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TO BE COMPLETED 81' APPI.ICANT EVALU�TION FOR <br /> �. W�Itf AGENCY CSE ONL� <br /> a. Suriace: <br /> I1 Is there any suriace waier body on �r in ihe immediate vicinicy oi the sito (mc�udinc <br /> year-round and seasonai streams, saltwater, laku, ponds, wetlands)? If ya. ducribe rype ; <br /> and provide namu. If appropnate. sia[e what scream or river it flows inco. <br /> �J i <br /> i <br /> ') Will the pro�ect require any work over, in, or adjacent to (within 200 (eet� [he dacnbed � <br /> wamrs7 I(yes, plwse dacribe and attach available plans � <br /> �.� /j� ! <br /> � <br /> � <br /> :1 Esumate the amount oi fill and dredee material that would be olaced in or removed <br /> irom suriace u•ater or wetlands and indicate tne area oi the s�te tha[ wouid be atfected. In- <br /> dkam tne source oi till matenal. <br /> /�:�.'�v ":: <br /> i <br /> �l �yill the praposal require surface water Withdrawals or diversions'! Give general do- <br /> scription. purpose, and approzimate quanutia if known. � <br /> /"�J�.,' � <br /> i) Does the pr000sal lie within a 100-year tloodplain? If so, note location on the site � <br /> plan. <br /> i <br /> ti-'�� � <br /> ;I <br /> � <br /> 61 Doa the pr000sal involve any discharges of waste matenals to suriace waters' If so. "��� <br /> descnoe the type oi waste and anucipated volume o(discharge. � � ' ;l} <br /> �`- '- i ' <br /> ti <br /> � <br /> , <br /> b. Ground; ' <br /> I l Will ground water be withdrawn, or will water be discharged to ground waiu? Give <br /> eeneral description. purpose, and aoproximate quamities if known. <br /> !%/G� � - (�i . ,. L�� r:-?—:'(�-- � �� <br /> � � <br /> . �_ -X� .. - /ti.. �1 i �.�.� (._, . <br /> '_) Descnbe waste material that will be dischar¢ed into the ground Rom septic tarks or <br /> ocher sources, ii any (for example: Domestic sewage; industrial, containing the ioliowme <br /> chemicals . . .; a¢ncultural: etc.l. Descnbe the general size of the svstem, the number ot <br /> such systems, the number of housu to be served (if applicsble), or the number of animals ar <br /> humans the systemis) are ezpected to serve. <br /> /:- _ i <br /> '( I /; � i <br /> I <br />