HomeMy WebLinkAboutHAUSER, CHARLESBOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Town Hall, 53095 Main Road
P.O. Box 728
Southold, New York 11971
TELEPHONE
(516) 765-1892
CREEK STRUCTURES INVENTORY
Current Owner's Name: 1~ ~ ~ ~
Address: ~ :~'~ ~" ' ~-~-~
Index
No. ~
Creek:
Purchase Date:
Telephone No.:
Previous Owners:
Date of Field Work:
Permit Applicant:
Permit No.:
Permit Specifications:
Specifications Found:
Condition:
~0v~
BOARD OF TOWN TRUSTEES
Town O~ Southold
Southold, _New York 11971
Main Road
Rev. 6/72
APPLICATION FOR A BULKHEAD, DIKE, OR JETTY
1. Does this project i~ the qse of WETLANDS as defined in the Southo, ld Town Wetlands
Ordinance? Y[cS orkt:j~ If it does, you must file thro6gh the Town Clerk s Office.
2. Is the proposed work en~t~ifhin the boundaries of your own property os substantiated
by your Deed or SurveyOr NO. If. it is, a Permit is NOT required from this Board,
but the Town Building nsl~ector should be contacted for full details.
3 Applicant's name and address: .... ~...~..:..,~ ?..~
........................ _ ....... ..................... : .................
4 ontr ctor~no eon ad res
· C asmdd, ss~~ ............................................................
............... ................ i .........................
..... .........................................................................................................................
After issuance of Permit, I expect to: (mark with an X)
(o) Commence work AT ONCE ~'; ASAP · UNKNOWN TIME
(b) Complete work in I DAY ............ ; I MO. ~...; 1 YR ............. ; FUTURE .............
Secure the correct Area Map from the Secretary of this Board, and by using an X WITHIN
A CIRCkE as a mark, indicate as closely as possible the location of this project. On the
reverse side~ provide a SCALE DRAWING which will show Ordinary Hig'h Water ~Mark as well
as the size and shape of the structure or work to be done. Also include all dimensions for
portions which extend offshore from the O H. W. M.
Provide the following documents:
(al A Licensed Engineer's Survey of the property involved.
(b) A copy of the Contractor's Plan and Specifications.
9. Does this project extend into Town Waters beyond a,n imaginary linej~-~oundary formed
by existing works of a similar nature along this area's shoreline? YES o/~.~f it does, state
the approximate distance beyond, ............ ft.
Will thins construction require the Filling of any bnd offshore of the Ordinaj~J,qh Water
Mark o. the Dredging of any material from Town Lands under water? YES ~ NO. jif it does
Form A/4 (Application for Dredging/Fil lng) must be completed and attached '~-I~rt of this
application.
In requesting approval of this application, I submit tho,t: the information presented herein
is true and correct to the best of my knowledge and belief; I am the person accountable for
the performance of the work in accordance with the plans and specifications attached; I have
read or am familiar with the provisions of any Southold Town Ordinance pertinent to the work
involvea; and further, intend to adhere to and abide by the Terms and Conditions of the
Permit, when and if issued to me.
Accepted by:
Dated: