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( <br />Ti: 8E COMPLFifD B\ �PPLIUNT <br />3 �Later <br />a. Suriace: <br />I1 Is thcre anv sur(ace waier bod� on or in the immediate vicinity of the site (including <br />year—round and susonal streams, saltwater, lakes, ponds, wetlands)? If yes, deseribe type <br />ana provide nama. I; appropriate, sute wi�at s[ream or nver it (lows into. <br />No. <br />:) Will :he projea reouire any work over. in, or adjacent to (wichin 200 feet) the deseribed <br />w:iers° !( ya, please descTibe and attach available plans. <br />\o. <br />3) Estimate the amount of fill and dredge maietial tha[ would be placed in ar removed <br />frort� suriace water or wetlands and indicate the ara o( the sice that would be affected. In- <br />dic:,te �he souree of fill matenal. <br />\one. <br />4) Will the proposal require sur(aa wua withdnWals or diversiom2 Give `enerzl da <br />xnpiion, purpose, and approxirt:ate qwnci[ia i( known. <br />No. <br />S) Das the propcsal lie within a IO�yar (laodplain? If so, ncte loation on the �ite <br />plan. <br />No. <br />6) Does che propoul involve �ny diseharaa of wute maierials to surf�a wuers? !f so, <br />descriix che rype of wute and anticipated volume of diseharae. <br />No. <br />b. Ground: <br />1) Will ground water be withdrawn, or will w�ter be diseharged to sround wata? Give <br />genenl ducriptian, purpoae, and �pproximate quantitiet if known. <br />No. <br />2) Deseribe �vuu macerial that will be discharged inio the `round from uptie unks w <br />other wurar, if any (for ezample: Domauc sewage; industtial, conuinin` the followin6 <br />chemials ...; �grieultunl; ne.). DeuT'be the �enenl :ize of the :ystem, the number of <br />such syscems, the number of houses to be smed (if appliable), or the numSer of anim�ls or <br />humans the system(s) arc expocted to serve. <br />None. <br />Ev�LUATION FOR <br />�GENCY USE OHLY <br />