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Home My WebLink AboutTR-53-4-20Albert I. Krupski, President Jolm HolzapfeI, Vice President William G. Albertson Martin H. Gan-ell Peter Wenczel BOARD OF TOWN TRUSTEF~ TOWN OF SOUTHOLD Town Hail 53095 Main Road P.O. Box 1179 Sonthold, New York 11971 Telephone (516) 765-1892 Fax (516) 765-1823 COASTAL EROSION MANAGEMENT PERMIT Permit Number: 53-4-20 Name of Applicant/Agent: Name of Permittee: Doris Brown Address of Permittee: Mattituck. Property Located: same P.O. Box 915, 1979 Bergen Avenue, DESCRIPTION OF ACTIVITY: to relocate house and septic system landward from bluff. Current foundation will be left and covered with wood and well will be used as long as possible. Ail in accordance with Natural Resources Conservation Service ( letter enclosed). Date of permit issuance: October 26, 1995 This permit is valid for a period of two years from the date of issuance. SPECIAL CONDITIONS: y/Bluff restoration through a re-vegetation plan is a necessary special condition of this permit. A relocation agreement is attached hereto and is a necessary special condition of this permit. A maintenance agreement as attached with application and is a necessary special Condition of this permit. Albert J. Krupski, Jr. President, Board of Trustees AJK/jmd Albert J. Kmpski, President John Holzapfel, Vice President William G. Albertson Martin H. Garrell Peter Wenczel BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall 53095 Main Road P.O. Box 1179 Southold, New York 11971 Telephone (516). 765-1892 Fax (516) 7654823 Octok~r 19, 1995 Doris K. Brown P.O. Box 915 1979 BergenAve MattituckNY 11952 RE: SCTM ~112-1-17 Dear Ms. Brown, On Thursday, October 18, 1995 the Southotd Town Board of Trustees inspected your property and have agreed that your house did indeed need to be moved back from the edge of the bluff due to severe erosion. However, the Board agreed that if the house were to be placed back landward and put at a straight angle rather than at the angle it is now, you would be well behind the Coastal Erosion Hazard Line. The Board also feels dry wells should be placed to prevent run-off down the bluff and a stabilization planting plan for the restoration of the eroded bluff. We are enclosing the name and phone n~umber of an agency that will be able to help you provide this. If you have any questions, please contact our office. Albert J. Krupski, Jr. President, Board of Trustees ~KZdjh Encl. Cc. ZBA Bldg. Dept. ./ .% Albert J. Krupsld, President John Holzapfel. Vice President William G. A!bertson Martin H. Gan:ell Peter Wenczel Town Hall 53095 Main Road P.O. Box 1179 Southold. New York 11971 Telephone (516) 765-I892 Fax (516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only C~oastal Erosion Permit Application Wetland Permit Application Grandfather Permit Application Trustee Lands Permit Application CoWaiver ,~/ / celled App 1 icatio~: ~ './~/ erical Review: mpl~eted Appllcatlon7 ~F~/~ I nc omp lete SEQRA Classification: Type I__~Tlrpe II__Unlisted ~,oordination: (date s~ut), /C~ Referral Sent: ~"~z$~/_~,,_w L~ead .Agency Determination: __~fechnicat Revi.ew.- (date)_ .' ~s~n: ~pproved (Y/N) (~ate) -- Name of Applicant -~Ot%,1'5 Suffolk County Tax Map Number: 1000 i .TOISN OF SOUTHO[D Property Location: (provide LILCO Agenu: (if applicable) Address: Pole a, distance to cross streets, Phone: and location) ~Board of TrUstees Application Land Area (in square feet): Area Zoning: ~ ~ Previous use of property: Intended use of property: GENERAL DATA Prior permits/approvals for site improvements: Agency Date If yes, Has any permit/approval ever been revoked Governmental agency? provide explanation: No prior permits/approvals for site improvements. or suspended by a Yes Project Description (use attachments if necessary): C Board of Trustees Applic~on COASTAL EROSION APPLICATION DATA Purposes of proposed activity: ~ ~l~ ~L~"~{ Are wetlands present within 75 feet of ~ No Yes Does the project involve excavation or filling? No ~ Yes ~0 ~ ~D '~ ~ If Yes, how much material will be excavated? ~ow much material will be filled? Manner in which material will be removed or deposited: the proposed activity? (cubic yards) (cubic yards) Describe the nature and extent of the environmental impacts reasonably anticiDated resulting from implementation of the project as proposed. (Use attachments if necessary) Appendix A State Environmentalr Quality Review FULL ENVIRONMENTAL ASSESSMENT FORM Purpose: The fu EAF is designed to help aDolicants and agencies determine. In an orderly'manner, whether a oroiec: or acttan may be significant, The question of whether an action may be significant is not always easy to answer. Freauent- Iy, there are asaec~s afa proiect that are subiective or unmeasureable_ It is also' understood that those who determine ~ignifi~;~nce may have iittm or no formal knowledge of the environment or may be technically expert in environmental analysis. In addition, r0any wee have knowJeoge.m one particular area may not be aware of the broaaer concerns affecting the question of significance. The full EAF is intended4o ore,vide a method whereby applicants and agencies can be assured that the determinatran process has been orderly, comprehensive in nature, yet flexibie to allow introduction of information to fit a prelect or action. Full EAF Components: The full EAF is compr'i~ed of three parts: Part ~: ?rev(des'objective data and information about a given project"and its site. By identifying basic project data. it assists a reviewer m me aha, vsis that takes alace in Parts 2 and 3. *art 2: =ocuses on identifying the range of possible imnacts that may occur from a proiect or action, It provides ~uiaance as to whether an rmpact is []ke'v to be considered smatl to moderateor whether it is a [;otentiailw large ~mpac[. The forqn also identifies whether an impact can be mitigated or reduced. Part 3: If any impact in Part 2 ~s identified as 0otentiaJly-large, then Part 3'is used to evaiuam wneme~ or not me DETERMINATION et SIGN1FICANCE~Ty.pe I and Unlisted Actions Identify the Portions of. EAF completed /or this project: [] Part 1 [] Part 2 [~Part 3 Upon review of the informauon recorded o~ this EAF (Parts 1 and 2 and 3 if appropriate), and any eerier suonorting inf6rmation, and considering both the magitude and importance of each impact, it is reasonably determined bv me lead agency that: A. The prelect will not result in any large and imDortan~ impact[s) and. therefore, s one which will no[ have a significant ~mpac[ on the environment, therefore a negative declaration wlll be prepared. [] B. Although the proiec~ could have a s~gnificant effect on the environment, there will not be a significant effect for this Unlisted Action because the mitigation measures described in PART 3 have been required, therefore a CONDITIONED negative declaration will be prepared.* [] C. The proiect may result in one or more large and important impacts that ma'~ have a significant impact on the enwronmenr, therefore a positive declaration wlil be prepared. * A Conditioned Negative Declaration is dnJy valid for Unlisted Actions / Name of Ac[ion Name el Lead Agency Prin~ or T- )e Name of Responsible Officer m Lead Agency Tide of Resoonsm~e Officer Signature of Resoonsible C fficer in Lead Agency $1gna ture of Prer;arer [1 f different from responsible officer} Date 1 - ~-~PART 1--PROJECT INFORMAT,¢'%i . Preparec~ by Project Sponsor NOTICE: This document is designed to assist in detecmining whether the action ~roooseo may have a s~gmficanr ell on the env,ronment. Please compiet~ the entire form; Parts A through E. Answers To (hese uuesuons will be'c(~nsider as oart of the application for approval and may be subiect to further verif cation ann ~ublic rewew. Provide an', additio, informdtion-you believe will be needed to complete Parts 2 and 3. It is expected that completion of the full lEAF will be dependent on information currently avaiIable a nd will not invo, new studie~ research or investigation. If information requiring such additional work is unavailable, so indicate and spec each~ instance. NAME OF ACTION aU$1NS~$ TELEPHONE 8USIN ESS TE~:EPHON E ADDRESS CiTY/PO ~TATE ZIP CODE DESCRIPTION OF ACTION Please Complete Each Question--Indicate N.A. if.not applicable A. Site Description Physical setting of overall project, both develobed and undevelooed areas. 1. Present land use: r-turban [~Industriat [-1Commercial ~Residential Isuburban} E]Rurai (non-lam I~Forest F'lAgriculture I-1Other 2. Total acreage of project area: /-~. c~,','~ acres. APPROXIMATE ACREAGE PRESENTLY AFTER COMPLETION Meadow or grushland (Non-agricultural) acres acres Forested acres acres Agricultural (Includes orchards, cropland, pasture, etc.) acres acres Wetland (Freshwater or tidal as per Articles 24, 25 of ECL) acres acres Water Surf.ace Area acres acres Unvegetated (Rock, earth or fill) acres acres Roads, buildings and other paved surfaces acres acres Other (Indicate type) acres acres. 3. What is predominant soil type(s) on project site? c~,~. a. Sod drain;age: ,~Well drained [G~'~'~ % of site ~Mode~:ateb, wetl drained % of s:te E3Poorly drained % of s:~e b. If any agricultur,~l land is involved, how man'-' acres of soil are classified within soil groue 1 through 4 of the NYJ Land Classification System? acres. (See I NYCRR 370] 4. Are there bedrock outcroppings on project site? ~Yes a. What is depth to beorock? (in ieeti Albert J. Krupski. President Johtl HolzapfeI, Vice President William G. Albertson Martin H. Garrell Peter Wenczel BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall 53095 Main Road P.O. Box 1179 Southotd. New York 11971 Telephone (516) 765-1892 Fax (516) 765-1823 COASTAL EROSION MANAGEMENT PERFiIT Permit Number: 53-4-20 Name of Applicant/Agent: Name of Permittee: Doris Brown Address of Permittee: P.O. Mattituck. Property Located: same DESCRIPTION OF ACTIVITY: Box 915, 1979 Bergen Avenue, to relocate house and septic system landward from bluff. Current foundation will be left and covered with wood and well will be used as long as possible. All in accordance with Natural Resources Conservation Service ( letter enclosed). Date of permit This permit is issuance. issuance: October 26, 1995 valid for a period of two years from the date of SPECIAL CONDITIONS: y/Bluff restoration through a re-vegetation plan is a necessary special condition of this permit. A relocation agreement is attached hereto and is a necessary special condition of this permit. __ A maintenance agreement as attached with application and is a necessary special condition of this permit. Albert J. Krupski, Jr. President, Board of Trustees AJK/jmd 10/25/95 15:22 ~$16727,~60 SCS ~I'F'EP.H~AD ~001 Dep .ar~._ent of AgricuLTtUre Conservation service Riverhead County Center Room E--16 Kiverhead, New York 11901 October Z6. 1995 Box 915 ~at~ituck, New York 11952 De~. Browl~= Based upon my onsite insp.eotion of your propeauF and the erosion probtemyou are experiencing on the blzLff. Iwouldrecommend the following course of action: First the house should be relocated directly to the south away from the bluff and not to the west as is cu_~re~tly proposed. The bluff is actively eroS~ng, including the area directly in front of the proposed house site. The house should be ~et back away from the edge of the bluff a ~D~m%l~ of one hundred feet or as far back as currant town code will allow. Vegetative stabilization of this site will be very difficult Since the erosion appears to be caused by wave action at the toe of the slope. As the bottom half erodes there is nothing left to support the upper hail and it will eventually slide downward causing further erosion. In order for vegetation to have a chance at stabilizing th~ site will requ~e diligent efforts on ~our Dart to monitor and immediately repair eroded sections of e bluff as they occur. Cape American Beachgrass does the best job of stabilizing bluff sites. It develops a deep extensive root system whic21 holds the sand in · place. Beachgra~s should be planted while dormant due to the high 'mortality rate that occurs when it is planted while actively ~rowing. The best time to plant is at the end of or beq~-,~g of April. Establis~-ent at this t~me limits the plants exposure to severe storm activity end it gets the benefit of a full growing season. Plant .on one foot centers over the entire eroded portion of the bluff. Follow the planting instructions in the enclosed planting guide. it is a goc~l idea to create a dlversity of plant~ on a critical sit~ so that if one shows sigr~ of stress or mortality the others wil! .t~.e over and =ontinue to proteo~the.$Ite. The' following grass mixture will create ~h~ diversity: 10/26/95 i5:23 '~5167273160 SCS RIVERI:IEAD ~002 See~ w~ ~ture Switchgrass Variety Bla~kwelI or S~el~er lbs/1000 fta 1 Big bluestem Niagara Little bluestem Aldous or Camper Sand lovegrass ~27 or Bend 1 or WeeDing love~rass 1 Coas~nl p~ cgrass Atlantic 1 Seeding s~ould~a~e place a~ early in the springa~Dos~ible and prior to F~y 1st. I would recommend seeding immediately after t~ebeacb~rass is planted. Apply the seed using a hyd~o~eeder whioh is a piece of equipment~/%at allows the o~-rator to mix the geed, fertili~er, and mu lob material into a tank of water. The slurry mixture is then ~amDed%brough a hose onto the slope. I have inoluded planting guides for all oft he plants recommended as well as a lis% of souroes for these qrasses. If you have questions er if I can be of further assistance please don't hesitate to call Sincerely, Allan S. Connell District Conservationist cc: Southold Town Trustees Telephone (516~ 765-1~01 Town Hall. 53095 Main Road P.O. Box 1179 Southold. New York 11971 SOUTHOLD TOWN CONSERVATION ADVISORY COUNCIL At a meeting of the Southold Town Conservation Advisory Council held Thursday, OctOber 19. 1995 the following recommendation was made: No. 1307 DORIS KERR BROWN 112-1-17 Hold - no survey - application incomplete Albert J. Kmpski. President John Holzapfel. Vice President William G. Albertson Martin H. Garrell Peter Wenczel BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall 53095 Main Road P.O. Box 1179 Southold, New York 11971 Telephone (516) 765-1892 Fax (516) 765:1~23 October 19, 1995 Doris K. Brown P.O. Box 915 1979 Bergen Ave MattituckNY 11952 RE: SCTM %112-1-17 Dear Ms. Brown, On Thursday, October 18, 1995 the Southold Town BOard of Trustees inspected your property and have agreed that your house did indeed need to be moved back from the edge of the bluff due to severe erosion. However, the Board agreed that if the house were to be placed back landward and put at a straight angle rather than at the angle it is now, you would be well behind the Coastal Erosion Hazard Line. The Board also feels dry wells should be placed to prevent run-off down the bluff and a stabilization planting plan for the restoration of the eroded bluff. We are enclosing the name and phone number of an agency that will be able to help ~u provide this. If you have any questions, please contact our office. Albert J. Krupski, Jr. President, Board of TruStees AJK/djh Encl. cc. EBA Bldg. Dept. ,'11 Albert J. IQ'upsld. President John Holzapfet. Vice President William G. Albenson Martin H. Garrell Peter Wenczel Town Hall 53095 Main Road P.O. Box i179 Southold. New York 1 I971 Telephone (516) 765-1892 Fax (516; 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only C~oastal Erosion Permit Application Wetland Permit Application Grandfather Permit Application Trustee Lands Permit Application 7~.lerical Review: f~ I nc omplete SEQ~ Classification: ~e I T~ II__Unlisted ~ordination: (date s~t b '~ Referral Sent: [~t~/ ~eceipt of CAC Report: (dAt~ Lead kgency Dete~ination: c~ical Review: (date)_ ' ~lsion: ~pproved (Y/~) (~ate) ~pplicati6n Fee: Name of Applicant ~0~15 Suffolk County Tax Map N~er: 1000 - Property Location: (provide LILCO Pole Agent: (If applicable) Address: distance to cross streets, and location) Phone: Board of Trustees Applica~on Land Area Area Zoning: Previous use of Intended use of GENERAL (in square feet): property: property: DATA Prior permits/approvals for site improvements: Agency Date ~0 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): Board of Ttustees Applic~on COASTAL EROSION APPLICATION DATA Purposes of proposed activity: '~ Are wetlands present within 75 feet of the proposed activity? ~ No Yes Does: the p~oject involve excavation or filling? %<' Yes If Yes, how much material wil2 be excavated? How much material will be filled? Manner in which material will be removed or deposited: (cubic yards) (cubic yards) Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attac.hments if necessary) ~ ~ 6-17.2.1 ,~J SEQR Appendix A State Env to,mental' Quality Review FULL ENVIRONMENTAL ASSESSMENT FORM ?urpose: The full EAF is designed to help applicants and agencies determine, in an oraer y'mann~r, whemer a ~ro*ect . o~ action m~v be s[~n f cant The question of whether an action,maY be significant is not always easy to answer. Freauent- - Jy, mere are ~spects of ~ gro]ec: mat are subjective or unmeasureabJe. It is als~ understood ~hat those who determine ~gnifi~nce may h~ve ii,tie or no formal knowledge of the environment or may be technically exDe~ in env~ronmenta~ analvsis, [n addition, many WhO, have knowJedge2n one particular area may not be aware or the bYoaaer concerns affecting the question of The full EAF is intended to orovide a method whereby a ~plicants and agencies can be assured that the determinatfon process has been orderly, comprehensive ~n nature. Yet fJe~Jble [o allow introduction of informat Fut] EAF Components~ The full EAF is comprised of three parts: P~t 1: Provides-objective data and.information about a given proiect and it~ site. ~y identifying basic projec~ data, ~ assists a reviewer in the anawsis that takes place in Par~ 2 and ?a~t ~: :ocuses on identifying the range of possible impacts that may occur from a project or act on. t orovfdes E;uidance ~s to w~ether an impact is Ji~e'-/~o be considered small to mooeram or whether large Imp~ct. ~he form. ~]so identifies whether an lmoact can be mitigated or reduce~, Pad 3: ff ~ny impact in Part 2 is identified as ootentJallvdarge, then Part 3' is used to evaluate whether or not the impact ~s actua[t,f ~moortant. DETERMINATION OF SiGNIFICANCE--Type I and Unlisted Actions Identify the Portions of. EAF completed for this project: ~ Part I [] Part 7: []Part 3 Upon review of the information recorded on this EAF Parts q and 2 and 3 if appropriate), and any other suooorting inf6rmation andconstc_=rmg both the mag~tude and im 0ortance of each imoact, itis reasonabt'- determined bvthe lead agency mat: A. The prolect wiil not result in any large and imoortant impact[s) and. therefore, is one which will not have a signifJ.cant Jmoact; on the environment, merefore a negative declaration will be prepared. B. Although the prolect could have a s~gnificant effect on the environment, there will not be a s;§nificant effect for this Unlisted Action because the mitigauon measures described in PART 3 have been require(]. therefore a CONDITIONED negative declaration will be prepared.' C, The project may result in one or more large and important impacts that may have a significant im pact on the environment, therefore a positive declaration will be prepared. · ^ Conditioned Negative Declaration is only valid for Unlisted Actions / Name of Action Name of Lead Agency Print or Type Name of Resnonsible Officer in Lead Agency Title of Resoons~ole Officer Signature of Resoonsibie Officer in Lead Agency Sigr~acure of Preparer If different from responsibieofficer} ~-PART 1--PROJECT INFORMAT;r~N Prepared by Project Sponsor NOT,CE: This document is designed to assist in determining whether the action 3roooseg ma~/ have a s~gmficanr on the enmronment. Please complete the entire form, Parts ^ through E. Answers rD mese ouestmns wiit be'consider as Dart of'the application for approval and may be subiect to further verification and public remew. Frowde an'. additior information you believe will be needed to cornolete Parts 2 and 3. It is exoected that completion of the full EAF will he deoendent on information currendv available and will not inve, new studie., research or investigation. If information requ~rin§ such additional work s ~ navailable, so indicate and spec each- instance. NAME OF ACTION ADDRESS BUSINESS TELEPHONE CiTY/PO ~TATE ZIP CODE DESCRIPTION OF ACTION Please Complete Each Question--Indicate N.A. if not applicable A. Site Description Physical setting of overall project, both developed and undeveloped areas. 1. Present land use: r-lUrban Fqlndustriat '~Commercial ]~Residential (suburban) [SRurai (non-larD [-IForest FlAgricuJture ~Other 2. Total acreage of project area; ~ ~:~- acres, APPROXIMATE ACREAGE PRESENTLY AFTER COMPLETION Meadow or Brushland [Non-agricultural) acres acres Forested acres acres Agricultural (Includes orchards, cropland, pasture, etc.) acres acres Wetland ('Freshwater or tidal as per Articles 24. 25 of ECL) acres acres Water Surf.ace Area acres acres Unvegetated (Rock, earth or fill) acres acres Roads, buildings and other paved surfaces acres acres Other r nd cate type) acres acres 3. What is predominant soil type(s} on prolect site? ~/b~*J) a. Soil drains, ge: .~Well drained ((~-~ % of site U]Mode~:ately well drained % of sire r~Poorh~ drained % of site b. If any agricultural land is involved, how many acres of sod areclassifledw~ in soil groupl through4of the NYJ Land Classification Ss, stem? · acres. (See 1 NYCRR 370). 4. Are there bedrock outcroc rungs on project site? C]Yes ¢J~No a. Wh~t ~s depth to bedrock? (in feet) .. ,. ,-~% ,,, '~%. Approx~mate:percen[a?¢~- }ropos~:d oromc[, s~[e w~m.~ slot)es: . ~.~ ,o ~ ~ ~1%% or greater % 6. Is prelect substantfally conuguous ~o. or contam~a bud~mg, s~e, or d~strict, isled on the 5~te or [ne Not,eno: -' Re~is~er~ of Historic P]aces~ ~Yes ~No . ~Xc (~'. ls proje.ct substantially conbguous to a site listed on the Register of Nationai Natural Landmarks~ ~Yes 8. What is the depth of the water table? (in feetl 9. Is site located over a primary, princloal,.or sole source aquiferS' FqYeg ~No 10. Do hunting, fishing or sheJI fishing opportunities 3resent/y'exist in ~e proiect area? .,,~Yes ~No 11. Dbes project site contain any species of pia~t or animal life mat is identified as threatened or endangered? ~lYes ~No According to Iderdfv each species 12. A~e there any unieue or unus0al land forms on the urojec~ site? (i.e.. cliffs, dunes, other geologic, al formations 13. Is the ~Yes [~o If yes, exolain 14. Does the oresen: site inctude scenic views known to be imoortan[ to the community? ~No 15. Streams within or conuguous to project area: a. Name of Stream.and name oi River ~o which it is tributary projp-c:- sit.; ~resentlv used by the community or neighborhood as an open space or recreation area? 20. Has the site ever been used for the disoosal of solid c~r hazardous wastes? 16. Lakes. ponds, wetIand areas within or contiguous to project area: a. Name ,~9 ¥~_ b. Size (in acres) 17. Is the site servea by exisung public ut! ties~ ,~Yes a) If Yes, does sufficient caoaclty exist to allow connection? .¢~Yes ~No b) if Yes will ~mprovements be necessary to allow'connecrlon~ ~Yes ~No 18. is the site located n an agricultural district certified oursuant ~o Agriculture and Markets Law, Article 2S-AA. Section 303 and 304~ [Z]Yes ~No 1'9. is the site located in or substantially conbguous co a Criticat Environmental Area designated pursuan~ ~o Article g of the ECL. and 6 NYCRR 6177 ~]Yes C1No I'qYes ~'¢'N o B. Project Description. 1. Physical dimensions and scale of projeet (fill in dimensions as appropriate) a. Total contiguous acreage owned or controlled gv project sponsor /'¢". ~¢'~"' --~ b', Project acreage to be develooed: C acres. acres initially; - acres ultimate[v, -' c. Pr. eject acrqage to remai¢ undeve!oped acres. d. Length of aroject, in miles: (If appropriate) e. If the proiect is an expansion, indicate percent of expansion pronosed f. Number of off-street parking spaces existing ; proposed g. Maximum vehicular :ries generated per hour (upon completion al~ proiect)? h. If res~eentiat: Number and type of housing um~s: One Fatuity Two Family In/dali,. Ultimately i. Dimens OhS (in feetl of largest proposed structure j. Linear feet of frontage along a public thoroughfare prolect will occupy is? )vlultioie Family Condomin Jm height; r'~?) t' width; zJr'O / length. (~ ft. 3 ~'~2. How rouen, naturat material (i.e~rock earm etc.) will be removed fram t?'xslte? -~ons/c~ubic varas 3. Will disturbed areas be redain ~? ~Yes '~No ~NA ~::_~ a. If yes, for ,what m~en~ec purpose is the site being reclaimed~ b. Will ~opsoil be stockpiled for reclamation? ~Yes ~No c. Will upper subsoil be stock ~i]ed for reclamation? ~Yes ~No 4. How many acres of vegetabon (trees. shrubs, ground cover~) will be removed from site? ~ acres. 5. Will any ma~ure fores~ {over 100 years old) or other ]oc~[[wim~or~an~ vegetation ~e ~emoved by this project~ ~No 6~ If single phase project: Anticipated perio~ of'construct]on ~ ~ month~. (including demolition). 7. If multi-ohased: a. Total number of phases anticipated b. Anticioated data'of commencement phase c. Approximate completion d~ite of final ohase (number). d. Is phase 1 functionally dependent on subseauem )hoses? 8. Will blasting occur during construction? [DYes .~No 9. Number of iobs generateD: during construction '10. Number of jobs eliminated b~7 this prolect monm / f/~/,~' '/ear. (including demolitiom. /[~es liND _9-- ,~ ; ~after project ~s comolete O C) 11. Will proiect reau~re relocation of any proiect~ or facilities? ~Yes ,~No If yes, exDiain 12, Is surface liquid Waste disposal involved? I~Yes ~No a. If yes, indicate wpe of waste (sewage, industrial etc.) and amount b. Name of water body into which effluent wiJ be discharg~eo 13. Is subsurface liquid waste disposal involved? []Yes .~'No Type 14. Will surface area of an existing water bod~ 'nctease or decrease bv ~ro~osa]? Exolain t5. [s project or any portion of project located in a t00 year flood piain? ~Yes 16. Will the ~roject generate solid waste? []Yes ~No a. If yes, what-is the amoun~ per month tons b. If yes, will an existing solid waste facility be used? ~Yes I-[No c. If yes,.give name ; location d. Will any wastes not go into a sewage disposal system or into a sanitary landfill? ~Yes e. If Yes, explain 17. Will the project involve the disposal of solid waste? E]Yes ~No a. If yes, what is the antlcinate~rate of disposal? tens/month, b. If yes, what i~ the anucipated s.ite life? years. 18. Will proiect t~se herbicides or pesticides? ]~Yes ~No 19. Will project routinely produce odors (more than one hour per day)? E]Yes ,~'No 20. Will project produce operating noise exceeding the local ambient noise levels? EDYes 21. Will ;roiect resu/t in an increase in energy use? E]Yes ~No If yes , indiczi~e type£s) If wa~er supply is from wells, indicate p~mpmg capacity ~t')z) 22. gallonslmmu[e. 23. Tot;,' a~lticipated water ~s,~ge per day _/{q ~:~i~ gallons/da;. 24. Does proiec~, invo[ve Local. State or Federal funding? ~Yes ~No ~f Yes. explain /~/it S SD ~' ~Yes .,~No / CRy, TOwn Vdlage 8nard ~Yes ~No ~ City, Town, Village Planning Goard ~Yes ~No · City. Town Zoning Board ~es ~No City, County Health Oeaar~ment ~Yes ~No Other Local Agencies gYes ~No Other Regioaat Agencies ~Yes ~No State Agencies ~Yes ~No 'Fed~at Agencies ~Yes ~No C. Zoning and Planning Information 1'. Ooe~ prooosed action involve a pl~nnmg-or . If Yes, indicate decision required: zomng decision? OYes Da~e C]zoning amendment [zoning variance J~]sDeciaJ use permit []subdivision _ ~site Dian Onewirews~on of master Dian Oresource management Dian E3other 2. What is the zoning classification(s]of the site? 3. What is the ma×~mom potential development of the site if devetooed as oermitted Dy the oresent zoning./ 4. What is the proposed zomng o~ the site~ . .$- What is the maximum ootential develooment ot the site if develooed as 9ermiU:ed by the proposed zomng? 6. I~ the prooosen action consistent WnD the recommended uses in adooted local land use oians~ F~Yes ON 7. What are the -~redominant ]an~ use~s~and zomax' , classifications witt~in a % mile radius of prooosed a~don~ 8. Is Lhe proposed action compatible with .~djoininglsnrroundieg h~od uses within a ~,4 mia? ~]Yes ~N 9. If the proposed action s the subdiv~sion ~f land. how many Jots are aroposed? a. What is the mlmmum Jot s~ze proposed[ 10. Will proposed action require any authorization(s) for the formatioD off,ewer or water districts? ~Yes ~N~ 11. Will the proposed action crea~e a demand for any communiw provided services (recreation. education ~oiice fire protection)? ~Yes ~No a. if yes. is existing canacity sufficient Jo handle projected demand? ~Yes ~No 12. Will the prooosed action result in the ~leneralion of Iraffic significantly above present levels? ~Yes ~No a. If yes. is dad ex,)ting road nc,~work adeeuate to handle the additional traff~c~ ~Yes ~No D. Informational Details Part 2--PROJECT IMPACTS AND THEIR MAGNITUDE Responsibility of Lead Agency General Information {Read Carefully) · In completing the form the reviewer should be guided bv the auestion: Have m~ responses and determinations been reaso nable~. The reviewer is not expected to be an exoert environmental analyst. · Identifying that an impact wi[[ be ootentiaH'v large [column 2) does not mean that it is also necessarily significant. Any large Jmoact must be evaluated in PART 3 to oetermine significance. Identifying an impact in column 2 simply asks mat ~r be looked at further. · I'he Examples provided are to assist the rewewer bv showing types of impacts and wherever possible the threshold of magnitude that would trigger a resoonse in column 2. The examples are generally applicable throughout the State and for most situations. But. for any specific project or site other examoles and/or lower thresholds may oe appropriate for a Potential Large mpact response, thus reqmring evaluation i~ Part 3, · The moacts of each project, on eacn site, in each locality, will vary. Therefore the examotes are Ilustrative anq have been offered as guidance. They do not constitute an exhaustive iisi of imoac~s and thresholds to answer each question. · The ~umber of examples per question does qot indicate the importance of each question. · I~ identifying impacts consider long term. short term and cumlative effects. Instructions [Read carefully} a. Answer each of the 19 questions in PART 2. Answer Yes if there will be an'/ mpact. b. Maybe answers should be cons]oereo as Yes answers. c. If answering '{es to a question then check the appropriate oox (coiumn I or 2) to indicate the potential size of the imoact. If irt 0act threshold equals or exceeds any example nrovided, check column 2. if impact will occur but threshold is lower than example, check column 1 d. If rewewer has doubt about size of me ~mpact then consider the impact as potentially large and proceed to PART 3 e. tf a potentially large impact checked m column 2 can be mitigated bv change(s) in the proiect to a small to moderate impact, also check the Yes box rt comm~ 3. ^ No response indicates thai such a reduction is not nossible. This must be explained in Part 3. IMPACT ON LAND 1 Wil| the proposed action result in a physical change to the project site? (]NO ~YES Examples that would apply to column 2 · Any construction on slopes of 15% or greater, (15 foot rise Der 100 foot of length), or where the general slopes in the project area exceed 10% ,, Construction on land where the depth to the'water table is less than 3 feet. · Construction of oared parking area for 1.000 or more vehicles. · Construction on land where bedrock is exposed or generally within 3 :eet of existing ground surface. · Constructmq that will continue for more than 1 year or involve more than one ohase or stage. · Excavation for mining purposes that would remove more than 1.000 tons of natural material {i.e. rock or soil) oer year. · Construction or exoans~o~ of a sanitary landfill · Construction in a designated floodway. - Other impacts 1 2 3 Small to Potential Can Imoact Be Moderate Large Mitigated By Impact Impact Project Change []Yes []No [] []Yes []No [] []Yes []No [] []Yes []No ~ []Yes []No [] []Yes []No [] ~Yes []No ~ ~Yes []No ~ []Yes ' [~No 2. Will there be an effect to an~ umque or unusual ]and forms founc on the site? (i.e., cliffs, dunes, geological formations, etc.)[Z]NO E]YES · Specific land forms: [] [] []Yes ~No iMPACT ON WATER 3 Wil] propose(] action affect any water body designated as protected? (Under Articles 15 24. 25 of the Environmental Conservation Law, ECL) [Z]NO [Z]YES E~amples that would apply to column 2 · Developable area of site contains a protecte0 water bod',. · Dredging more than 100 cubic ,.ards of material from channel of a protected stream. · Extension of utility distribution facilities through a protected water bodP. · Constructioh in a designated freshwater or tidal wetland. · Other impacts: 1 2 3 Smatl to Potential Can Impact Be Moderate Large Mitigated By impact Impact Project Change [] [] []Yes []No [] [] []Yes []No [] [] []Yes ~No [] [] [~Yes []No ~ ~ []Yes [] No 4. Will proposed action affect any non-protected existing or new body of water? F~NO E]YES Examples that would apply to column 2 · A 10% increase or decrease in the surface area of any body of water or more than a 10 acre increase or decrease. · Construction ofa bodv of water that exceeds 10 acres of surface area. · Other imnac~s: E [] ~lYes []No [] ~ []Yes []No ~ J~ []Yes []No 5 Will Prouosed Act[on affect surface or groundwater aualitv or auantltv? []NO E]YES Examples chat would a~pt¥ to column 2 · Proposed Action will require a discharge permit. o ?ropose(J Action rePuires use of a source of water that does not have approval to serve oroposed (project) action. · Proposed Action reauires water supply from we!Is with greater than 45 gallons per minute pumping capacity. · Construction or operation causing any contammatlorl of a water supply system. · Proposed Action will adversely affect groundwater. * Liouid effluent will be conveyed off the s~te To facilities which presently do not exist or have mapequate capadt¥. o ProPosed Action would use water m excess of 20.000 gallons per day. · Proposed Action will likely cause siltation or other discharge into an existing body of water to the extent that there will be an obvious visual contrast to natural conditions · Proposed Action will reou]re the storage of petroleum or chemical products greater than 1.100 gallons. · Proposec~ Action will allow residential uses in areas without water and/or sewer serwces. · Proposed Action locates commercial and/or industrial uses which ma'. reauire new or expansion of existing waste treatment andlor storage facilities. *' Other impacts: [] [] []Yes [~No [] [] []Yes []No [] [] []Yes []No [] [] []Yes I~No [] [] []Yes []No [] [] []Yes ~]No [] [] []Yes []No [-- [] -']Yes []No [-- [] []Yes []No [] [] ~Yes []No [- [] []Yes []No [] [] []Yes []No Wi[[ proposed action alter drainage flow or patterns, or surface water runoff? [~NO E3YES Examples that would 3DOIV to column 2 Proposed Action would change flood water flows 7 [] [] []Yes [~No · Proeosed Action may cause substantial erosion. · Proposed Action ~s ncomnatible with existing drainage patterns. · Proposed Action w allow deveiooment in a designated floodway. · Other impacts: 1 Small to Moderate Impact 2 Potential Large Impact 3 Can Impact 13e Mitigated By Project Change [] [] []Yes []No [] I-q []Yes []No [] I~ []Yes E~]No [] [] I~Yes []No IMPACT ON AIR Will 2rooosed action affect air quaiitv? E]NO []YES Examples that would apply to column 2 · Proposed Action wi] induce %000 or more vehicle trips in any given ' hour. · Proposed Actmn will result in the incineration of more than I (on of refuse 2er hour · Emission rate of total contaminants will exceed 5 lbs, per hour or a heat source oroducin§ more than 10 million BTU's per hour. · Proposed action will allow an increase in the amount of land committed to industrial use. o Proposed action will altow an increase in the density of industrial devefooment within existing industrial areas. · Other ~mpacts: [~ [] []Yes }-']No [] [] []Yes []No [] [] []Yes []No [] [] []Yes []ko [] [] [] Yes [] No [] [] []Yes []No IMPACT ON PLANTS AND ANIMALS 8 Will Proposed Action affect any threatened or endangered species? [~NO I~YES Examples that would appi'/ to column 2 · Reduction of one or more species listed on the New York or Federal list. using the site. over or near site or found on the site. · Removal of any portion of a critical or significant wildlife habitat. · Application of pesticide or herbicide more than twice a year, other than for agricultural purposes. · Other ~mpacts: [] [] []Yes []No [] [] []Yes [-]No [] [] []Yes ~No [] [] []Yes []No 9 Will Proposed Action substantially affect non-threatened or non-endangered species? []NO [YES Examples that would appw to column 2 · Proposed Action wou[d substantially interfere with an~ resident or m~gratory fish, shellfish or wildlife species. · Prooosed Action requires the removal of more than 10 acres of mature forest [over 100 years of age) or other locally important vegetation. IMPACT ON AGRICULTURAL LAND RESOURCES 10 Will the ProPosed Action affect agricultural land resources? ~NO ~YES Examples that would apply to column 2 · The proposed action would sever, cross or limit access to agricultural land (inc[udes crooland, hayfields, oasture, vineyard, orchard, etc.) [] [] []Yes []No [] ~ EYes []No [] []Yes []No ·Constructton activit,~ would excavate or compact the sod profile of agrlc Jltura] ]and · The proposed action would irreversibly convert more than 10 acres of agricultural land or F located ~n an ~,gricuituta District. more than 2.5 acres of agricultural land · The 3roposed action would disrupt or orevent installation of agricultural land managemen: systems (e.g.. subsurface drain lin'es outlet ditches. str~o crolJpmg); or create a need!for such measures (e.g cause a farm field to drain poorly due to incr, eased runoff) · Other imoacts Small ~o Moderate Impact 2 Potential Large impact 3 Can Impact Be Mitigated By Project Change [~]Yes []No E]Yes []No ~Yes []No []Yes []No IMPACT ON AESTHETIC RESOURCES 11 Will orooosed action affect aesthetic resources? ONO OYES df necessar,,, use the Visual EAF Addendum m Section 617.21. Appendix B.) Examples that would appw tc co*umn 2 · Proposea Iand uses. or project components obviously different from or in snarp contrast to current surrounding land use patterns, whether mammade or natural, · ProBosed ]and uses. or prolect comoonents visible to users of aesthetic resources which will eliminate or significantly reduce their enjoyment of the aesthetic ouaiities of that resource, · Project comoonents that will result n the elimination or significant screening of scenic wows known to be important to the area. · Other Impacts: [] [] [] [] [] []Yes []No []Yes [~,No []Yes []No [~]Yes ~No In PACT ON HISTORIC AND ARCHAEOLOGICAL RESOURCES 12 Will Proposed Action imoact any site or structure of historic pre- historic or paleontological moortance? ~NO OYES Examples that would appw to column 2 · Proposed Action occurring wholly or t)artia[[v within or substantiailv conuguous to anv facHitv or site listed on the State or National Register of historic o[aces. · Any imoact to an archaeological site or fossil bed located within the orolect site. · Prooosed Action will occur n an area designated as sensitive for archaeological sites on the N¥S Site Inventory. o Ctner impacts: [] [] [] [] [] [] Yes --]No ~]Yes []No FqYes _~No []Yes ~No IMPACT ON OPEN SPACE AND RECREATION 13 Will Proeosed Action affect the quantity or quality of existing or future coon spaces or recreational opportunities? Examples that would apply TO :olumn 2 ~NO FqYES · The permanent foreclosure o]a future recreational opportunity. · A major reduction of an }pen soace important to the commumtv · Other imoacts: [] [] [] ~Yes []No [~,Yes []No ~lYes []No IMPACT ON TRANSPORTATION 14 Wil there De an effect to existing transportation systems? []NO []YES Examples that would aPPly to column 2 · Alteration of present patterns of movement of people and/or gooas. · Proposed Action w/II result in major traffic problems. · Other ~mpacts: 1 Small to Moderate Impact 2 Potential Large Impact 3 Can Impact Be Mitigated By Project Change DYes ~L~No DYes D'INa []Yes [No IMPACT ON ENERGY 15 Will proposea action affect the community's sources of fuel or energy supply? ~NO []YES Examples that would apply to column 2 · Proposed Action w' cause a greater than 5% increase in the use 3f any form of energy m the municipality. · Proposeo Action will repulre the creation or extension of an energy transmission or supply system to serve more than 50 single or two lam/Iv residences or to serve a major commercial or industrial use. · Other mpacts: [Yes [No ~Yes [No [Yes i~]No NOISE AND ODOR IMPACTS 16. Will there be objectionable odors, noise, or vibration as a result of the Proposed Action? ~NO []YES Examples that would apply to column 2 · Blasting within 1.500 feet of ~ hospital school or other sensitive facility. · Odors w/Il occur routine[~ (more than one hour per day). · Proposed Action wi]] produce operating noise exceeding the [ocal ambient no,se levels for noise outside of structures. · Proposed Action w/i[ remove natural barriers that would act as a no~se screen. · Other impacts: []Yes I-INo ~Yes F-lYes [~No [~]Yes [No I~Yes ~No IMPACT ON PUBLIC HEALTH 17. Will Proposed Action affect public health and safety? ~NO E}YES Examples that would apply to column 2 · Proposed Action may cause a risk of explosion or release of hazardous substances (i.e. oil, pesticides chemicals radiation, etc.) in the event of accident or upset conditions, or there may be a chronic Iow level discharge or emission. · Proposed Action may result in the burial of "hazardous wastes" in any form i.e. toxic, pmsonous, highly reactive radioactive, irritating, infectious, etc.) · Storage facilities for one million or more gallons of ]iouified natural gas or other flammable lipuids. · Proposed action may result in the excavauon or other disturbance within 2.00{2 feet of a site used for the disposal of solid or hazardous · Other moacts: 10 ~]Yes [No [~Yes [~No [~Yes ~No [Yes I-iN0 F'qNo 1 2 IMPACT ON GROWTH AND CHARACTER Small to Potential OF COMMUNITY OR NEIGHBORHOOD Moderate Large 18 Will proposed action affect the character of the existing community? Impact Impact []NO []YES Examples that would apply to column 2 · The oermanent population of the city. town or village in which the [] [] OYes []No prolect is ocated ~s likely [o grow by more than 5%. · The municipal budget for capital expenditures or operating services [] [] F-lYes []No will increase by more than 5% per Year as a result of this proiect. · Proposed action will conflict witt~ officially adopted ~[ans or goals. [] ~ ~]Yes []No · Proposed action will cause a change in the density of ]and use [] ]~} []Yes J-~No · Proposed Action will replace or eliminate existing facilities, structures [] --] ~]Yes []No or areas of historic ~mportance to the community. · Develooment will create a demand for additional community services [] [] []Yes []No (e.g. schools, police and fire, etc.) · Proposed Action will set ~n important precedent for future projects [] [] []Yes []No · Prooosed Action will create or eliminate employment. [] [] OYes []No · Other impacts: [] ~ ~--~Yes []~0 3 Can mDact Be Mitigated By Project Change 19 Is there, or is there likely to oe. oubiic controversy related ro potential adverse environmental impacts? []NO ~YES If Any Action in Part 2 Is Identified as a Potential Large Impact or If You Cannot Determine the Magnitude of impact, Proceed to Part 3 Part 3--EVALUATION OF THE IMPORTANCE OF IMPACTS Responsibility o[ Lead Agency Part 3 must be prepared if one or more impact(s) is considered to be potentially large, e,~en if the impact(s} may be mitigated. instructions Discuss the following for each impact identified m Column 2 of Part 2: q Briefly describe the impact. 2. Describe (if applicable) qow the impact could be mitigate(] or reduced to a sma[l to moderate impact bv proiect change[s). 3 Based on the information available decide if it s reasonable to conclude that this impact is important. To answer the question of im[~ortance, consider: · The orobabiiitv of the ~mpac[ occurring · The duration of the imoact · Its irreversibilit',, including oermanent[v lost resources of value · Whether the mpact caq or will be controlled · The regional conseouence of the impact · Its ootentia] divergence from local needs and goals · Whether known objections to the project relate to this imoact. [Continue on attachments) 11 DESCRIPTION,,~ EXISTING VI-SUAL ~NVIRONMEN 4. From each item checked in questionfi environment. chec. k those which generalI/ describe me surrounding Within *~A mile. ~ 1 mile Essentially undeveloped [] [] Forested [] [] Agricultural [] [] Suburban residential [] [] Industrial [] [] Commercial [] [] Urban [] [] River, Lake, Pond [] [] Cliffs, Overlooks [] [] Designated Open Space [] [] Flat [] [~ Hilly ~ [] Mountainous [] [] Other .- [] [] NOTE: add attachments as needed 5. Are there visually similar projects within: 'Y2 mile [-']Yes []No *1 miles []Yes []No *2 miles []Yes []No *3 miles []Yes []No · Distance from orolecr site ar'e provided for assistance. Substitute other distances as appropriate. EXPOSURE /5. The annual number 6f viewers likely to ooserve the proposed project is NOTE: When user data is unavailable or unknown, use best estimate, CONTEXT 7. The situation or activity in which the viewers are engaged while viewing the proposed act an is Activity Travel to and from work Involved in recreational activities Routine travel by residents At a residence At worksite Other FREQUENCY Holidays/ Daily Weekly Weekends Seasonally [] [] [] [] [] [] [] [] 2 ,7.21 Appendix B Sta-m Environmental Quality Review Visual 'EAF Addendum This form ma), De used to 2rovide additional information reiating to Question t i of Part 2 of ] the Full gAF. ~To be compie'.ed by Lead Agency) Distance Between Visibility Project and Resource (in ;qlles) 1. Would the project be visible from: 0-¼ v~-~,2 V=-3 3-5 5+ · A parcel of land which is dedicated to and avaiiable ~ [] [] ~ [] to me pubIic for the use, enjoyment and aoorec~ation of natural or man-made scenic qualities? · An overlook or parcel of land dedicated to public ~' [] [] [] [] obse,wadon, enjoyment and appreciation pf natural or man-made scenic qualities? · A site or structure li~ted on me National or State [] [] Z ~' [] Regmters of Historic Places? · State Parks? [] ?~ [] --~ [] · The State Forest Preserve? [] · National Wildlife Refuges and state game refuges? . [] [] ~ []. [] · National Natural Landmarks and other outstanding [] [] [] [] natural features? · National Park Service lands? [] ~ [] [] [] · Rivers designated as National ~Sr State Wild. Scenic [] ~ ~J [] [] or Recreational? · Any tra.nsportatior- corridor of high exposure, such [] [] [] [] [] as part of the Interstate System. or Amtrak? · A governmentally established or designated interstate [] [] [] [] [] or inter-county foot trail, or one formaily proposed for es~amishment or designation? · A site, area. lake, reservoir or highway designated as [] [] ~ [] [] scenic? · Municipal park. or designated open space? [] [] [] [] County road? ~ [] [] [] [] ' State? [] [] [] [] [] · Local road? C 2. Is the ¢isibillty of the projec~ seasonal? i.e. screen'ed by summer foliage, but visible during omer [~Yes ~No 3, Are any of the resources checked in question 1 useo Dy me puauc JuNng the time of year dur ng which the project will be visible? ~Yes F-~No QT~ER AGENCIES T~IAT MIen'±' BE APPL!C/~BLE U.S. A~my Corp. of Engineers New York District 26 Federal Plaza New York, NY 10278 Phone: 212-264-0184 FAX: 212-264-0523 State of N.Y. Dept. of State Coastal Management 162 Washington Avenue Albany, New York 12231 Phone: 518-474-3642 N.!.S. Depu. of Environmental Conservation SUNY, Building 40, Room 219 Stony Brook, NY 11790 Phone: 444-0365 Fax: 444-0373 Suffolk County Depar~men~ of Health County Center Riverhead, NY 11901 852-2100 or 852-1440 Board of Trust~es Applicz~.~on County of Suffolk State of New York BEING DULY DEPOSES AND AFFIRMS THAT HE/S~/E IS ~ ~PLIC~ FOR'~ ~O~ DESCRIB~ P~IT(S) ~ ~T ~ ST~M CO~AIB~ ~IN ~UE TO ~ BEST OF HIS/~ ~O~GE ~ B~iEF, ~ ~ ~L WO~ WILL BE DO~ IN ~ ~ SET FOR~ ~ ~IS ~PLi~ON ~ AS ~Y BE ~PROV~D BY THE SOUTHO~ ~ ~ OF ~US~S. ~ ~LIC~ AGeS ~ HO~ ~ ~ OF SO~'~O~ ~ T~ ~ ~US~ES'~SS ~ ~E ~OM ~ ~ ~ D~GES ~ C~ BY ~R~ OF SAID P~T(S'), IF ~. I ~Y AUTaO~ZE ~ ~US~ES, ~ TO ~ 0~O ~ TO CON~ION WI~ ~ OF ~IS Si n~~ ' Notarlz Public CLAIRE L. GLEW Nota~ Public. State of NewYork No. 4879505 ~;/- Commission Expires December 8,19 -- ~'Board of ~r~stges Applic~n 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 Southoid Board of Town Trustees on my behalf. (Owner's signature)