4930 ELM ST 2018-01-02 MF Import

TO BE COMPLETED BY APPLICANT EVALUATION FOR AGENCY USE ONLY 3. Water a. Surface: 1) Is there any surface water body on or in the immediate vicinity of the site (including year—round and seasonal streams, saltwater, lakes, ponds, wetlands)? If yes, describe type and provide names. If appropriate, state what stream or river it flows into. N/A 2) Will the project require any work over, in, or adjacent to (within 200 feet) the described waters? If yes, please describe and attach available plans. N/A 3) Estimate the amount of fill and dredge material 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. N/A 4) 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 100—year floodplain? If so, note location on the site • plan. N/A 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. N/A b. Ground: 1) Will ground water be withdrawn, or will water be discharged to ground water? Give general description, purpose, and approximate quantities if known. N/A 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. N/A • 4.