HomeMy WebLinkAboutPleasant Grove Subdivision SEQR form.pdf 617.20
Appendix C
State Environmental Quality Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only
PART I-PROJECT INFORMATION To be completed b A licant or Project Sponsor)
1. APPLICANT/SPONSOR 2. PROJECT NAME
Jason Sokoloff Pleasant Grove Subdivision
3. PROJECT LOCATION:
Municipality Village of Cayuga Heights County Tompkins
4. PRECISE LOCATION(Street address and road intersections,prominent landmarks,etc.,or provide map)
Tax Parcel 1 1.-2-8 aka 176 Pleasant Grove Road
5. PROPOSED ACTION IS:
❑� New Expansion Modification/alteration
6. DESCRIBE PROJECT BRIEFLY:
Subdivide existing 2.423 acre lot with existing single family home into three separate lots as follows:Parcel A to be a 1.02 acre
buildable lot with access from Pleasant Grove Lane; Parcel B to be 0.64 acre lot with existing house with access from Pleasant Grove
Road;Parcel C to be 0.60 acre buildable lot with access from Pleasant Grove Road.
7. AMOUNT OF LAND AFFECTED:
Initially 2.423 acres Ultimately 2.423 acres
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
❑✓ Yes ❑ No If No,describe briefly
9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT?
ZResidential ❑ Industrial Commercial Agriculture ❑ Park/Forest/Open Space Other
Describe:
The original lot has existing residential development on the north,west and south sides of the property.There is a private golf
course across the street to the east.
10. DOES ACTION INVOLVE A PERMIT APPROVAL,OR FUNDING,NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY
(FEDERAL,STATE OR LOCAL)?
❑Yes ❑✓ No If Yes,list agency(s)name and permit/approvals:
11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
❑ Yes ❑� No If Yes,list agency(s)name and permitlapprovals:
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION?
Yes ❑✓ No
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Applicant/sponsorname: Jason Sokoloff Date: 5/19/11
Signature:
If the action is in the Coastal Area, and you are a state agency, complete the
Coastal Assessment Form before proceeding with this assessment
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PART II - IMPACT ASSESSMENT To be completed by Lead Agency)
A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR,PART 617.49 If yes,coordinate the review process and use the FULL EAF.
11 Yes ❑ No
B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR,PART 617.67 If No,a negative
declaration may be superseded by another involved agency.
Yes ❑ No
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING:(Answers may be handwritten,if legible)
Cl. 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. 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. Long term,short term,cumulative,or other effects not identified in C1-05? Explain briefly:
C7. 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)?
❑ Yes ❑ No If Yes,explain briefly:
E. IS THERE,OR IS THERE LIKELY TO BE,CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS?
Yes No If Yes,explain briefly:
PART III-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 significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CE4.
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 action WILL
NOT result in any significant adverse environmental impacts AND provide,on attachments as necessary,the reasons supporting this determination
Name of Lead Agency Date
Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer
Signature of Responsible Officer in Lead Agency Signature of Preparer(If different from responsible officer)
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