5613 COLBY AVE 2018-01-02 MF Import

EVALUATION FOR TO BE COMPLETED BY APPLICANT +GENCY USE ONLY ?. Water a. Surface: )) Is there any surface water body on or in the immediate vicinity of the site I including year—round ana seasonal streams. saltwater. ;aka. ponds. wetlanasl? If yes. describe type i and provide names. If appropriate. state what stream or river it flows into. Nore 2) Will the project require any work over. in. or adjacent to lwtthin 200 feetl the described waters? If yes, please describe and attach available plans. N/A 3) Estimate the amount of fill and dredge rratenal that would be placed in or removed from surface water or wetlands and indicate the area of the site that would be affected. In- dicate the source of fill material. /A 3) Will the proposal require surface water withdrawals or diversions? Give general de- scription. purpose. and approximate quantities if known. N/A 5) Does the proposal lie within a I00—year (loodplain? If so. note location on the site Plan. No 6) Does the proposal involve any discharges of waste materials to surface waters? If so, describe the type of waste and anticipated volume of discharge. No b. Ground: 1) Will ground water be withdrawn. thdapproximatew.or will lgwater be discharg to ground water? Give general description, purpose. No 2) Describe waste material that will be discharged into the ground from septic tanks or other sources. if any (for example: Domestic sewage: industrial. containing the following chemicals .: agricultural: etc.). Describe the general size of the system. the number of such systems. the number of houses to be served (if applicable). or the number of animals or humans the system(s) are expected to serve. `T/A G