LGPC Marina App. " 4
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THIS APPLICATION IS FOR THE:
Marina ON0) 0 Modification to an Existing
APPLICATION FEE ENCLOSED: (check or
moneyorder only)
1. OWNER nl�r. 34s. DMs. ODr. 10911111111"
1111091 N1 AMAMI
• NME
ADDRESSWAFff
MAILING
1, pir
KaW
MISSION
If other parties have deeded or rlakefront, please provide names and malting addresses of
all involved parties on c♦. sheet
COMPANY
MAILING ADDRESS
DR..
NAME OF MARINA
�yI
WHEN
DID MARINA OPERATIONS AT THIS FACIUTY?
TOWN
0 DRESDEN
FORT vM p 1'"III HAGUE
U
iIIN li BOLTON
M 4 • =IU to Tax q 7 WX. AND
1 PROPERTY MOORINGS CURRENTLY ON
PROJECT&Survey(attach colyy) DOCKS 0--Jf*—MOORINGS (Please ffil In a number or 0 for each)
PROPOSED ACTIVITIES
xf
� qw
All
5. MARINA
w
Check the types of servicesoffered orproposed andindicate the numberAuvessels wherew 4 N
13
I II
N mooring rental* �� Public
ww Ik Mk BoatLaunch D Private
..r Boat ILaunch
11 Indoor winter boat storage* 0 Boat Sales 0 Sale of Marine Products
I Towing
0 Outdoor winter boat storage*
o Outdoor Quick Launch ����. ��IIID VIII A 0 Paramm :.
C3 Motorized Bow an 7_06-trucUon/Classes-state type
El Nori-Motorizeid Boat Rentals
11
r'l Personal Watercraft "`
Ej Tour Boat(s)0 Charter Vessels
---------------------------------
Additional Details
*Include berths used by customers only. Do not include slips, moorings or winter storage areas used by rental
vessels or other vessels owned by the
arina or upland owner. Number customer berths,on the facility plan.
Attach sheet with descriptions . .o • boats; type, length . size of aw
aI. 411MOIJUJUAW110111a2110AUT&A101 ZITU141A41:2AVM 0111k trillillillill
0''n-
OF THE VESSELS BERTHED AT
Holding Tanks? Port-a-Pottles? No facilities?
V VRO » wra ,sar , ! DOSED?„,
M
If relyingr w to provide pump-out
M for all marinas which do not JM ab
ARE PETROLEUM PRODUCTS SOLD HERE? 13 Yes Ilo
If yes,what Is the DEC Bulk Storage Permit Number?
If yes, is there a SpillPrevention Plan No (include
spill plan application)
IS A BOAT CLEANINGAREA Mb M r
'�Io (mark location on facility plan)
VEHICLE PARKING SPACES ARE AVAILABLE AT THE SITE? _(mark on facility plan)
HOW
MANY
yy, a TRAILER PARKING
r a tlF SPACES
ARE
AVAILABLE?
k M1 Mk
AREREST ROOMSAVAILABLE TO CUSTOMERS AT ALL TIMES BETWEEN MAY I AND OCTOBER
W'Yes This Is required for all marinas. Mark the rest room's location on facility plan &attach Wastewater System
Evaluation
Report instructions)
rw
PERMITS OR APPROVALSREQUIRED FROM NE AGENCIES OR MUNICIPALITIES
Agency hermit or Approval Date Applied Date Issued
7. ADJOINING LAKEFRONT PROPERTY TY OWNERS(available from your town or county real property dept.)
NAME NAME
"TAX MAP# �� "TAX MA '#
MAILING � �'� AILING
ADDRESS a ADDI ESS
�� �� � 6
B. CERTIFICATION
I hereby affirm that the Information on this form and all attachments submitted herewith Is true to the bast of my
knowledge and belief. As a condition to the issuance of a permit,the applicant accepts full legal responsibility for all
damage, direct and Indirect,or whatever nature,and by whomever suffered, arising out of the project described
herein and agrees to indemnify and save harmless the Mate from suits,actions,damages and costs of every name
and description resulting from the said project.
During the processing of this application Lake George Dark Commission (LGPC)personnel or their assigns may need
to visit this site to inspect, measure, make drawings and/or take photographs. I hereby agree that LGPC staff or their
assigns may eater upon and pass through this property In order to Inspect the project site or facility„without prior
notice, between the hours of 8:00 a.m. and :00 p.m., Monday through Friday,while the application is pending. In the
event that the project site or facility is posted with any form of"posted"or"keep out"notices, or fenced In with an
unlocked gate,this permisslon authorizes LGPC staff or their assigns to disregard such notices or unlocked gates at
the time of Inspection
SIGNATURE OF OWNSR(Note title if signing for a rpor�tion oras ociation) DATE
4—- L� 1, 41'!�/,",t__ ::1
INCLUDE DE WITH THIS FORM M -Failure to include any one of the required harass will result In are Incomplete notice and
delay in processing your application.
El ,Application fee
LI Site location reap
13 Facilit" Plan- to scale showin aII I�uildin s,docks, moorings and location of services provided and any other
required nformation(see applica !on instruc ons)
Full or Short Environmental Assessment Form (confirm form type with Commission staff)
Wastewater System Evaluation Deport, SPDES permit or If on public sewer, a letter from the municipality
approving the proposed use.
Addendum A Co-owner Signature Mage(if lakefront is jointly or commonly owned)
El Addendum FI Parties with deeded or contractual access to this lakefront
* Addendum C Public Vessel Form (if needed)
I Addendum D Pump-out agreement if needed
U:kS AREDkLGP Program_Environmental Permits,~Torrrs'M mese arina p,wp d 1/ 0115
Page 3 of
New York State Department of Environmental Conservation
Division of Water
625 Broadway
Albany,New York 12233-3505
7AM1ftWWM
WMEMMMMMMMW
low No Exposure Certification for Exclusion from SMS Storm Water Permitting
.............
1. owner/Facility Information
Owner:Operator Name:
City/Stat`c�
Mailing Address: City/StaWZiP:613_/ f
C C Z
ontact�Sam Phone No.:
ontact Name: 6L
��If W19 . .....
Facility Name: F
'
City/State/Zip:orE��'',''
Street Address:
County: bol. kelr�e� Latitude: Longitude. SIC Code:
Is the focality eviously covered d under SP1 ES stortriNvater If yesw enter permit number.NYR
permit a,es ftNo f"l"at complawk at this section WUI tervt as a termination 0)(your'NISOP towalew
11, Exposure Checklist
Are an,'of the following materials or activities exposed to precipitation,now or in the foreseeable future N 0
(Please check either"Yes"or"No"in the appropriate box.) If you answer"Yes"to any of these questions(1) YES
through(l!),jqu_are nq-t,eligible for the n2Sxposure exclusion.
Using,storing or cleaning industrial machinery or equipment,and areas where residuals from using,
LLE2d,rt or olcaning industrial machin ore u osed to storm water
remain and are
\taterials or residuals on file ground or in storm water inlets from spilWicaks
3 � `tlaterials or products frorw°t peat industrial activity
i � `Materials tat products during loading�tlrlloadirrg or Transporting a,ctivatics
Materials or products stored outdoors(except final products intended r outsideuse c,g..new
6 30sure to storm water does not result in the disAircri*n ollulants)
M
Materiank
Materials contained in open,deteriorated or leaking storage drums,harrels, tanks.and similar containers
Materials or products handletitstored on roads or railways owned or maintained by the discharger .......
Waste material(except waste in covered,ratan-leaking
containers(e.g.,durnpster))
10 Application or disposal of process wastewater(unless otherwise permitted)
?articulate matter or visible deposits of residuals from roof stacks and/or vents not otherwise regulated
outflow
I ,i,e_under an alr t uatit P controljertnit)and evident in the storm water 0 u
111. Certification
1,;«r,,A ,ander penalt)^tat'133 that I hove rt.,ul md und4miand the efisibffiry,rcquiments rot oaimnig a co"tion of,*Tao cxPosurC'*=d abcxistung an"clusiun from S P DES itorm
ftom the industrt,A(36hry
gtr wniantioated by aXp*5Ute to indW*031 activitues or rnioerw, rlvc,
mkoing,f certiry undcr penalty of law tbor thercme no dischmpi of storm w �aars
w4 "n4itUd in this document(extept ai altowcd ulWor 40 CFR 1222,26(gl(1W l'undent3nd that i wn abhsawd to iubitaft a no veposute ecrtificokn rom once every
oar ty ,
to Fe��*DES pernsitfing Whonry and,if rcquew&to the operator or the local munitittalscen3te itom aver&ysmm tots 4t into which the faciliditchops i wheZ,
i qmderstand that I must AHow the SPDES pcmjtthtqlauthority.arNIS4 OPM40e where the di�whlrge as into the kaca6 MS4,to partom dnspcodonsto confirm the
3VM 3tA u on eq C L, I�:nacritjaul�hat I mu" ttt'Al" ,rqa ar,ocrin s4ir*i N!'nut L,-'�- I
11 0 P r a 4 wn n
_,rj,_�mofno,expojur*3k#4,,o make such�n*pccfian reports PublictY
I=Q"oft��r
4mAn iw,.�oqutr
wiur.+m 4V3W!04* tw.1�IWKWC.�11114 140(MMIOR Qrnk%�,!�star.nq N�k 'V,� <11o"4&v nd
joma4.,J 4'o
i.apl va
or Ino uw 'vff,
lanrut`ed Nai,ne': Title/P osition:
-,-*—1t
f D5VIam: _51
.5
4/ Clear Form
Short Environmental Assessmeliffortn',
art I t �
a
� �Coel FEB �
16
Part I-Project Information. The applicant or project sponsor Is responsible' fair tete 641etl Part1. R ponses
become part of the application for approval or funding,are subject to public review,and inay-be, ra J� t't a '" verlftcatiom
��V �
Complete Part I based on inf6r tion currently available. If additional research or investigation vroulad'be fully
respond to any item,please answer as thoroughly as possible basad on current inftannation.,
Complete all items in Part 1. You may also provide any additional inf6rmation which you believe will be needed by or useful
to the lead agency,attach additional pages as necessary to supplement any itera,
Pant I-Project and Sponsor Information
Flame of tion, r Project;
410 ,
Project.Location(describe,and attach a location map)-
Oz. d__L
Brief Description of Proposed. ctiorr:
he aee41--
lame applicant or onsor: � Telehone:�f
Addresos• �y
ityIPC . Mate dip bode:
1. toes the proposed action only involve the legislative adoption of a plan,local law,ordinance, YES
administrative rule,or regulation?
If Yes,attach a narrative description of the latent of the proposed action and the environmental resources that P El
may be affected in the municipality and proceed to Part 2. If no,continue to question 2.
. Does the proposed action require a permit,approval or funding from any other governmental agency? 0 _ S
If""des,list agency(s)name and permit or approval:
01- 4-e& 84 64>m rte' , Of
.a.Total acreage of the site of the proposed action? acres,
b.Total acreage to be physically disturbed" acres
c.Total acreage(project site and any contiguous properties)owned
or controller)by the applicant or project sponsor? acres
4, Checlr all land uses that occur on,adjoining and near the proposed action,.
O Urban 0Rural(non-agriculture) [3Industrial commercial residential(suburban)
O orest 13Agriculture aquatic 00ther(specify):
OPar .land
Page 1 of
Is,the proposed action, 0 YES lel?A
a..A permitted use under the zoning regulations?
b.Consistent with the adopted comprehensive plan?
. Is the proposed action consistent with the predominant character ofthe existing built or natural
NO YES
landscape?
7Is the site of the proposed action locatedin,or does it adjoin,a state listed Critical Environmental ? NO YES
If"'acs,identify: El
h. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YE
b.Imre public transportation service(s)available at or near the site of the proposed action? ��,
c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? M
. Does the proposed action meet or exceed time state energy code requirements? NO YES
If the proposed action will exceed.......requirements,describe design features and technologies:
..................... .........................
141. 4 ff1_die proposed action connect to an existing public/private water supply? D �
If No,describe method for providing potable water:� I El
11.Will the proposed action connectto existing wastewater utilities? � NO YES
If No, describe method for providing wastewater treatment: OYK 'r-' G M j
1 . a.Does alae site contain a structure that is listed on either the Mate or National Re-gister of iistoric l C) YES
Places?
b.Is the proposed action located in an archeological sensitive area?
13, a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO"
wetlands or other waterbodies regulated by a federal,state or local agency? EL D
b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody� D El
If identify the wetland tA ell e- o body and trent of alterations in square feet or acres:
14. Identify time typical habitat types that occur on,or are likely to be found on the prgject site, check all Haat apply.
ff Shoreline 0Forest 0Agricultural/grasslands (J Early mid-successional
Wettand rl Urban [3 Suburban
16.Does the site of the proposed action contain any species of animal,or associated habitats,listen
by the Mate or Federal government as threatened or endangered? 11
16. Is the project site located in the 100 year flood plain? NO YES
_LL EL
17.Will the proposed action create storm water discharge,either frown point or norm-point sources? NO YES
If Yes,
a.Will storm..water discharges flow to adjacent properties? NO YES E]E] 11
b.Will stormwater discharges be directed to established conveyance systems( ffand stag drains)?
If Yes,briefly describe: D [:]YES
Page Z of 3
18.Does the proposed action include construction or other activities that result in the impoundment of NO I YES
water or other liquids(e.g.retention pond,waste lagoon,darn)?
If Yes,explain purpose and size:
19.Has the site of the proposed action or an adjoining property been the location of an active or closed NO VIES
solid waste management facility?
If Yes,describe- 0 D
............
.............
20, Has the site of the proposed action or an adjoining property been the subject of rernediation(ongoing or NO YES
completed)for hazardous waste?
If Yes,describe: 0 El
To T"M BEST 0"MY
;�-'D OVE IS TRUE AND ACCURATE TO THE BEST OF MY
KNOWLEDGE
:7�-"A
Applicant/sponsor name,—w Are Date-
Signature.-Jo e"2
...................
PRINT F Page 3 of 3
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NEWYORK Lake Cjeorg�
ESTATI
oreo�Z &
Opp Nny. Park Commission
........... . ....
P-)q Georve Rd,Pd Box 749Lake George NY R28451518,60,9347 fax W 66R-500t fl fiPlokcglgpc'stale rly www](Joc%tnto
,Gy wry
APPLICATION FOR PER FOR MARINAS
ADDFENDUM D - Marina pump-out Agreement
This is asup and attachment to appucations for the construction, operation or modification of
P s men
ement
;1
CasA as.
This is to certify that t A creflp'l P eq'/n agrees to provide purn p-out service to
customers of
sig. y
11a w er/0 tor a