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� � � ( �_ <br /> TO BE COMPLETED BY APPLICA�T EVALUATION FOR <br /> �GENCY USE ONIY � <br /> ?. W7tt� <br /> a. Surface: <br /> 1) Is there any surface Water body on or in the immediatc vicinity of the site (including <br /> aear—round and seasonal streams, saltwater, laku, ponds. wetlands)'! If yes, describe type <br /> and provide names. If appropriate, state What stream or river it flows inro. <br /> N� <br /> '_) Will the project require an�� Work o�er, in, or adjacmt to (within 200 (cet) the described <br /> waters° If yes, please describe and attach available plans. <br /> NA. I <br /> � <br /> ; <br /> 31 Estimate thc amou�t of fill and dredge material that would be placed in or removed ' <br /> from surface water or wc lands and indicate che arca of the site chac would be affected. In- � <br /> dicate the source of fill material. /� Q i <br /> � <br /> ») Will the proposal require surface water withdrawals or diversions? Give genaal de- i <br /> scription, purpose, and approximaie quantities if knoWn. <br /> ��� <br /> 5) Does the proposal lie within a 100—year (loodplain? If so, note location on the site <br /> plan. <br /> ,�(�G <br /> 6) Does thc proposal involve any discharges of waste materials ta surface waters° If so, i <br /> describe the type of waste and anticipaced volume of discharge. <br /> Ni4 <br /> b. Ground: <br /> I) Will ground watet be withdraw•n, or will water be discharged to ground water? Give <br /> general description, purpose, and approximate quantitia i(known. <br /> �'�� <br /> 2) Describe waste material that will be discharged into thc ground from septic tanks or <br /> other sourcu, if any (for ezample: Domestic sewage; industrial, containing the following <br /> chemicals . . .; agricultural; etc.). Dacribe the general size of [he system, the number of - <br /> such systems, the number of housa to be served (if applicable), or the number of animals or <br /> humans the system(s) are ezpected to serve. <br /> ; Ncy� <br /> ��8' <br /> , � <br />