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HomeMy WebLinkAboutRichards, Jane os�FFolr James F King,President o� CQG P O Box 1179 Jill M.Doherty,Vice-President a y Southold,NY 11971 Peggy A.Dickersonti ? Telephone(631)765-1892 Dave Bergen A nom, Fax(63 1)765-6641 Bob Ghosio,Jr Southold Town Board of Trustees Field InspectionMorksession Report Date/Time: Coastline Cesspool and Drain on behalf of JANE RICHARDS requests an Administrative Permit to install an 8'X 6' pre-cast overflow pool with traffic bearing casting to grade. Located: 540 Terry Path, Mattituck. SCTM#123-6- 19 Type of area to be impacted: _Saltwater Wetland Freshwater Wetland Sound Bay Distance of proposed work to edge of wetland Part of Town Code proposed work falls under: _Chapt.275 . Chapt. 111 other Type of Application: Wetland _Coastal Erosion _Amendment Administrative_Emergency Pre-Submission Violation Info needed: Modifications: Conditions: Present Were: _J.King _J.Doherty_P.Dickerson D. Bergen_ B.Ghosio, D. Dzenkowski other Form filled out in the field by Mailed/Faxed to: Date: tea—+��. nom' e Vj C' ca.X _ tv 8it'6p �\ t•::': }•'fin'/pt.�"'F� y \ -� � - � '• fide:vyZik - '• � - •� - .• '1-' ,_ - ;r';:+:: <c� ' �t`J , .ib:d,�, �iy .i,,e,— s:;%••;;L!;.`'%.`^,rji�..C''i`b�c' _ y. ',L.F. 1 - ''t&;c:. s:,1?. y.%.Y•r(.ic_y,xs_�,, r•;h._. '-t 11 , hIF Sf4`F� d «- t: E c. p UL 1009 Southhold TownDOW of ~` , . .; ' L.O SXR ;-- ,'-�" � � btu wt h eta � � � - . . -._ � • _ .. - -- - ., -�' te ti gid-�s _- --- - - ?� J U L Southhold Town Board of Trustees k,: - n Umoj,pjo44jnoS 600? 3-21. ........... iMa.11 16, 'R ... ........... ... ..........I or --(i z I 0" A" aoia Uv (A I ,o:«: sfE scc Mo.of . _ ,a fFG,61,f fQ S1L 161,E 0910-ar Wid lf[ T'' Wid� � ll( 4cnu1 , � }I1� sa 2 • S W f iov�o Yff-ff, / _/ll� ° rt /. /r. /- J • Y I H •11 � i 1.19-0 , �S� l..._r ,..•_. ...._r 11 JJJ""" 1011 P6.Yd ` ,� u •.•r_r •14 SfF fFt 16 �q] •• \1\ ,\6 yy- O 1 CREEK 3 1 t f :. Vol u p t6 5 w Nmr" % O ad � u.f BAY ,e 44 AHK: a PE , u Cf -r —_ — —_.— NOTICE COUNTY OF SUFFOLK © i """ SWTHOLD sECTOR Mo E _. ._� _ (Ill —p — -_—_ — R a 1�.f a Red Property Tax Service Agency T Dmtm 1110123 ,M T 11101 M P ]aoo PROPERTY 4M OR ,.,yy.-_F•'ye•-'i'.r-'='""i0 3G" - _ ____ __ n���_.«rr .>=l...za� _ _ James F. King,President �*OF SOUjy� Town Hall Jill M.Doherty,Vice-President 53095 Route 25 Peggy A. Dickerson P.O. Box 1179Southold,New York 11971-0959 Dave Bergen G Bob uno-$Lo, Jr. i0 Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Permit Applicatioy _Wetland.Permit Application i Administrative Permit / —Amendment/Transfer/Extension _VV�eceived Application: 6-9, Received Fee:$ ✓ D E Q V Completed Application v —Incomplete JULSE RA Classification: 6 Zoog Type I Type 11 , Unhsted _Coordination:(date sent). Southhold LWRP Consistency Assessment Form Board et d T, _CAC Referral Sent: steel _Date of Inspection: _Receipt of CAC Report: _Lead'Agency Determination: - _Technical Review: _Public Hearing Held: _Resolution: Name of Applicant �,����� Address Phone Number:( 90.3 Suffolk County Tax Map Number: 1000 - /,z;73 Property Location: (provide LILCO Pole#, distance to cross streets, and location) AGENT: '�, s��.�� 5. oe (If applicable) Address: 2�S ,t.� ow- Phone:,��/� Board of Trustees Application GENERAL DATA Land Area(in square feet): Area Zoning: �ZG/E� rg/ Previous use of property: 40595 Intended use of property: /cam Covenants and Restrictions: Yes V No If"Yes",please provide copy. Prior permits/approvals for site improvements: Agency Date V No prior permits/approvals for site improvements. HasFany 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 Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA. Purpose of the proposed operations: Area of wetlands on lot: square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands: q5 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? 57 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_ reason of such proposed operations (use attachments if appropriate): PROJECT ID NUMBER 617.20 SEAR 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) 1 APPLICANT/SPONSOR 2.PROJECT NAME 3.PROJECT LOCATION: unic,p,ry'e , c� County l� 4.PRECISE LOCATION:,Street Addess and Road Intersections, Prominent landmarks etc -or provide map 5.IS PROPOSED ACTION. ❑ New ❑Expansion 10(odification/alteration 6.DESCRIBE PROJECT BRIEFLY: 2 Pv-ecos-A-- 7.AMOUNT OF LAND AFFECTED- Initially acres Ultimately acres 8.WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? [ayes ❑ No If no,describe briefly: 9 WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply) Residential ❑Industrial ❑Commercial ❑Agriculture ❑Park/Forest/Open Space ❑Other (describe) 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) [D'res ❑No If yes, list agency name and permit/ approval: _PIECI OF ME ALID I ORAPPROVAL? ❑Yes. 19Dlo If yes, list agency name and permit / approval: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/*APPROVAL REQUIRE MODIFICATION? Ekes Sift . I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE/TO THE BEST OF/�M_Y'KNOWLEDGE Applicant / Sponsor Na t�j`�ll tG' M W. (JQ 1F e� S ide n , LSuGLs� �C S I� U,' Signature v 1 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 Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR,PART 617 47 If yes,coordinate the review process and use the FULL EAR Yes 0 No B. WILL ACTION 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. Yes Ej 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 pattern,solid waste production or disposal, potential for erosion,drainage or flooding problems? Explain briefly: C2. Aesthetic,agricultural,archaeological,historic,or other natural or cultural resources;or community or neighborhood character?Explain briefly: C3. Vegetation or fauna,fish,shellfish or wildlife species,significant habitats,or threatened or endangered species?Explain briefly- C4. rieflyC4. A community's existing plans or.goals as officially adopted,or a change in use or Intensity of use of land or other natural resources?Explain briefly. F_ C5 Growth,subsequent development,or related activities likely-to be induced by the proposed action?Explain briefly- C6. rieflyC6. Long term,short term,cumulative,or other effects not identified in C1-05? Explain briefly- C7 rieflyC7 Other impacts(including changes in use of either quantity or type of energy? Explain briefly: D WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA CEA? If es,ex Iain briefl ❑ Yes E244o E. IS THERE,Oft IS THERE LIKELY TO BE,CONTROVERSY RELATEDTO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes explain: E] Yes Eallo - PART III-DETERMINATION OF SIGNIFICANCE(Tobe completed by Agency) INSTRUCTIONS: For each adverse effect identified above,determine whether it is substantial,large,important or otherwise significant. Each effect should be assessed in connection with its(a)setting(i.e.urban or-rural);(b)probability of occurring;(c)duration;(d)irreversibility;(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 Check this box if you have Identified one or more potentially large or significant adverse impacts which MAY occur-Then proceed directly to the FUL EAF 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 actio WILL NOT result in any significant adverse environmental impacts ANDprovide, on attachments as necessary, the reasons supporting thl determination. Name o Mad Agency Date Print or a Name o Responsi a in Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(If different from responsible officer) Board of Trustee's Application County of Suffolk State of New York -W/.1 p0j,2 Iliah, 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 TOWN 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(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES.IN CONJUNCTION WITH REVIEW OF THIS APPLICATION Signature SWORN TO BEFORE ME THIS DAY OF ,2009 _ Q Notary Public DEBORAH H.YANDWER No"a0A �� Y61 Commission E)#res April28, 12 Board of Trustees Application AUTHORIZATION .! (where the applicant is not the owner) I, AcS to k-V RRoZI residing .at (print owner of property-) (mailing address) CC A-cry. do hereby authorize A\\ (Agent) c\<, apply for permit(-s) from the Southold Board of Town Trustees on my behalf: (Owner' s signature) 8 APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and.employees.The purpose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. nn n YOUR NAME: Cts`(�3,/-, 4 J��t V %n!M l f . .�C n \Yle l_e S OD (Last name,first name,iuiddle initial,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate:the.other SSU\ cp— person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee r — Change of Zone Coastal Erosion y Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other,name the activity.) Do you personally(or through 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, including 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 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 town 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%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant isnot a corporation); C)an officer,director,partner,or employee of the applicant;or D)the.actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this Ljjday of 20 Signature Print Name Form TS 1 f Town of Southold --LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. 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. 2. 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 willbe evaluated as to its significant beneficial and adverse effects upon the coastal area(which includes all of Southold Town). 3. 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- supporting 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 SCTM# PROJECT NAME �i� SLlaart The Application has been submitted to(check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees 1. 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: Nature and extent of action: 0Ill��iF.�y,./ Location of action: Site acreage: ,,pp Present land use: . 1E& , All Present zoning classification: A!!; Syl�i9/ 2. 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: o 0 0 ��Ox (c) Telephone number: Area Code( ),�/d 903 /539 L/Jl//'� (d) Application number,if any: 'Will the action b 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 dNot 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 0 No M Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LW" Section III—P licies Pages 6 through 7 for evaluation criteria F1 Yes F1 No Not Applicable 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 fa.ges 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 u 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 IH—Policies; Pages 22 through 32for evaon criteria. lua ' Yes No Not Applicable 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 f r 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 was es. See LWRP Section iII—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes ❑ No Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP SectionlIl—Policies; Pages 38 through 46 for evaluation criteria. ❑ YXI No Not Applicable Attach additional sheets if necessary • WORKING COAST POLICIES Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III Policies; Pages 47 through 56 for evaluation criteria. ❑ Yes ❑ NoNot Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town aters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes ❑ 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 ev luation criteria. ❑ Yes ❑ No IiNot Applicable Attach additional sheets if necessary Policy '13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies;,Pages 65 through 68 for evaluation criteria. ❑ Yes ❑ No Not Applicable PREPARED BY� ��� /WA TITLE 0 eie� DATE /�%' James F. King,President J ��0� so yo Town Hall Jill M. Doherty,Vice-President ,`O l0 53095 Route 25 P.O. Box 1179 Peggy A. Dickerson jig jigSouthold,New York 11971-0959 Dave Bergen Bob Unusio, Jr. .'�c`� �� Telephone(631)765-1892 I�COU '� Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOW1V'OF SOUTHOLD Office Use Only " _Coastal Erosion Permit Application _Wetland Permit Application Administrative Permit _Amendment/Transf /Extension �S ceived Application: 7 (Q D `� Received Fee:$ E _ZComrppleted Application JULInco Tete 6 2009 _SEQRA Classification: Type I Type II Unlisted Coordination:(date sent) Southhold To Board of Tru Wo LWRP Consistency Assessment Form Stees _CAC Referral Sent: _/Date of Inspection: _Receipt of CAC Report: —Lead-Agency Determination:. Technical Review: _ ublic Hearing Held: Resolution: Name of Applicant Address Phone Number:( ) ,S/6 'OV3 t Suffolk-County Tax Map Number: 1000 - Property Location: (provide LILCO Pole#, distance to cross streets, and location) AGENT: (If applicable) oe Address: 0 Phone:` ] rd of Trustees Applicatic - S J GENERAL DATA Land Area (in square feet): Area Zoning: IG/Eyrt/ Previous use of property: 40q5 Intended use-of property: Covenants and Restrictions: Yes V No If"Yes", please provide copy. Prior permits/approvals for site improvements: Agency Date 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): I I Board of Trustees Applicati— WETLAND/TRUSTEE LANDS APPLICATION DATA. Purpose of the proposed operations: ?.v l/1Ic/EtdA Area of wetlands on lot: square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands: 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: 6 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): 617.20 SEAR 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) 1 APPLICANT/SPONSOR ,, 2.PROJECT NAME 3.PR,OJECT LOCATION: ^ Municipality �_d County 4 PRECISE LOCATION:,Street Addess and Road Intersections, Prominent landmarks etc -or provide map 5.IS PROPOSED ACTION ❑ 'New F] 'Expansion F�;Kodificafion/alteration 6.DESCRIBE PROJECT BRIEFLY LL=JJ 7 AMOUNT OF LAND AFFECTED- Initially acres Ultimately acres 8 WILL .PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? EYes ❑ No If no,describe briefly- , � 9 WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply) 'Residential ❑Industrial ❑Commercial ❑Agriculture ❑Park/Forest/Open Space ❑Other (describe) i 10 DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) [-.,-4fes ❑No If yes, list agency name and permit/ approval: t , V PERMIT OR APPROVAL? ElYes 19Dlo If yes, list agency name and permit / approval: 12. AS A RESULT OF PROPOSED ACTION WILL. EXISTING PERMIT/'APPROVAL REQUIRE MODIFICATION? ❑Yes Elft I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE r� Applicant / Sponsor Nam �j��1/G' rn W. �Q�k Pres I(�e COLO&-"%� �S � Z, � '0� Signature �� !T/ r _J 1 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 Agency) A. DOES ACTION EXCEED ANY TYPE 1 THRESHOLD IN 6 NYCRR,PART 617 4? If yes,coordinate the review process and use the FULL EAF ❑Yes' 0 No B WILL ACTION 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 Yes 0 No C. COULD ACTION RESULTIN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING (Answers maybe handwritten,if legible) C1 Existing air quality;surface or groundwater quality or quantity,noise levels,existing traffic pattern,solid waste,production or disposal, potential for erosion,drainage or flooding problems? Explain briefly- C2. rieflyC2. Aesthetic,agricultural,archaeological,historic,or other.natural or cultural resources;or community or neighborhood character?Explain briefly C3 Vegetation or fauna,fish,shellfish or wildlife species,significant habitats,or threatened or endangered species?Explain briefly- .___...._ C4.,A community's existing plans or goals as officially adopted,or a change in use or intensity of use of land or other natural resources?Explain briefly: C5 Growth,subsequent development,or related activities likely-to be induced by the proposed action?Explain briefly- C6. rieflyC6. Long term,short term,cumulative,or other effects not identified in C1-05? Explain briefly C7 Other impacts(including changes in use of either quanti or ty a of energ ? Explain briefly _ D WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA(CEA)? If yes,ex Iain briefl Yes [�+No E. IS THERE,OR IS THERE LIKELY TO BE,CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes ex Iain: Yes F;;tNo PART 111-DETERMINATION OF SIGNIFICANCE(To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above,determine whether it is substantial,large,important or otherwise significant. Each effect should be assessed in connection with its(a)setting(i.e.urban or rural);(b)probability of occurring;(c)duration;(d)irreversibility;(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 669121ifiGaAGe,must evadate the potential ifnpa Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur,Then proceed directly to the FULL EAF 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 actio WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting thi determination. -OCj Name oTUead Agency Date Pnn or a Name of Responsible in d Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature'of Preparer(If different from responsible officer) _oard of Trustees Application County of Suffolk State of New York 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 TOWN 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(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION 1 Signature SWORN TO BEFORE ME THIS DAY.OF 13j ,20� Q NotaryPublic DEBORAH,H.VANDGER N Na 01 A61861�Uk Commission Expires April 28, 12 ^ard of Trustees Applicatj AUTHORIZATION ,(where the applicant is not the Owner) , I, -)Acr)LcS Ln k*REtO----a residing .at Qp scx (print owner of property) (mailing address) , � x do hereby authorize (Agent) apply for permit(s) from the \ Southold Board of Town Trustees on my behalf. (Owner' s signature) 8 � APPLICANUAGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURF, FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The puMpse of this form is to provide information which can alert the town of possible-conflicts of interest and allow it to take whatever action is necessary to avoid same. YOUR NAME: ��`� 4 ���It'll 1 C� 1 (lt; CeS �� (Last name,first name,qiiddle initial,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate the.other CP_ 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 (If"Other',name the activity.) Do you personally(or.through 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, including 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 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 town 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%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal orbeneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this day of 20 Signature Print Name Form TS I iA Town of Southold —LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. 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. ,2. 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 sign ificant beneficial and adverse effects upon-the coastal area(which includes all of Southold Town 3. 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- supporting 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 SCTM# PROJECT NAME �iy�S 0 Oe,4w,v�,-Xo The Application has been submitted to (check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees 1. 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: Nature and extent of action: l J , Location of action: Site acreage: Present land use- Present zoning classification:_ 2. 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: ✓�F �f�,y/2� (b) Mailing address: (c) Telephone number: Area Code (d) Application number, if any: WiR the action b 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 dN o-t 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 ElYes Yes 1:1No U Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III—P licies Pages 6 through 7 for evaluation criteria ❑ Yes ❑ No Not Applicable 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 Vages 8 through 16 for evaluation criteria ❑ Yes ❑ No It 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 ❑ ro( No U Not Applicable r 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 evaluat'on criteria. ❑ ❑ G 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 f r evaluation criteria. F] 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 was es. See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes ❑ No Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III—.Policies; Pages 38 through 46 for evaluation criteria. ❑ WE] No Not Applicable' Attach additional sheets if necessary WORKING COAST POLICIE.' Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III Policies; Pages 47 through 56 for evaluation criteria. ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town aters. See LWRP Section III-Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes ❑ 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 forl luation criteria. Yes NoNot Applicable Attach additional sheets if necessary Policy '13. Promote appropriate use and development of energy and mineral resources. See'LWRP Section III-Policies;.Pages 65 through 68 for evaluation criteria. ❑ Yes ❑ No Not Applicable PREPARED BY����� �� TITLE ! e:-55 ' DATE / �' O��S�FFO�,�cO ELIZABETH A. NEVILLE �`1` Gy Town Hall, 53095 Main Road TOWN CLERK o= P.O. Box 1179 H Z Southold, New York 11971 REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER • `F Fax(631) 765-6145 RECORDS MANAGEMENT OFFICER y?J�l �aO� Telephone (631) 765-1800 FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net OFFICE OF THE TOWN CLERK' TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISTRICT APPLICATION CONSTRUCTION or ALTERATION PERMIT CESSPOOL or SEPTIC TANK Residential @ $10 or Non-Residential @$25 Application No. Permit No. Applicant Name CC C YlSA-1 l cy Ce S�oc^_C)\ -- Applicant Mailing Address L �)D``S C,Q�Gn Qf Septic Tank or Cesspool_ Ij Brief Description of Proposed Construction or Alteration -�'� C (AN( `D:eCA'( C'_CA5't �nJ Location of Proposed Construction/Alteration: �SCZ rnP S Owner of Property: C_c S Owner Mailing Address: C�QGA-AA-k:2C-V-, LhX k\gSa Owner Property Address: O 1 e_rn_� a-A-1L) L)CAC Us-A Name and phone number of contact person Tax Map No: Section Block Lo Lot Cross Street NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW CONSTRUCTION REQUIRES,SURVEY WITH HEALTH DEPARTMENT APPROVAL Signature of Applicant Date Received by: