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1, Board Of Southold Town Trustees
'i SOUTHOLD, NEW YORK
PERMIT NO. ......... ` l?_ - DATE: .4.7,f-—
..............
�S ISSUED
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Pursuant to the provisions of Chapter 615 of the Laws of
the State of New York, 1893; and Chapter 404 of the Laws of the
State of New York 1952; and the Southold Town Ordinance en-
` titled "REGULATING AND THE PLACING OF OBSTRUCTIONS k
�i IN AND ON TOWN WATERS AND PUBLIC LANDS and the
REMOVAL OF SAND .
;I , GRAVEL OR OTHER "MATERIALS FROM '
LANDS UNDER TOWN WATERS;" and in accordance with the
Resolution of The Board adopted at a meeting held on .......
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I9 / and in consideration of the sum of $ • .�'.�'. paid by s
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of ....,, �. subject z
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Terms and Conditioj listed on the reverse side hereof, �F
itis ai of Southold Town Trustees authorizes and permits the following:
all in accordance with the detailed specifications as presented in k
the originating application. ! «
IN WITNESS WHEREOF, The said Board of Trustees here- `
b causes its Corporate Seal to be affixed, and these resents to
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be subscribed by a majority of the said Board as of this date.
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TERMS and CONDITIONS
The Permitte j—
residing at -' -L--�— N. Y., as
part of the consideration for the ' ce of the Permit does understand and prescribe to the fol-
lowing:
1. That the said Board of Trustees and the Town of Southold are released from any and
all damages, or claims for damages, of suits arising directly or indirectly as a result of any oper-
ation performed pursuant to this permit, and the said Permittee will, at his or her own expense,
defend any and all such suits initiated by third parties, and the said Permittee assumes full liability
with respect thereto, .to the complete exclusion of the Board of Trustees of the Town of Southold
2. That this Permit is valid for a ;period of J �' mos. which is considered to be the
estimated time required to complete the-work involved, but should circumstances warrant, request
for an extension may be made to the Board at a later date.
3. That this Permit should be retained indefinitely, or as long as the said Permittee wishes
to maintain the structure or project involved, to provide evidence to anyone concerned that auth-
orization was originally obtained.
4. That .the work involved will be subject to the inspection and approval of the Board or
its agents, and non-compliance with the provisions of the originating application, may be cause for
revocation of this Permit by resolution of the said Board.
5. That there will be no unreasonable interference with navigation as a result of the work
herein authorized.
6. That there shall be no interference with the right of the public to pass and repass along
the beach between high and low water marks.
7. That if future operations of the Town of Southold require the removal and/or alterations
in the location of the work herein authorized, or if, in the opinion of the Board of Trustees, the
work shall cause unreasonable obstruction to free navigation, the said Permittee will be required,
upon due notice, to remove or alter this work or project herein stated without expenses to the Town
of Southold.
8. That the said Board will be notified by the Permittee of the completion of the work auth-
orized.
9. That the Permittee will obtain all other permits and consents that may be required sup-
plemental to this permit which may be subject to revoke upon failure to obtain same.
A/4 - Rev. 6/72
BOARD OF TOWN TRUSTEFS
Town Of Southold
Main Road
Southold, New York 11971
APPLICATION TO DREDGE and or FILL
I. Does this project involve the use of WETLANDS as defined in the Southold Town Ordinance
in Wetlands? YES or NO. If it does, your application must be filed through the Town Clerk's
Office. /A _
2. Applicant's name and address: ...�L: ly�yf lZjf�.....f /►'T� v
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3. Contractor's name and address: ......./..�......... ...........................................................................
.................................................................................................................................................................
4. Explain briefly the purpose of this application:
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5. After issuance of Permit, I expect to: (mark with an X)
(a) Commence work— AT ONCE ............: ASAP .X.....; UNKNOWN TIME .............
(b) Complete work in — 1 DAY ............: 1 Mo. ..X......; 1 YR. ............; FUTURE .............
6. Secure the correct Area Map from the Secretary of this Board, and by using an X WITHIN
A CIRCLE as a mark, indicate as closely as possible the location of this work. On the reverse
side of this map, provide a SCALE DRAWING which will show the Ordinary High Water
Mark and the size and shape of the structure or work. All dimensions offshore of the
O. H. W. M. should also be shown and include any free standing pilings which will remain
at completion.
7. Provide the following documents:
(a) A Licensed Engineer's Survey of the property involved.
(b) A copy of the Contractor's Plans and Specifications.
8. Has any previous application for this work been,die/nied by any other local government agency?
YESor NO. If it has been, name the agency. ./.�14'.:...............................................................
Date of denial ........................................
9. If dredging is contemplated, give your estimate of the following.
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(a) Average depth of water at M. L. �N.where dredging, .. ......... ........ ......................... ft.
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(b) Maximum depth of dredging below the bottom, ....... .................................................... ft.
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(c) Maximum length of dredged area ............ .. .`............................................... ft.
(d) Maximum width of dredged area ....... .j?.......................................................... ft.
(e) Maximum amount of material to be dredged ..... ....... C. yds.
10. If filling is expected, give your estimate of the following:
(a) Maximum amount of material required..................................................................... c. yds.
(b) Explain how fill will be obtained and where it will be placed.
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11. In requesting approval of this application, I submit that: I am the person accountable for the
performance of the work in accord with the plans and specifications attached hereto; I
have read or am familiar with the provisions of any Southold Town Ordinance pertinent to
the work involved; and further, I intend to adhere to qnd abide by the Terms Conditions
of the Permit.
Accepted by: Dated:
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