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TO SE COM�LETED !Y APPUCANT EVALUAT(ON FOR <br /> 3• W�K► �GENCY USE ONLY ' <br /> a. Surfatt: <br /> I) Is therc any surfaa water body on or in the immediate vianity of the site (including � <br /> year—round and swwna� streams, saltwater, laka, ponds, wetlands)1 If ya, ducribe cype � <br /> and provide nama. [f appropriate, state what stream or river it flows into. <br /> NO <br />, 2) Wiil the project requirc any work over, in, or adjacen[ to (within 200 fxt) the dacribed <br />� wa�ers? If ya, plau dactibe and attach available plant. <br /> NO <br /> 3) Estima�e the amount of fill and drcdge material that would be piaad in or removed <br /> (rom surfaee wacer or wetlands and indicate the area o( the site thu would be affected. In- i <br /> dicace che wura of fil) material. <br /> rdoNe <br /> , <br /> . 4) Will the proposal requirc surface water wi�hdnwals or divenions? Give genenl de- I <br /> , scription, purpose, and approximate quanti[ia if known. <br /> NO <br /> 5) Does the propaal lie within a IOayar Itoodplain? (f so, note loadon on the site <br /> plan. <br /> r�o <br /> 6) Doa the proposal i +olve any discharga of waste materials to surfaa waters? If w. <br /> dacribe the type of w^ and anqcipncd volume of discharge. j <br /> NO ' <br /> b. Ground: I <br /> I) Will ground water be withdnwn, or will water be diuharged to ground water? Give <br /> �enertl dacription, purpose, and approximate quantitia if knowo. <br /> NO <br /> 2) Describe wute material that will be discharged into the ground from septic ianb or <br /> other sourca, if any (for eaample: Domatic sewaae; industrial, contunins the following <br /> chemicals . . .; agricultunl; etc.). Dacnbe the genenl siu of the system, the number of <br /> sucli systems, the number of houta to be served (if applicable), or the number of animats or <br /> Aumans the system(r) are expectcd to serve. <br /> NONE <br /> � <br />