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T.0 BE COMPLETED 81' �PPLIC��T <br />j, :�'71tf <br />1. SUf�1CG�• <br />I) Is there zny suifacawacer body an or in the immedia�c lands)'. If �va Sdesc �y� ding <br />.ear—round and seasonal streams, saltwaier. lakes, ponds. YP� <br />lnd pro��de names. If appropriate, state what stream or ri�er it flows into. <br />�o <br />?) Will the project require any work over, in, or adjacent to (within 200 feet) the dacrihed <br />waters' If yes. please desc:ibe and at[ach available pians. <br />�o <br />3i Esumate the amou�it oi fill and dredge maee:ial [hat would be placed in or removed <br />Crom suriace water or wed and indicaie :he area of che sf�e that would be affected. in- <br />dicam the iource ut iill m: .�I. <br />�one <br />3) Will the proposal require surlace water withdrawals or diversions'! Give gencral de- <br />scripcion, purpose, and approximate quantitia if known. <br />On—si[e ��ater <br />S) Does the proposal lie within c 100—year (loodplain° �� so, note locatian on the site <br />plan. <br />�o <br />6) Does the proposal involve any discharga of waste materials to sur(ace waters? If so. <br />describe the rype of waste and anticipated volumc :f discharge. <br />�o <br />b. Ground: <br />�) Will ground water be withdrawn, or wili water be discharged to ground wa[er? Give <br />general dacription, purpose, and approximate quantities if known. <br />No <br />2) Describe waste material that will bc dischar3ed ieto the ground from sep[ic tanks or <br />other sources, if any ;for ezampie: Domestic sewage; industrial, eontaining the foilawing <br />chemicals ...; agricul�ural: etc.). Dacribe the generel size oC che tystem, the number of <br />such systems, the number of housa to be servcd (iF apFlicablej, or the number of animals or <br />humans the syscem(s) are ezpected to serve. . <br />�one � <br />e�n��nuun run <br />ACENCY USE ONLY <br />; /\.b� �c(G <br />! and �h li�eiafrd <br />� �tichd �un <br />��a�y�. �. <br />Iy;� Ul;re�tZy f� <br />I//�l �v� � <br />� G--�yyyi. C�2 <br />i <br />! ��rn.- i�.o <br />i si tG C�Uic^'�`G� <br />I-� �`.2 ���� <br />� S%5vm/ <br />I � 3rd f}ve. Stj <br />i ��I� <br />� �� � <br />.f�e o��aw <br />�QGl�OSS <br />j�'l,ai" Ok� <br />�, �azfrrnu�t <br />y,•�-� �,-io� �v <br />I No� �k.- �/��- <br />