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TO BE COMPLETED BY �PP[JCANT <br />J. Water <br />a. Surface: <br />1) Is cherc any surfaa water bod,v on or in the immediaie �ianicy of the sice (inelu�eng <br />yar-round and seasonal sttwms, xaltwater. Iaka, ponds, wmlands)? IF yu, dacribe rype <br />and provide nama. I( aporopriate, sute what strum or river it flows into. <br />��D <br />?) Will che project require any Work over, in �r adjacenc ta (within 200 (eet) che described <br />waten? If ya, please dacribe and attech available plans. <br />�� <br />3) Estimate the xmount of fill aad drcdge material [hat would be placed in or rcmoved <br />frort; surface wacer or weclandc and indicate ihe area of the sice that would be affecced. In- <br />diate the wuree of fill material. <br />�C�/ r�/ <br />4) Will tha proposal require surf�ce watcr wiehdrawals or diversibns? Give genenl de- <br />uripcion, purpose, and approximate quancitia if known. <br />/Y � <br />S) Doa the proposal lie within a IOd-year Iloodplain? If so, nate loca[ion on ihc site <br />plan. <br />� � <br />6) Doa the proposal involve any diiehar�es of wasee materials to surface waters? If so, <br />deseribe the cype of wute and andcipated volume of dixharge. <br />/V � <br />b. Ground: <br />1) Will around water be wi[hdnwn, or will weter be diuharged ;o ground water? Give <br />general dacription, purpoi4 and approxima�e quaneitia if known. <br />/Y � <br />2) Dazribe wasee material that will be discharged into the ground from septic tanks or <br />ether sourca, it any (for example: Domatie sewage; industrial, connining the following <br />chemicals ...; agrieultural: etc.). Desaibe the general size o( the system, the number of <br />such systems, the number of houtes to bt served (if applicable), or che number of animals or <br />humans the syscem(s) are eapeetai to serve. <br />�x�+i��r iv <br />4. <br />EVALUATfON FOR <br />AGENCY USE ONIY <br />