Application with SEQR form Jown of Queens uNGy APPLICATION NUMBER
0o
"RESIDENTIAL
SITE PLAN REVIEW Date Submitted to Department
APPLICATION
To Be Reviewed By: Queensbu ry Planning Board
J
Adirondack Park Agency Referral: _
Type I or Class A: ❑ Warren County Planning Referral e 4 , � ( Lceived
Type II or Class B: Received by: (initial)
RLAI
-"°�I L LME COPY
1. Applicant's Name: _ R A �/M Is this an application
9 / l TZ GE C A L1) �,� for an Amendment
Street Address: to a previously
City, State, Zip: N• Z! 8 APPROVED Site Plan'
Telephone No. 5i
P ( 6) 79z--3 7 Yes
�o
p X No
Z. Agent: ! /r9
Street Address:
City, State, Zip:
Telephone No. ( )
3. Owner's Name:
Street Address:
City, State, Zip:
Telephone No. ( )
4. Ownership Intentions, i.e., purchase options:
SINGLE 1-AMIL) /FS /b /Il71AL
5. Property Location: 19 Fl TZCErgL GT 6A/ LA �)
C� UEEAJ.S P �/
6. Description of how to find the prcperty: QUAKCP— P-b Ta COudlRY CLU{3 Rom_
C:OTOE.uD aFQocWL. Z Crud 7?b �s su) C` FOSS RoU112) foa'b kD. Ti
1VIAn1N/S 0. Go Y?-MiCE %Up-Lip IRIGNr drJ ra F,TzGEAALD RD. 4F7-ee-
y,�.�oc7 Fi J7P-IVEwAy/ onl LEFT Cior,u& %a GAe-4G,=
7. IN THE SPACE PROVIDED BELOW, draw an overview (site location) of where
your property is located in the Town of Queensbury.
Show north arrow, street corners (name them) and identify your property.
note: this particular map does not have to be drawn to scale.
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Wwk, ~b�r.�� n oriin oui
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n• ve c`awA
�.F .ono.o.�ce
EXIT � C o Q' O w ccouux,r.
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a OI ♦.lay �;` ,\C o a t o
7A. State the section of the Zoning Ordinance which requires that this proposal have
Site Plan Review: (�• 6/0
8. Tax Map Number: Section: '41 Block: Lot: 3
9. Zone Classifcation: w R- /A
10. Is the lot in question within 500 feet of a County or a State Right of Way or Park,
Municipal Boundary, or watershed draining any County or State facilities, requiring
review of the WARREN CCUNTY PLANNING BOARD:
Yes: X No:
11. List all required County, State, Federal permits, approvals, and status:
b-'RRREN C06'AJ PLAmiNlNG Bn/4R-b
12. Present Use of Property: L c Fi4 L y - P-CS /lb/:A/77-i} L
13. Proposed Use of Property: describe the proposed project:
ADD/.vU �► aaX ao � on� � sroRy Fi�N„�� ��oM w;Ti-� r�
SMALL 3/47-//ROOM AA,V 117 i/�cffG D 9�xZ2� �Eclk To
lhHE EXIsTIN6 �bW4 LC /n/G
14. A. Total Lot Acreage: 4o. 77
B. Total Site Area /square feet or acres: 73 S4 Fi
C. Total Gross Floor Area of Residence(s)
(new construction) / SS 5 sq. ft.
D. Total Gross Floor Area of Addition sq. ft.
15. Any previous Planning or Zoning Board determinations made regarding this property?
Yes No
If yes, please state previous application number(s):
g2E-19 VAr- IR.uG6
and Applicant's name: �- -
16. Any deed restrictions, easements, or covanents?
Yes X No
If yes, please explain in detail: A RieHT-6F-WA)I EXtST.S a6T[W,cFe-A) 0,eES6x17
R6 Sr'b6"cE SHa eELI AJE Fe>;TE Ttu o A�Ta,tii,n/6 7'eopereTic S o TH6
NECK AD�ATip+J 41 ILL -6E St: B*cA� rVP—THTR. T/f*ll/ THE Pr-ESca/TSrXucToeE'
wiLLN6F /Mrt D47 qA/y /A/6eEsS 6P— EG6, 2ESS.
2
17. A. Anticipated date to start construction: MA e c-14 f 751
B. Anticipated date to finish construction: SP21AJ G 17V
C. Please provide the following information (use additional pages if necessary):
1. An estimated project construction schedule:
AF9 �L Fenr�nlnlG
APP-iL IMAI ROOFg �XTE2/a2
18. Character of surrounding lands (Suburban, Commercial, Industrial, Wetlands, etc.):
N �l�/fT3al2 fja�� �� cati. PLE%EL>/ S�rUGLL
19. Current condition of Site (buildings, brush, open field, forest): \
L EysZ- c,e,+ss a E� ( /zr /wave ye,�',a- d f-tJA1V
20. Current Sewage Disposal System (condition, type, tank size, location). J
Condition to be determined by inspection of system by appropriate authorities.
NL W SEPT/c 2y-ST5-M Z'ivSTALLE) .1-' �, y /I88
Ccws,sTs a� A �000 �laL, Sc pT/ �= i Any f< %HA! r���s
eI S /4r-�c A165 Fl,eOM
IF this site plan is within 500 feet of a body of water and involves the addition
of habitable space or increases the use of the property (conversion from seasonal
use) the requirement of the attached checklist (letter H) must be addresses by a
licensed engineer.
21. Proposed Sewage Disposal System (type, tank size, location):
No CCcA yE,2slrrU 4?-/Vo A2)bi7lonl14G. BED )'oohs
22. List the names and location of the parcel (Include Tax Map Number and Zone) of
adjoining property owners:
HOW TO USE THE TAX MAPS
Every property in Queensbury is identified by a number. These numbers relate
to the Town Tax Maps. Each parcel has a 3 number code by which you can locate
it in the Town.
If you know the name of the person who owns the property you can find the
Tax Map Number of the parcel by looking up the person in the "Alphabetical Listing
Book'. This listing has the owners name and identifies his property by the tax map
number.
3
If you have a Tax Map Number but need to know the owner you look in the
"Numerical Listing Book". This book identifies the property owners.
If you only know the property location and need to find the owner, the adjacent
neighbors or the zoning, you need to go to the Tax Map. The first sheet of the tax
maps shows the Town broken into a number of areas which are numbered. These
areas indicate which map (below the cover sheet) to look onto for the property.
This map number is also the first number of the tax map identification number.
For example, in number 32-2-12.3, the 32 indicates Section Number 32. The Section
Number appears in the lower right hand corner of the map. Once you are on the
correct map you need to find the Block Number. The Block Number is the second
number on the tax map. For example, in 32-2-12.3, the 2 is the Block Number.
The Block Number usually has a circle around it.
The last number of the tax map is the parcel number. For example, 12.3 would
indicate the exact piece of property. This number is usually on the map parcel or
has an arrow indicating to which parcel it belongs.
If you have to identify property or adjacent properties for an application it
is very important that you accurately identify the numbers. The first number is
the Section Number. The second number is the Block Number and the third number
is the Parcel Number.
NORTHERLY:
Tax Map Number:
Zone:
Name: Z3Ei2NA2� C6}TyE�lnlL- �uC�HEk l�/
Location: 3 MC —DaA)A LD -ST G F,.
SOUTHERLY:
Tax Map Number:
Zone: W 2 - 1 A
Name: ELI Z A 13 T'N C ALCO &i1gY
• Location: T eo G &A/ ST' Gr f
EASTERLY:
Tax Map Number: Ff Z G f—,<A z� 0,�ZD
Zone:
Name:
Location:
WESTERLY:
Tax Map Number: G L EV L A {<C'
Zone:
Name:
Location:
4
A COMPLETE APPLICATION IS NECESSARY FOR PLACEMENT
ON THE QUEENSBURY PLANNING BOARD AGENDA
APPLICANT PLEASE READ
The Planning Department requires 14 maps of your site plan, one original application
and 13 copies of the application with narrative and supporting reports, if applicable. Also,
Z copies each of the deed and survey plat. Review fees as required.
In support of your application, it would help the Planning Board if a copy of the
elevations showing how the structure(s) will appear were made available to them.
All maps must be folded to an 8% by 14 inch or smaller format. All components
of the submittal must contain all information required under the applicable Town Law or
Regulation and Planning Department checklist.
Ser.l.ton 5.041 Application and Fees for Site Plan Review Approval. In addition to
the fee listed on the schedule of fees, the Planning Board may charge a fee
to developers of projects requiring legal and technical review provided that
the fee charged reflects the actual cost of legal and technical assistance to
the Planning Board. This fee is not to exceed One Thousand ($1,000) Dollars
without notice to the applicant.
The necessary information that you will need for a complete site plan is listed on
the next page: (Queensbury Planning Board Checklist)
WE RECOMMEND YOUR PURCHASING THE ZONING ORDINANCE SO THAT YOU MAY
BE FULLY APPRISED OF ALL TOWN OF QUEENSBURY REGULATIONS.
Please return the original application with all pages intact.
ry Applicant please initial h
7
Signature of Applicant
)I /1
Signature of Agent
Dated this rday of K year " s'
ANY MODIFICATIONS OR STIPULATIONS ON A SITE PLAN WHICH IS A P P R O V E D
BY THE PLANNING BOARD SHALL BE IDENTIFIED ON A REVISED SITE PLAN AND PRESENTED
TO THE PLANNING DEPARTMENT WITHIN 10 DAYS OF THE MEETING AT WHICH THE SITE
PLAN IS APPROVED.
OTHER PERMITS MAY BE REQUIRED FOR CONSTRUCTION OR ALTERATIONS SUBSEQUENT
TO APPROVAL BY THE PLANNING BOARD OR ZONING BOARD OF APPEALS. IT IS THE
APPLICANTS RESPONSIBILITY TO OBTAIN THESE.
I have read the above and understand the instructions:
Signature of Applicant or Agent
5
QUEENSBURY PLANNING BOARD CHECKLIST
THE SITE PLAN: Draw to scale (preferably 1 inch = 40 feet or less) a detailed description
of the proposed site.
Items A through J must be included on the Site Plan drawing.
Items K through Z shall be included on the Site Plan if applicable.
A. Title of drawing, including name and address of Applicant and person responsible
for preparation of such drawing.
B. North arrow, scale and date.
C. Boundaries of the property with dimensions in feet, including zoning boundary
delineations.
D. Existing watercourses, wetlands, and other waterbodies.
E. Location of all existing principle and accessory structures and their uses with exterior
dimensions and lot-line and waterfront setbacks.
F. Location of all proposed principle and accessory uses and structures with exterior
dimensions and setbacks.
G. Location of any existing or proposed easements, driveways, outdoor storage and
A refuse containment areas, including setbacks.
1 H. Location of existing and proposed sewage disposal facilities including lot line,
waterfront and well setbacks. For proposed system or if expanding use, include
design details, construction materials, flow rates or number of bedrooms served
and percolation test results. Also, location of existing sewage and water systems
on adjoining lots.
I. Location and description of existing public or private water supply.
J. Description of the method of securing public or private water and location, design
and construction materials of such facilities.
K. Proposed maximum daily water usage in gallons per day.
L. Location and design of all existing and proposed parking and loading areas, showing
driveways, ingress, egress, handicapped parking and curbing. For proposed parking
and loading areas, include design details, construction materials and dimensions.
M. Total number of existing parking spaces, including the number of those to remain
or to be removed, those to be paved, those to be gravelled, and total number of
proposed new paved spaces and proposed gravelled spaces, including basis for
determining parking adequacy.
N. Provision for pedestrian and handicapped access.
O. Location, design and construction materials of all existing or proposed site
improvements including drains, culverts, retaining walls, and fences.
P. Location of fire and other emergency zones, including the location of fire hydrants.
Q. Location of all existing and proposed energy distribution facilities and other utilities,
including electrical, gas, solar energy, telephone, etc. For proposed facilities, include
design details and construction materials.
R. Location, setbacks, and size of all existing and proposed signs, including design and
construction details of proposed signs.
S. Location and proposed development of all buffer areas, including existing vegetative
cover and screening of storage or refuse areas.
6
T. Location and design of all existing and proposed outdoor lighting facilities.
U. Identification of the location and amount of building area proposed for retail sales
or similar commercial activity.
V. General landscaping plan and planting schedule, including existing trees over 3 inches
in diameter.
W. Grading and stormwater management plan, showing existing and proposed contours
and including drainage calculations.
X. Percent of lot which is presently permeable, including composition of ground cover
(grass, shrubs, gravel, etc.)
Y. Percent of lot which is proposed to be permeable, including composition of ground
cover.
Z. Other elements integral to the proposed development as considered necessary by
the Planning Board and staff.
Applicant please initial e
Additional Information Needed if applicable to your situation:
As of June 20, 1989: The Planning Department requires the following information for
the Queensbury Planning Boards review,
If you are expanding a nonconforming preexisting use as per Article 9 of the
Queensbury Zoning Ordinance effective October 1988, you are required to submit
elevational drawings of your proposed project/plan. Include all sides.
-- 8 EN
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J--- El El El e
EXAMPLE: front elevation EXAMPLE: side elevation
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---- Rniq SlbE VIEW
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�J �H-t�l--il �•! --n:� s4'a eT
�A,� -baWNstlo"I S ii l
RAYMOND E. ERB
The 20'x22' addition to our residence will be a one story frame
structure with a 3' crawl space underneath. Any exterior uncovered
areas will have blue vinyl siding installed, the same as on the
present house.
Rain gutters will direct water to the east side of the building
(away from the lake and facing Fitzgerald Road) . Present residence
gutters will be changed to also drain water to the east side.
. Decorative shrubs will be placed on slope on the lake side of
this addition, as well as on the east side.
AUTHORIZATION TO ACT A AGENT FOR
I, (seller, owner) of premises located at
Tax Map Number hereby designate
as my agent regarding an application for (Subdivision, Site Plan Review, Variance) of the
above premises.
Deed Reference Book Page Date
Does the above parcel represent owner's entire contiguous holdings? Please attach
explanation.
Signed: Date:
PLEASE READ AND SIGN
"The parties hereto consent that the proceedings which result from the within
w application may be tape-recorded and transcribed by the Town Clerk or his agent and
r ' that such minutes as may be transcribed shall constitute the official record of all
proceedings regarding this application, unless the same may vary from the handwritten
minutes taken by the Town Clerk or the Secretary of the Planning Board or Zoning Board
of Appeals, in which event the handwritten minutes as to such inconsistencies shall be
deemed the official record."
ti
Applicant's Signature
Date: I /s//
TOWN OF QUEENSBURY
(As per Section 7.076 Seasonal Dwelling Unit Conversion)
SUPPLEMENTAL INFORMATION
A report prepared by a licensed professional engineer stating that the existing sanitary
septic system is suitable for year-round use, shall be provided. The report shall include:
1. Site plan with existing disposal system layout, size, and separation distances.
Z. Percolation test at existing disposal system.
3. Physical inspection and report on size and condition of septic tank, absorption
field, and other key system components. Unprotected steel tanks and leaking
components must be replaced.
4. Examination of the absorption system piping and crushed stone for evidence
of clogging.
5. Calculations to verify adequate size of system.
Signature of applicant/agent
e --
14-16-2 (2/87)-7c
617.21 SEOR
Appendix A
State Environmental Quality Review
FULL ENVIRONMENTAL ASSESSMENT FORM
Purpose: The full EAF is designed to help applicants and agencies determine, in an orderly manner, whether a project
or action may be significant. The question of whether an action may be significant is not always easy to answer. Frequent-
ly, there are aspects of a project that are subjective or unmeasureable. It is also understood that those who determine
significance may have little or no formal knowledge of the environment or may be technically expert in environmental
analysis. In addition, many who have knowledge in one particular area may not be aware of the broader concerns affecting
the question of significance.
The full EAF is intended to provide a method whereby applicants and agencies can be assured that the determination
process has been orderly, comprehensive in nature, yet flexible to allow introduction of information to fit a projector action.
Full EAF Components: The full EAF is comprised of three parts:
Part 1: Provides objective data and information about a given project and its site. By identifying basic project
data, it assists a reviewer in the analysis that takes place in Parts 2 and 3.
Part 2: Focuses on identifying the range of possible impacts that may occur from a project or action. It provides
guidance as to whether an impact is likely to be considered small to moderate or whether it is a potentially-
large impact. The form also identifies whether an impact can be mitigated or reduced.
Part 3: If any impact in Part 2 is identified as potentially-large, then Part 3 is used to evaluate whether or not the
impact is actually important.
DETERMINATION OF SIGNIFICANCE—Type 1 and Unlisted Actions
Identify the Portions of EAF completed for this project: art 1 15--Part 2 ❑Part 3
Upon review of the information recorded on this EAF(Parts 1 and 2 and 3 if appropriate), and any other supporting
information, and considering both the magitude and importance of each impact, it is reasonably determined by the
lead agency that
❑ A. The project will not result in any large and important impact(s) and, therefore, is one which will not
have a significant impact on the environment, therefore a negative declaration will be prepared.
❑ B. Although the project could have a significant effect on the environment, there will not be a significant
effect for this Unlisted Action because the mitigation measures described in PART 3 have been required,
therefore a CONDITIONED negative declaration will be prepared.*
❑ C. The project may result in one or more large and important impacts that may have a significant impact
on the environment, therefore a positive declaration will be prepared.
A Conditioned Negative Declaration is only valid for Unlisted Actions \
2_I
cName of Action
�1�d�1 j U1y7 r +�JtL:Lz7 —5OI
Name of Lead Agency
t1 1 qR_ CA-E-r I t'K
Print or Tsponsible Officer in Lead Agency Ti a of Responsi
Signature of Responsible Officer in Lead Agency Signature reparer(If differentfrom responsible officer)
Z ,7
Da b
1
PART 1—PROJECT INFORMATION
Prepared by Project Sponsor
NOTICE: This document is designed to assist in determining whether the action proposed may have a significant effect
on the environment. Please complete the entire form, Parts A through E. Answers to these questions will be considered
as part of the application for approval and maybe subject to further verification and public review. Provide any additional
information you believe will be needed to complete Parts 2 and 3.
It is expected that completion of the full EAF will be dependent on information currently available and will not involve
new studies, research or investigation. If information requiring such additional work is unavailable,so indicate and specify
each instance.
NAME OF ACTION
ADD/n1 A F/4� IG �on � DEG Td E- / S 7/e/6- 1LUELL/nI
LOCATION OF ACTION pnoluol S Addn v6 Munklp iffy ano Counts C.O U AJT'
/17F,iz6�414�h pD uCE�rJ-S/3UR — LuA,e9(=/0
NAME OF APPLICANT/SMNCCR �, BUSIN TELEPHONE
A N10 M D 1 1�
ADDRESS _
CITYlPO STATE DP CODE
UEcnJS/iv12V
NAME OF OWNER Of olffwent) ,!-r' BUSINESS HONE
-S/ �- E 1 )
ADDRESS
STATE LP CODE
crrymo /
DESCRIPTION OF ACTION , y E S 1 O�� TQ r�,,,/L y /� OU M 1+1 /1 14 A
a
AbbJ'n/ (, A s X ab N / ,
SNIAC-L. l3gTy deCaM /9Af /T 7 T/�GH4TI, � X
%Nc EX )_S/iu <5 l�G, c t-Z- rLfG
Please Complete Each Question—Indicate N.A. if not applicable
A. Site Description
Physical setting of overall project, both developed and undeveloped areas.
1. Present land use: ❑Urban ❑Industrial ❑Commercial XResldential (suburban) ❑Rural(non farm)
❑Forest ❑Agriculture ❑Other
2. Total acreage of project area: • 7 7 acres.
APPROXIMATE ACREAGE PRESENTLY AFTER COMPLETION
Meadow or Brushland (Non-agricultural) acres acres
Forested
acres acres
Agricultural (Includes orchards, cropland, pasture, etc.) acres acres
.Wetland (Freshwater or tidal as per Articles 24, 25 of ECL) acres acres
Water Surface Area acres acres
Unvegetated (Rock, earth or fill) acres acres
Roads, buildings and other paved surfaces acres acres
Other (Indicate type) RES1IEN T111L y° u S/_� 267- . 77 acres •7 '] acres
3. What is predominant soil type(s) on project site?
a. Soil drainage: Well drained 6 c) % of site ❑Moderately well drained % of site
❑Poorly drained % of site
b. If any agricultural land is involved, how many acres of soil are classified within soil group 1 through 4 of the NYS
Land Classification System? N acres. (See 1 NYCRR 370)_
4. Are there bedrock outcroppings on project site? Dyes Apo
a. What is depth to bedrock? 2VEQ SFr- (in feet)
2
S. App:oximate percentage of proposed project site with slopes: W10% /TD % 010-15% %
015% or greater %
6. Is project substantially contiguous to, or contain a building, site, or district, listed on the State or the National
Registers of Historic Places? Dyes XSNO
7. Is project substantially contiguous to a site listed on the Register of National Natural Landmarks? Dyes )Ve(Jo
8. What is the depth of the water table?>SFT (in feet)
9. Is site located over a primary, principal, or sole source aquifer? ❑Yes %No
10. Do hunting, fishing or shell fishing opportunities presently exist in the project area? WYes ❑No
11. Does project site contain any species of plant or animal life that is identified as threatened or endangered?
❑Yes %fNo According to
Identify each species
12. Are there any unique or unusual land forms on the project site? (i.e., cliffs, dunes, other geological formations)
Dyes 014,o Describe
13. Is the project site resently used by the community or neighborhood as an open space or recreation area?
❑Yes site
If yes, explain
14. Does the present site include scenic views known to be important to the community?
OYes Al
15. Streams within or contiguous to project area:
a. Name of Stream and name of River to which it is tributary
16. Lakes, ponds, wetland areas within or contiguous to project area:
a. Name G L E NL E L�K EE b. Size (In acres)
17. Is the site served by existing public utilities? Pg�es ❑No
a) If Yes, does sufficient capacity exist to allow connection? XKes ❑No
b) If Yes, will improvements be necessary to allow connection? ❑Yes jrNo
18. Is the site located in an agricultural district certified pursuant to Agriculture and Markets Law, Article 25-AA,
Section 303 and 304? Dyes $No
19. Is the site located in or substantially contiguous to a Critical Environmental Area designated pursuant to Article 8
of the ECL, and 6 NYCRR 617? Wes ❑No
20. Has the site ever been used for the disposal of solid or hazardous wastes? OYes *o
B. Project Description
1. Physical dimensions and scale of project (fill in dimensions as appropriate) _
a. Total contiguous acreage owned or controlled by project sponsor acres.
b. Project acreage to be developed: •77 acres initially; N acres ultimately.
c. Project acreage to remain undeveloped N/A- acres.
d. Length of project, in miles: A (If appropriate)
e. If the project is an expansion, indicate percent of expansion proposed
f. Number of off-street parking spaces existing Z; proposed 2-
g. Maximum vehicular trips generated per hour )LVA (upon completion of project)?
h. If residential: Number and type of housing units:
One Family Two Family Multiple Family Condominium
Initially
Ultimately
i. Dimensions (in feet) of largest proposed structure 'ZS height; •S width; 16' length.
j. Linear feet of frontage along a public thoroughfare project will occupy is? 4,5'.31 ft.
3
2. How much natural material (i.e., rock, earth, etc.) will be removed from the site? c
�A —aorriiubic yards
c
3. Will disturbed areas be reclaimed? )(Yes ❑No ❑NSA
a. If yes, for what intend« purpose is the site being reclaimed? feC GKA S 5 NL- ✓ SHP,UFP
b. Will topsoil be stockpiled for reclamation? Dyes %No
c. Will upper subsoil be stockpiled for reclamation? J9Yes ❑No /��,
4. How many acres of vegetation (trees, shrubs, ground covers) will be removed from site? (a acres.
5. Will any mature forest (over 100 years old) or other locally-important vegetation be removed by this project?
Dyes ;1�40 /
6. If single phase project Anticipated period of construction 4 �" months, (including demolition).
7. If multi-phased: '
a. Total number of phases anticipated N A (number)_
b. Anticipated date of commencement phase 1 month year, (including demolition).
c. Approximate completion date of final phase _ _ month —^' year.
d. Is phase 1 functionally dependent on subsequent phases? Dyes ❑No
B. Will blasting occur during construction? Dyes �*0
9. Number of jobs generated: during construction ; after project is complete
10. Number of jobs eliminated by this project La .
11. Will project require relocation of any projects or facilities? Dyes {io If yes, explain
12. Is surface liquid waste disposal involved? Dyes IgNo
a. If yes, indicate type of waste (sewage, industrial, etc.) and amount
b. Name of water body into which effluent will be discharged
13. Is subsurface liquid waste disposal involved? Dyes PgNo Type
14. Will surface area of an existing water body increase or decrease by proposal? Dyes Xlo
Explain
15. Is project or any portion of project located in a 100 year flood plain? Dyes ON
16. Will the project generate solid waste? Dyes NO
a. If yes, what is the amount per month tons
b. If yes, will an existing solid waste facility be used? Dyes ❑No
c. If yes, give name ; location
d. Will any wastes not go into a sewage disposal system or into a sanitary landfill? Dyes ❑No
e. If Yes, explain
17. Will the project involve the disposal of solid waste? Dyes �XNo
a. If yes, what is the anticipated rate of disposal? tons/month.
b. If yes, what is the anticipated site life? years.
18. Will project use herbicides or pesticides? Dyes $NO
19. Will project routinely produce odors (more than one hour per day)? Dyes *0
20. Will project produce operating noise exceeding the local ambient noise levels? Dyes )!WO
21. Will project result in an increase in energy use? Dyes 34No
If yes , indicate type(s)
22. If water supply is from wells, indicate pumping capacity gallons/minute. i"RTE'¢. 100n.rr3 F40m
G4—N LAKE'
23. Total anticipated water usage per day N gallons/day.
24. Does project involve Local, State or Federal funding? Dyes ilo
If Yes, explain
4
25. Approv;As Required: Submittal
Type Date
City, Town, Village Board ❑Yes ❑No
City, Town, Village Planning Board -XYes []No �� PLAA) REVIL WJ FE/3 1551
i
City, Town Zoning Board )kYes ❑No A2EH VA,2//}AJ
City, County Health Department Dyes ❑No
Other Local Agencies ❑Yes ❑No
Other Regional Agencies ❑Yes ❑No
State Agencies Dyes ❑No
Federal Agencies ❑Yes ❑No
C. Zoning and Planning Information
1 . Does proposed action involve a planning or zoning decision? 'X.Yes ❑No
If Yes, indicate decision required:
❑zoning amendment 9zoning variance ❑special use permit ❑subdivision �ite plan
❑new/revision of master plan ❑resource management plan ❑other
2. What is the zoning classification(s)of the site?
3. What is the maximum potential development of the site if developed as permitted by the present zoning?
4. What is the proposed zoning of the site? S H L
S. What is the maximum potential development of the site if developed as permitted by the proposed zoning?
N / A
6. Is the proposed action consistent with the recommended uses in adopted local land use plans? �es ❑No
7. What are the predominant land use(s) and zoning classifications within a I/ mile radius of proposed action?
SI/J&LC FAryt,L)� gESiDE,uT/AL
S. Is the proposed action compatible with adjoining/surrounding land uses within a '/4 mile? Xxes ❑No
9. If the proposed action is the subdivision of land, how many lots are proposed?
a. What is the minimum lot size proposed?
10. Will proposed action require any authorization(s) for the formation of sewer or water districts? ❑Yes ,Xlo
11 . Will the proposed action create a demand for any community provided services (recreation, education, police,
fire protection)? Dyes �LNo
a. If yes, is existing capacity sufficient to handle projected demand? Dyes ❑No
12. Will the proposed action result in the generation of traffic significantly above present levels? Dyes X(No
a. If yes, is the existing road network adequate to handle the additional traffic? ❑Yes ❑No
D. Informational Details
Attach any additional information as may be needed to clarify your project. If there are or may be any adverse
impacts associated with your proposal, please discuss such impacts and the measures which you propose to mitigate or
avoid them.
E. Verification
I certify that the information provided above is true to the best of my knowledge.
Applicantl&pon V Name A ZM 6A1)t> E, EX�B Date Z L/ 9/
Signature ry — Title c�
If the action is in Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding
with this assessment.
5
Part 2—PROJECT IMPACTS AND THEIR MAGNITUDE
Responsibility of Lead Agency
General Information (Read Carefully)
• In completing the form the reviewer should be guided by the question: Have my responses and determinations been
reasonable? The reviewer is not expected to be an expert environmental analyst
• Identifying that an impact will be potentially large (column 2) does not mean that it is also necessarily significant.
Any large impact must be evaluated in PART 3 to determine significance. Identifying an impact in column 2 simply
asks that it be looked at further.
• The Examples provided are to assist the reviewer by showing types of impacts and wherever possible the threshold of
magnitude that would trigger a response in column 2. The examples are generally applicable throughout the State and
for most situations. But, for any specific project or site other examples and/or lower thresholds may be appropriate
for a Potential Large Impact response, thus requiring evaluation in Part 3.
• The impacts of each project on each site, in each locality, will vary. Therefore, the examples are illustrative and
have been offered as guidance.They do not constitute an exhaustive list of impacts and thresholds to answer each question.
• The number of examples per question does not indicate the importance of each question.
• In identifying impacts, consider long term, short term and cumlative effects.
Instructions (Read carefully)
a. Answer each of the 19 questions in PART 2. Answer Yes if there will be any impact
b. Maybe answers should be considered as Yes answers_
c. If answering Yes to a question then check the appropriate box (column 1 or 2) to indicate the potential size of the
impact If impact threshold equals or exceeds any example provided, check column 2. If impact will occur but threshold
is lower than example, check column 1.
d. If reviewer has doubt about size of the impact then consider the impact as potentially large and proceed to PART 3.
e. If a potentially large impact checked in column 2 can be mitigated by change(s) in the project to a small to moderate
impact also check the Yes box in column 3. A No response indicates that such a reduction is not possible. This
must be explained in Part 3.
V—Icte
2 3
Potential Can Impact Be
Large Mitigated By
IMPACT ON LAND Impact Project Change
1 . Will the proposed action result in a physical change to the projec�tWe?
DNOp9YE5Examples that would apply to column 2 // \\• Any construction on slopes of 15% or greater, (15 foot rise per 100 ❑ ❑Yes ❑No
foot of length), or where the general slopes in the project area exceed
10%.
• Construction on land where the depth to the water table is less than ❑ ❑ Dyes ❑No
3 feet
• Construction of paved parking area for 1,000 or more vehicles. ❑ ❑ ❑Yes ❑No
• Construction on land where bedrock is exposed or generally within ❑ ❑ El Yes ❑No
3 feet of existing ground surface.
• Construction that will continue for more than 1 year or involve more ❑ ❑ ❑Yes ❑No
than one phase or stage.
• Excavation for mining purposes that would remove more than 1,000 ❑ ❑ ❑Yes ❑No
tons of natural material (i.e., rock or soil) per year.
• Construction or expansion of a sanitary landfill. ❑ ❑ ❑Yes ❑No
• Construction in a designated floodway. ❑ ❑ ❑Yes ❑No
• Other impacts
.Q ❑ ❑Yes ❑No
hfilQtJ�i Eo
2. Will there be an effect tr. _ay unique or unusual land f rms found on
the site?(i.e.. cliffs, dunes, geological formations, etc.) O DYES
• Specific land forms: ❑ ❑ Oyes ❑No
6
1 2 3
Small to Potential Can Impact Be
IMPACT ON WATER Moderate Large Mitigated By
3. Will proposed action affect any water body designated as protected? Impact Impact Project Change
(Under Articles 15, 24, 25 of the Environmental Conservation Law, ECL)
NO DYES
Examples that would apply to column 2 ��
• Developable area of site contains a protected water body. ❑ ❑ Dyes ❑No
• Dredging more than 100 cubic yards of material from channel of a ❑ ❑ ❑Yes ❑No
protected stream.
• Extension of utility distribution facilities through a protected water body. ❑ ❑ ❑Yes []No
• Construction in a designated freshwater or tidal wetland. ❑ ❑ ❑Yes ❑No
• Other impacts: ❑ ❑ ❑Yes [--]No
4. Will proposed action affect any non-protected existing or new body
of water? FNO DYES
Examples that would apply to column 2
• A 10% increase or decrease in the surface area of any body of water ❑ ❑ ❑Yes ❑No
or more than a 10 acre increase or decrease.
• Construction of a body of water that exceeds 10 acres of surface area. ❑ ❑ Dyes ❑No
• Other impacts: ❑ ❑ [Dyes [-]No
5. Will Proposed Action affect surface or groundwater
quality or quantity? DYES
Examples that would apply to column 2 y
• Proposed Action will require a discharge permit ❑ ❑ ❑Yes ❑No
• Proposed Action requires use of a source of water that does not ❑ ❑ Dyes ❑No
have approval to serve proposed (project) action.
• Proposed Action requires water supply from wells with greater than 45 ❑ ❑ []Yes ❑No
gallons per minute pumping capacity.
• Construction or operation causing any contamination of a water ❑ ❑ ❑Yes []No
supply system.
• Proposed Action will adversely affect groundwater. ❑ ❑ []Yes ❑No
• Liquid effluent will be conveyed off the site to facilities which presently ❑ ❑ Dyes [-)No
do not exist or have inadequate capacity.
• Proposed Action would use water in excess of 20,000 gallons per ❑ ❑ Dyes ❑No
day.
• Proposed Action will likely cause siltation or other discharge into an ❑ ❑ ❑Yes ❑No
existing body of water to the extent that there will be an obvious visual
contrast to natural conditions.
• Proposed Action will require the storage of petroleum or chemical ❑ Cl ❑Yes ❑No
products greater than 1,100 gallons.
• Proposed Action will allow residential uses in areas without water ❑ ❑ Dyes ❑No
and/or sewer services.
• Proposed Action locates commercial and/or industrial uses which may ❑ ❑ ❑Yes ❑No
require new or expansion of existing waste treatment and/or storage
facilities.
• Other impacts: ❑ ❑ ❑Yes ONO
6. Will proposed action alter drainage flow or patterns, or surface
water runoff? ON YES
Examples that would apply to column 2 ❑ [--)Yes ❑No
• Proposed Action would change flood water flows.
7
1 2 3
Small to Potential Can Impact Be
Moderate Large Mitigated By
Impact Impact Project Change
• Proposed Action may cause substantial erosion. ❑ ❑ El Yes ❑No
• Proposed Action is incompatible with existing drainage patterns. ❑ ❑ ❑Yes ❑No
• Proposed Action will allow development in a designated floodway. ❑ ❑ Dyes ❑No
• Other impacts: ❑ ❑ ❑Yes ❑No
IMPACT ON AIR f
7. Will proposed action affect air quality? -NO DYES
Examples that would apply to column 2
• Proposed Action will induce 1,000 or more vehicle trips in any given ❑ ❑ Dyes ❑No
hour.
• Proposed Action will result in the incineration of more than 1 ton of ❑ ❑ ❑Yes ❑No
refuse per hour.
• Emission rate of total contaminants will exceed 5 lbs. per hour or a ❑ ❑ ❑Yes ❑No
heat source producing more than 10 million BTU's per hour.
• Proposed action will allow an increase in the amount of land committed ❑ ❑ ❑Yes ❑No
to industrial use.
• Proposed action will allow an increase in the density of industrial ❑ ❑ ❑Yes ❑No
development within existing industrial areas.
• Other impacts: ❑ ❑ ❑Yes ❑No
IMPACT ON PLANTS AND ANIMALS
8. Will Proposed Action affect any threatened or end%NO
ed
species? DYES
Examples that would apply to column 2
• Reduction of one or more species listed on the New York or Federal ❑ ❑ ❑Yes ❑No
list, using the site, over or near site or found on the site.
• Removal of any portion of a critical or significant wildlife habitat ❑ ❑ ❑Yes ❑No
• Application of pesticide or herbicide more than twice a year, other ❑ ❑ ❑Yes ❑No
than for agricultural purposes.
• Other impacts: ❑ ❑ ❑Yes ❑No
9. Will Proposed Action substantially affect non-threat4n,6cl or
non-endangered species? 67NO DYES
Examples that would apply to column 2 ✓✓���V
• Proposed Action would substantially interfere with any resident or ❑ ❑ Oyes ❑No
migratory fish, shellfish or wildlife species. ,
• Proposed Action requires the removal of more than 10 acres ❑ ❑ ❑Yes ❑No
of mature forest (over 100 years of age) or other locally important
vegetation.
IMPACT ON AGRICULTURAL LAND RE:S0
10. Will the Proposed Action affect agricultural land r rces?
NO DYES
Examples that would apply to column 2
• The proposed action would sever, cross or limit access to agricultural ❑ ❑ Oyes []No
land (includes cropland, hayfields, pasture, vineyard, orchard, etc.)
8
1 2 3
Small to Potentlal Can Impact Be
Moderate large Mltlgated By
Impact Impact Project Change
• Construction activity would excavate or compact the soil profile of ❑ ❑ ❑Yes ❑No
agricultural land.
• The proposed action would irreversibly convert more than 10 acres ❑ ❑ ❑Yes []No
of agricultural land or, if located in an Agricultutal District, more
than 2.5 acres of agricultural land.
• The proposed action would disrupt or prevent installation of agricultural ❑ ❑ Dyes ❑No
land management systems (e.g., subsurface drain lines, outlet ditches,
strip cropping); or create a need for such measures (e.g. cause a farm
field to drain poorly due to increased runoff)
• Other impacts: ❑ ❑ El Yes ❑No
IMPACT ON AESTHETIC RESOURCES
11 . Will proposed action affect aesthetic resources? DYES
(If necessary, use the Visual EAF Addendum in ection 617.21,
Appendix B.)
Examples that would apply to column 2
• Proposed land uses, or project components obviously different from ❑ ❑ ❑Yes ❑No
or in sharp contrast to current surrounding land use patterns, whether
man-made or natural.
• Proposed land uses, or project components visible to users of ❑ Cl ❑Yes ❑No
aesthetic resources which will eliminate or significantly reduce their
enjoyment of the aesthetic qualities of that resource.
• Project components that will result in the elimination or significant ❑ ❑ ❑Yes ❑No
screening of scenic views known to be important to the area.
• Other impacts: ❑ ❑ ❑Yes ❑No
IMPACT ON HISTORIC AND ARCHAEOLOGICAL RESOURCES
12. Will Proposed Action impact any site or structure of istoric, pre-
historic or paleontological importance? O DYES
Examples that would apply to column 2
• Proposed Action occurring wholly or partially within or substantially ❑ ❑ []Yes ❑No
contiguous to any facility or site listed on the State or National Register
of historic places.
• Any impact to an archaeological site or fossil bed located within the ❑ ❑ ❑Yes ❑No
project site.
• Proposed Action will occur in an area designated as sensitive for ❑ ❑ Dyes ❑No
archaeological sites on the NYS Site Inventory.
• Other impacts: ❑ ❑ Dyes ❑No
IMPACT ON OPEN SPACE AND RECREATION
13. Will Proposed Action affect the quantity or quality of existing or
future open spaces or recreational opportunities? JJ �
Examples that would apply to column 2 \\tp DYES
• The permanent foreclosure of a future recreational o portunity. ❑ ❑ ❑Yes ❑No
• A major reduction of an open space important to the community. ❑ ❑ ❑Yes ❑No
• Other impacts: ❑ ❑ ❑Yes ❑No
9
1 2 3
IMPACT ON TRANSPORTATION Small to Potential Can Impact Le
14. Will there be an effect to existing transportation systT�rr99s�? Moderate Large Mitigated By
O OYES Impact Impact Project Change
Examples that would apply to column 2 IT
• Alteration of present patterns of movement of people and/or goods. ❑ ❑ []Yes []No
• Proposed Action will result in major traffic problems. ❑ ❑ ❑Yes ❑No
• Other impacts: ❑ ❑ ❑Yes ❑No
IMPACT ON ENERGY
15. Will proposed action affect the community s sou rc of fuel or
energy supply? NO OYES
Examples that would apply to column 2
• Proposed Action will cause a greater than 5% increase in the use of ❑ ❑ Dyes ❑No
any form of energy in the municipality.
• Proposed Action will require the creation or extension of an energy ❑ El [I Yes []No
transmission or supply system to serve more than 50 single or two family
residences or to serve a major commercial or industrial use.
• ❑ ❑ ❑Yes ❑No
Other impacts:
NOISE AND ODOR IMPACTS
16. Will there be objectionable odors, noise, or vibrati as a result
of the Proposed Action? NO OYES
Examples that would apply to column 2
• Blasting within 1,500 feet of a hospital, school or other sensitive ❑ ❑ ❑Yes ❑No
facility.
• Odors will occur routinely (more than one hour per day). ❑ ❑ Dyes ❑No
• Proposed Action will produce operating noise exceeding the local ❑ ❑ Dyes []No
ambient noise levels for noise outside of structures.
• Proposed Action will remove natural barriers that would act as a _ ❑ ❑Yes ❑No
noise screen.
• Other impacts: ❑. ❑ Dyes []No
IMPACT ON PUBLIC HEALTH
17. Will Proposed Action affect public health and safety
NO OYES
Examples that would apply to column 2
• Proposed Action may cause a risk of explosion or release of hazardous ❑
❑ ❑Yes No
❑
substances(i.e.oil,pesticides, chemicals, radiation, etc.)in the event of
accident or upset conditions, or there may be a chronic low level
discharge or emission.
• Proposed Action may result in the burial of "hazardous wastes" in any ❑ El ❑Yes ❑No
form (i.e. toxic, poisonous, highly reactive, radioactive, irritating,
infectious, etc.)
Dyes []No
• Storage facilities for one million or more gallons of liquified natural ❑ ❑
gas or other flammable liquids.
Yes ❑NO
• Proposed action may result in the excavation or other disturbance ❑ ❑ ❑
within 2,000 feet of a site used for the disposal of solid or hazardous
waste. ❑yes ❑No
• Other impacts: ❑ ❑
10
1 2 3
IMPACT ON GROWTH AND CHARACTER Small to Potential Can Impact Be
OF COMMUNITY OR NEIGHBORHOOD Moderate Large Mitigated By
18, Will proposed action affect the character of the existing community? Impact Impact Project Change
<1dr,x"f DYES
Examples that would apply to column 2
• The permarsent population of the city, town or village in which the ❑ ❑ ❑Yes ❑No
project is located is likely to grow by more than 5%.
• The municipal budget for capital expenditures or operating services ❑ ❑ Dyes ❑No
will increase by more than 5% per year as a result of this project.
• Proposed action will conflict with officially adopted plans or goals. ❑ ❑ ❑Yes []No
• Proposed action will cause a change in the density of land use. ❑ ❑ ❑Yes []No
• Proposed Action will replace or eliminate existing facilities, structures ❑ ❑ Dyes ❑No
or areas of historic importance to the community.
• Development will create a demand for additional community services ❑ ❑ ❑Yes ❑No
(e.g. schools, police and fire, etc.)
• Proposed Action will set an important precedent for future projects. ❑ ❑ ❑Yes []No
• Proposed Action will create or eliminate employment. ❑ ❑ ❑Yes ❑No
• Other impacts: ❑ ❑ Dyes [-]No
19. Is there, or is there likely to be, public controyer y related to
potential adverse environmental impacts? 1 O DYES
If Any Action in Part 2 Is Identified as a Potential Large Impact or
If You Cannot Determine the Magnitude of Impact, Proceed to Part 3
Part 3—EVALUATION OF THE IMPORTANCE OF IMPACTS
Responsibility of Lead Agency
Part 3 must be prepared if one or more impact(s) is considered to be potentially large, even if the impact(s) may be
mitigated.
Instructions
Discuss the following for each impact identified in Column 2 of Part 2:
1 . Briefly describe the impact.
2. Describe(if applicable)how the impact could be mitigated or reduced to a small to moderate impact by project change(s).
3. Based on the information available, decide if it is reasonable to conclude that this impact is important.
To answer the question of importance, consider:
• The probability of the impact occurring
• The duration of the impact
• Its irreversibility, including permanently lost resources of value
• Whether the impact can or will be controlled
• The regional consequence of the impact
• Its potential divergence from local needs and goals
• Whether known objections to the project relate to this impact.
(Continue on attachments)
11