (describe) 10. DOESACTI~ACTI INVOLVE A PERMIT APPROVAL. OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Fede..~l, State or Local) I-~Yes MNo If yes, list agency name and permit / approvak E~Yes ~/1No If yes, ~ist agency name and permit / approval: ? 12. AS 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 I THRESHOLD IN 6 NYCRR, PART 617,47 If yes, coordinate the review process and use the FULL FAF. [--]Yes r~No B. WILL ~CTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another involved agency. r-]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 pattsm, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain bdefiy: I C2. Aesthetic, agflcoltural, archaeological, historic, or other natural or cultund resources; or commu'~i'~[;'~)r neighborhood character? Explein b~iefly: C3. Vegetation or tauna, fish, shellfish or Wildlife species, significant habitats, or threatened or endangered ~? Explain bdefly: I C4. A community's existing plans or goals as officially adoptedl or a change in use or intensity of use oi land oi other natumi resources? Explain bdefly: I C5. Growth, subsequent development, or mleted activities likely to be induced by the proposed action? Explain bdefly: C6. Long term, short term, cumulative, or other effects not identified in C1 -C57 Explain bdefly: I C7. Other impacts linctudin~l chanties in use of either cluantit;/or t;/pe of ener~;/? Explain briefl;/: D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA {CEAI? Ill yes, explain briefly': E. IS THERE, OR IS THERE LIKELY TO BE~ CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If '~es explain: PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or otherwise signirmanL Each effect should be assessed in connection with its (a) setting (i.e. ud~an or rural); (b) probability of occurring; (c) duration; (d) irrevemibility; (e) geographic scope; and (f) 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 yes, the determination of significance must evaluate the potential impact of the proposed action on the environmental characteristics of Ihe CEA. Chec~ this box if you have identified one or more potentially large or significant adverse ~mpacfe which MAy occor, Then proceed directly to the FUU FAF and/or prepare a positive declaration. Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed actiof WILL NOT result in any significant adverse environmental impacts AND provide, on attachmente as necesse~j, the roasens supporting thi= determination. Board of Trustees Name of Lead Agency .~ Print or Type Name of Responsible Officer in Lead Agency ~/Signatum of Responsible Officer i~ead Agency Date President [] Title of Responsible Officer Signature of Preparer (If different from responsible officer) In preparation to apply for a permit to improve an accessory building on my property at 1470 Jackson St, I made an application to the Suffolk County Department of Health for a half bath. However the county is requiring that I upgrade the septic system on the main house (a two story single family). The septic system was original to the house built in 1967 and was built using brick materials. The system was inspected by Joseph Fischetti, PE and a new replacement system has been designed by him. The county will approve the replacement design and removal of the old structure but is requiring us to have a Town Wetlands Permit before granting approval. Therefore I am making an application to the Board of Trustees for a Town Wetlands Permit to replace the 45 year old septic block built system for a new system which will be up to code. Claire A. Manning Town of Southold Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM  PROPERTY LOCATION: S.C.T.M.#: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A STORM-WATEI~ GRADING, DRAINAGE AND EROSION CONTROL PLAN District Section Block Lot CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. SCOPE OFWORK - PROPOSFi) CONSTRUCTION fl',~t # / WORKASSF~SMF/~T [ Yes No a. What is the Total Area of the Project Parcels? (include Total Area of all Parcels located within /.?/ I Will this Project Retain All Storm-Water Run-Off the Scope of Work f~- Proposed Construction)/~,~-.~ ~ ~. Generated by a Two (2") Inch Rainfall on Site? / (sk IAc~s)- (This itam will thclude all run-off created by site b. What is the Total Area of Land Clearing cleadng and/or construction activities as well as all -- and/or Ground Disturbance for the proposed Site Improvements and the permanent creation of construction activity? o~ Z~I~) -('~" impervious surfaces.) (S.F., A--) 2 Doas the Site Plan and/or Survey Show Ail Proposed PROVID[ BRIEF PRO~CT DES~ON ~ ~ Pa~ .. ~) Drainage Structures Indicating Size & Location? This Item shall include all Proposed Grade Changes and '~-- L.~J /~)~'-p/~ ~ ? 4~p/C~' ~ ~,~'/~_.. Slopes Controlting Surface Water Flow. /~) (~.~ -~?//ff ~-~/ 3 Doas the Site Plan and/°r Savoy describe the er°si°n and sediment control practices that will be used to ' control site erosion and storm water discharges. Trois item must be maintained throughout the Enitre Construction Pedod. 4 Will this Project Require any Land Filling, Grading or Excavation where there is a change to the Natural Existing Grade Involving more than 200 Cubic Yards--L~ --V of Mater[al within any Parcel? 5 Will this Application Require Land Disturbing Activities Encompassing an Area in Excess of Five ~nousand (5,000 S.F.) Square Feet of Ground Surface? 6 is there a Natural Water Course Running through the D / Site? Is this Project within the Trustees jurisdiction General DEC SWPPP Requirements or within One Hundred (100') feet of a Wetland or Submission of a SWPPP is required for all Construction activities involving sell Beach? disturbances of one (1) or more acres; including disturbances of less than one acre that 7 Will there be Site preparation on Existing Grade Slopes are pert of a larger common p~an that will ultimately dietmb one or mom acres}of land; which Exceed Fifteen (15) feet of Vertical Rise to including Construction activities involving sell disturbances of less than one (1 acre where One Hundred {100') of Horizontal Distance? L..~J the DEC has determined that a SPDES pemd! is required for storm water discharges. 2. 'me SWPPP shall describe the erosion and sediment control practices and where 9Will this Project Require the Placement of Materiel, constructed to reduce the pollutants in storm water discharges and to assure Item Within the Town Right-of-Way or Road Shoulder--L~ -- STATE OF NEW YORK, / _ / coum ........... ss That l,/]~.././..t~...../..~...~..~.~(~.<~.,/~ ........................ being duly sworn, deposes and says that he/she is the applicant for Permit, And that he/she is the ........... 2~.~,,.?..(.~.Z.~Y~.~...~......~_~...~ ......................................................... Owner and/or representative of the Owner or Owners, and is duly authorized to perform or have performed the said work and to make and file ~n; that all statements contained in this application are true to thc best of his knowledge and belief; and that the work will be performed in the manner set forth in the application filed herewith. Sworn to before mc this; ........................ ../.~ ................ dayo£ ....... .~..~ ........................ ~o..l.~' otary Pubhc .... ~C~[:L~-~,~O- ............. . . ;~,F¥ CMblic, State of New York ~;i .......................... FORM - 06/10/ No. 4994753 .~ualitied in Suffolk County .,;remission Expires May 22, 20L/.. Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 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. 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 Southold Town). If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus~ each answer must be explained in detail~ listing both supporting and non- sum~ortin~ facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions, it shall not be undertaken. A copy of the LWRP 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. B. DESCRIPTION OF SITE AND PROPOSED ACTION scm# /i7- /)// The Application has been submitted to (check appropriate response): TownBoard [] Planning Board ~-~ Building Dept. ~ BoardofTrustees Nature and extent of action: 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) (b) Financial assistance (e.g. grant, loan, subsidy) (c) Permit, approval, license, certification: In preparation to apply for a permit to improve an accessory building on my property at 1470 Jackson St, I made an application to the Suffolk County Department of Health for a half bath. However the county is requiring that I upgrade the septic system on the main house (a two story single family). The septic system was original to the house built in 1967 and was built using brick materials. The system was inspected by Joseph Fischetti, PE and a new replacement system has been designed by him. The county will approve the replacement design and removal of the old structure but is requiring us to have a Town Wetlands Permit before granting approval. Therefore I am making an application to the 8oard of Trustees for a Town Wetlands Permit to replace the 45 year old septic block built system for a new system which will be up to code. Claire A. Manning Location of action: Site acreage: Present land use: Present zoning classification: 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: (b) Mailing address: (c) Telephone number: Area Code (d) Application number, if any: Will the action be directly undertaken, require funding, or approval by a state or federal agency? Yes [] No [~ If yes, which state or federal 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 LWRP Section III - Policies; Page 2 for evaluation criteria. ~Yes [] No ~ Not Applicable / Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III - Policies Pages 3 through 6 for evaluation criteria : Yes: No Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III - Policies Pages 6 through 7 for evaluation criteria 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 [~Yes ~-] No ~ Not Applicable 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 through 21 for evaluation criteria [~Yes [] No [~Not 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 through 32 for evaluation criteria. Yes No Not App~ble 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. ~-~ Yes ~--] No ~Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III - Policies; Pages 34 through 38 for evaluation criteria. ~Yes [] No [] Not Applicable M PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public re.sou.rces of the Town of/Soathold. See LWRP Section III - Policies; Pages 38 through 46 for evaluation criteria. ~/// ~'~ Yes~ No L~ Not Applicable Attach additional sheets if necessary WORKING COAST POLICIEJ Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in s~locations. See LWRP Section III- Policies; Pages 47 through 56 for evaluation criteria. [--] No ~ Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peeonie E~Yesand Town waters. See LWRP Section III - Policies; Pages 57 through 62 for evaluation criteria. ~ No ~ Not Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III - Policies; Pages 62 through 65 for evaluat/ion criteria. [] Yes ~ No[~l/i I ,~ Not Applicable Attach additional sheets if necessary Policy 13. Promot,e. appropriate use and development of energy and mineral Section III - Polie~; Pag~5 through 68 for evaluation criteria, resources. See LWRP [] Yes ~ No I~k~lot~Applicable P~PA~DBY SURVEY OF PROPERTY .~ITUATE: ~ ~=t=OLK TOHN-. ~LP E~)Pt=OLK C.,(X~, E:~RVE'YED 05-20-2010 i P-.EV I E:,ED 0-/-22-2011, J O~-Oq-2011 t .~dFFOLK COUNTY TAX # I I000 - lit - I0 - II I C:~RT~ TO: / JOI-l~ APPROVED BY BOARD OF TRUSTEES TOWN OF SOUTHOLD DATE 2..- SURVE"r'OP-. El 32.5' OL SP Hole, FdcE2on<::]id 17' PROPOSEP (::, DEDP-.OOI"i HOUSE SEPTIC __ 15OO CAL. S.T. IO' PlA. (3) LP 8~' PlA. O' PEEP PROPOSED STUDIO SEPTIC ; IOOO ®AL. S.T. /; (I) LP 8,' I21A. 12' PEEP ~:~'~ Oz< E JUL 1 8 2012 Southhold Town _ Board of Trustees SEPTIC PESI®N BY JOSEPH PISOHETTI P.E. N"¢S LICENSE NO. 52510 NOTES: · HONUHENT FOUNP FEHA FIRPI HAP ~6103C501 H F:~.:EVISED E~EPT. 25, 200q EXISTIN¢ .Er~'PTIC TO t~E P..EI,4OVED AND PILLEP INITH CLEAN SAND A~ ~ ~.C.P.H.~. 5TAN]2AF2,E:~, AREA = 4,(2...~32 S.F. OR I.Ob3E;, ACF2-.ES ®RAPHIE, E~C, ALE 1"=50' JOHN C. EHLERS LAND SURVEYOR 6 EAST MAIN STREEt N.Y.S. LIC. NO. 50202 R, ,~RH,~AD ...... ~ ~ 369-8288 Fax 369-8287 R~F.C 9;U sersUoh n\DrogNox\ 10!J0- ~ 27 updateA 07-20-20 ] 1 .pro