HomeMy WebLinkAboutTR-1313Board .Of'
Southo]d Town Trustees
SOUTHOLD, NEW YORK
PERMIT NO ........ .,~Z.~ ......
ISSUED TO ................ ~q~Z2...~9~ .......................................................................................
Pursuant to the provisions of Chapter 615 of the Laws of
the State of New York, 1893; and Chapter 404 of +he L~ws of the
Sf~fe of New York 19~2~ end the Soufhold Town Ordb~nce
rifled "REGULATIN~ AND THE PLACING OF OBSTRUCTIONS
IN AND ON TOWN WATERS AND PUBLIC LANDS ~nd the
REMOVAL OF SAND, ~RAVEL OR OTHER MATERIALS FROM
LAND~ UNDER TOWN WATERS;" and in accorda?~e wlfh
R~soluf~on of The Board adopted afa meeting held on'JL.z.~.z~:.....~
19...~ and ~ consideraf~on ~f the sum of $ .~ ~ ~aid 6v
...................~~ ~:.F~*; ...... : ............ ~:.:..~ ~..~.~.:~..~ .........
O~
Te ms and Cond~f~ listed on the reverse s~ae hereot,
of Soufhold Town Trustees aufhorizes and permffs the following:
irCCordanfh specificafbns as presenfed in
fhe
derailed
e orlg[naflng eppl[ca+ion.
IN WITNESS WHEREOF, The said Board of Trustees here-
by causes its Corporate Seal to be affixed, and these presenh fo
be subscribed by a majority of the said Board as of this da~e.
e"~-- .............. . .......... ~'"~Z: ~ ............ ~ ..............
..... ~.z~.~.?:~.~.... ~. :..~:~:.~...: .......................
Truslees
h~
BOARD OF TOWN TRUSTEES
Town Of Southold
Southold, New York 11971
Main Road
6/72
APPLICATION FOR A BULKHEAD, DIKE, OR JETTY
Does this project in,,v~ the use of WETLANDS as defined in the Southold Town Wetlands
Office.
the Town Clerk's
through
does, you must file
Ordinance? YES e~NO~;~lf if
2. Is the proposed work er~tir,,eJ'f~,ithin the boundaries of your own property as substantiated
b our Deed or Surve ~"YE.S~or NO If it is, a Permit is NOT required from this Board,
yy y. .
but the Town Building Insp~m~r should be contacted for full details.
3 Applicant's name and address: ...~.~.~.r~. .......................................................
....... ....... .........................................
.................... ............................................
5. Explain briefly the purpose of this application: ..~../?~..~~
After issua:nce of Permit, I expect to: (mark with an X)
(a) Commence work -- AT ONCE ............. ~-~'";"]'"';' UNKNOWN TIME
(b) Complete work in.- 1 DAY ............ ; I-M~. ............ ; 1 YR ............. ; FUTURE .............
Secure the correct Area Map from the Secretary of this Board, and by using an X WITHIN
A CIRCLE os a mark, indicate as closely as possible the Ioca¢ion of this project. On the
reverse side, provide a SCALE DRAWING which will show Ordinary High 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 aa imaginary line,~z~b_qundory formed
by existing works of a similar nature along this area's shoreline? YES o~O f it does, state
the approximate distan.ce beyond, . ........... ft.
10. Will this construction require lhe Filling of any land offshore of the Ordinar~h Water
Mark or the Dredging of any material from Town Lands underwater? YES ~NO.}f it does,
Form A/4 (Application for Dredging/Filling) must be completed and attached a~p~rt of this
application.
In requesting approval of this application, I su:bmit that: the information presented herein
Js 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 specificoti.ons attached; 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 and abide by the Terms and Conditions of the
Permit, when'a,nd if issued to me~
,Accepted by:
Dated: