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HomeMy WebLinkAboutTR-9329E o��g so�ryol Town Hall Annex Michael J.Domino,President 54375 Route 25 John M.Bredemeyer III,Vice-President ~ P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Krupski �O Telephone(631) 765-1892 Greg Williams 001 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD EMERGENCY WETLANDS PERMIT Permit No.: 9329E Date of Receipt of Application: October 29, 2018 Applicant: Stacy Wickham a/k/a Stacy Sheppard SCTM#: 1000-123-8-28.5 Project Location: 710 Park Avenue Ext., Mattituck Date of Issuance: October 30, 2018 Date of Expiration: 90 Days from Date of Issuance Reviewed by: Board of Trustees Project Description: Repair septic system exposed by nor'easter; re- cover and backfill with sand. Findings: The project meets the requirements for issuance of an Emergency Wetlands Permit as determined by the Board of Trustees. The issuance of an Emergency Wetlands Permit allows for the operations as indicated in the application received on October 29, 2018. Special Conditions: A full Wetland Permit must be obtained within 90 days in order to conduct any further activity on the property. This is not a determination from any other agency. /sevu�- Michael J. Domino Board of Trustees s VNKM.1 ALWUF--GXTEMSlsalol___ ----•--_-.-- __ A�� '�"' �% l 1hL�'F��7_�kr1 Pn r►.Tf� �V1L?�[YllS.l� ZIP - .-7S2u1b►_QS_ �l?7►��1� '5uFFOLJK Coum-tY NES MRkl "Y _ I y •� ;� I _ P• �-agar.�&�1r�.e 7 t� L%AU blow YASIL. D � r~RVW$ 1NU� i_—R�utsB�. �ue�sr �� r ZLTQ:f.._F��SL]LkRY.?Ir3+�Q'.s - PP+RUN�. l V144 �2`lLt P.C- ` $k aet�l�i!V,_MCI_ / r-�Wgi - / os.1 _ 0,0-- M EW P l L.E F OU oG P'I'1 cw•-- -1.F47_ c DU-["2`*,UE•' - - r 'LL.%SO E t�DBER1 C�IIC { r�Eia�uuu" r 5Y NI Q :Z;W-7 1`: knO :QFT__x,LMX-_- i a.l.ca coV� A,N.W. 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Real Property Tax Service Agency Y .�� 123 ,m 1m .1#{ PSq°c - c...ry c.m.r mr.nl..a,Nvn991 M ' .caErreE1: ' PROPEIiTV MAP fl�$QUj Michael J.Domino,President Town Hall Annex O,�►� yQ� 54375 Route 25 John M.Bredemeyer III,Vice-President P.O.Box 1179 Glenn Goldsmith Southold,New York 11971' A.Nicholas Krupsld N Telephone(631)765-1892 Fax(631) 765-6641 Greg Williams BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Emergency Permit Application -Coastal Erosion Permit Application Wetland Permit Application Administrative Permit Amendment/Transfer/Extension Received Application: Received Fee:$ Completed Application: Incomplete: SEQRA Classification: Type I_ Type II Unlisted Lead Agency Determination:_ i OCT Z 9 2�iq Coordination:(date sent): _ LWRP Consistency Assessment Form Sent: CAC Referral Sent: p Sr,W,tio!d;o.ti^ Date of Inspection: 1 ---- Bond of Tni�' ,_ J Receipt of CAC Report: Technical Review: Public Hearing Held: Resolution: Legal Name of Property Owner(s): Mailing Address: Po ft� Phone Number:- b3' (.0 , Suffolk County Tax Map Number: 1000- Property 000-Property Location: 9 �O - mkt3AOck, n 11 �— (If necessary,provide LILCO Pole#, distance t cross streets,and location) AGENT(If applicable): Mailing Address: Phone Number: Board of Trustees Applici )on Q GENERAL DATA Land Area(in-square feet): 1 l Area zoning: Previous use of property: Intended use of property: Covenants and Restrictions on property? Yes _ .No If"Yes",please provide a copy. Will this project require a Building Permit as per Town Code? Yes _No If"Yes", be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes No If"Yes",please provide copy of decision. Will this project req it any demolition as per Town Code or as determined by the Building Dept.? Yes No Does the structure(s)on property have a valid Certificate of Occupancy? Yes No 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?V No Yes If yes, provide explanation: ( tion Project Description use attachments if necessary): Over P Board of Trustees Applicr ''on WETLAND/TRUSTEE LANDS APPLICATION DATA o Purpose of the proposed operations: square feeA see s Area of wetlands on lot: q 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 C 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: 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): b Board of Trustees Applic;__",.on AFFIDAVIT BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMITS)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 BOARD OF 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,INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. Signature of Property Owner Signature of Property Owner SWORN TO BEFORE ME THIS _ DAY OF ,20 Notary Public DIANE DISALVO NOTARY PUBLIC-STATE OF NEW YORK No. 01D1475593 QU011fied in Suffolk County My Commission Expires April 30, 202 -r r i APPLICANT/AGENUREPRESENTATIVE TRANSACTIONAL DISCLOSURE.FORM Tho Town.-drc fr w1 ►�roams of 1~trtlesprohilrita tinCts of intettM on thi utiarigtown bIDeers ndcm- YOURNAME. V I ll. "1 `n (Last name,first name,aquddle mitia,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) ; Tax grievance Building Variance Trustee Coastal Erosion Change of Zone Approval of plat Mooring Exemption from plat or official map Planning Other (if"Other',name the activity.) Do you-personally(or through-yyoouur company..spouse►suiting,-ORWA of child)nava Wiejj iohWli.with any otllcer orefnplgyee of the'Town:of souihold?"Relalioriship''`irioludEs by'bloody ®8z.�T bus'ihe�S itttetest."Busttxssdnterestn moans a business, incldding,t piutrtthshlp;in-wbich lhe,tQwn aft�rxt or pnpla�reo has oven•a parilal ovrneiahip oP(or employment bY)icoiporntion tn'vihlch tk lawn o#It;er••or_empioy ,owns mot*than S%'bf t}t�sbas's 4 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 applicantlagcnt/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 alf that apply): A)the ovmcr o,'grtisierllian Sisot t si es.of the corporate stock of the applicant (When the ttppiicant is a Corporation); B)the legal.orbeflelidbd ownefbfittiy interest in-anon-corporate entity(when the applicant•li not a torpbrti�ot); of the applicant C)an Cutesy-,director,ptut*r,or employee pp icant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP -------------- ov Submitte� ,s h 61 day of� _ h Print Name Form TS 1