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� M::...�'.w [�i.�airyM <br /> '] <br /> �� P <br /> h <br /> A <br /> �_ . <br /> � H <br /> [�s7� - : 9E iO�7PLE�ED Ol' �ppLIU�T E�nLUAT10N FOR <br /> /D`.Cx � ���etv rGENCY USE ONLY ' <br /> ay y _ �uriace: <br /> rr+ �3C Is cherc an} suriace waier body an or m cne imc.ediate vicmii}• oi the si�e linciudin¢ <br /> Ky n �e�r—rouna ann seasonal strcams. saitwater. lakes, ponds. weilandsll If yes, descrioc rype � <br /> � O pC0 =•a oroviae names. If aoproonaie. state wnat scream or nver oi flows mto. y(j <br /> 'b H'31 <br /> pJ H <br /> H <br /> � xo <br /> yd i <br /> � n� _�. NIII the proieci reauire any work o�er, m. or adjacen[ to Iwithin 300 feeU the described <br /> � [A�O,� +aiers! If }es, pieasc aescribe and.anach avadable plans. �(J� I <br /> � y� � I <br /> ; <br /> H , <br /> � y I <br /> C y i i Esum;.m [ne amount oi fill and dradee matenal that would be placed in or romoved ; <br /> 'rom sunace waier or wetlonds and mdicato tne area o( the sne that would be a(fected. Im <br /> � t`��,j .:caie tne source oi lill maienai. NC N� � <br /> H O vi . <br /> - — _ � <br /> � <br /> al WiU the proposai require suriace watv w�nhdrawals or diversions' Gi��e ¢eneral dc � <br /> xnpuon, purpose, and approximate quanuucs ii known. n/ON Y. <br /> ,_� , <br /> 5) Dou the proposal lie within a 100—year (loodplain? If so, note location on the site <br /> '....,r+ plan. /IJ O <br /> �....,w <br /> �'� 61 Does the prope:al mvolve any discharges of wasee materials to surtace waters? If so, <br /> descnbe the type o(�.vaste and anucipated volume oi discharga NO <br /> �� � <br /> ��� b. Graund: <br /> 1) Will ground water be withdrawn, or will water be discharged to ground water° Give <br /> general description, purpose, and approximate quantitia if known. �Ja <br /> ��1 L <br /> 21 Ducribe waste material that will be dischargcd into the ground (rom septic tanks or <br /> , other sources, if any (for example: Domatic sewage; industrial, containing the following <br /> chemicals . . .; agricultural: etc.l. Describe ihe general size of the system, the number of <br /> such syscems. ihe number o(housu to be served (if applicable), or the number of animals or <br /> humans the sysptem(s) are ezpected to serve, ,5'�G4j E,Q S'eJS�`E m {o,� <br /> C ��[ f /��Qr• • <br /> � <br />