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�� <br /> M !E COMPIETED BY APPUCAM ' � �) "'".'J E�ALUATION ROII �� ��. <br /> • -- AGENCY U3E ONLY � <br /> ' a. w.ce. � <br /> a. Su�faa: • � i <br /> I) Is there any surfaa water bady on or in t6e immediate vicinity of t6e site (including � <br /> yar—round and sasonal strcams, sa�twaur, Iaka, ponds, wetlands)'! [f ya, describe type � <br /> and prwide nama. [f appropriata state what svnm or river it flows into. i ' <br /> �c�v2rla�ri- . ' <br /> 2) Will the project require any work over, in,or adjaant to (within 200 fat) the dncribed A �,� �=}- W�¢ I I', <br /> waters? If ya. please dacribe artd attac6 available plans. ��,��� ,� i !,I, <br /> ��as - acrc�s h�c�h� ��m ��2� w;u a� �..,,�� <br /> _ . � �' P�` i <br /> 3) Estimate the amounc of fiil and dredge macerial that would 6e placed in ar removed � � _�` I <br /> from surface water or wetlands and indiate the area of the site that would be affected. �n- <br /> dicate t6e source of fill material. �� <br /> � <br /> a <br /> 4) Will thc proposnl requirc sudace water wichdrawals or diversiona? Give general dr <br /> scripriort, purpo�e, and approximate quantities if known. � • <br /> I <br /> � <br /> 5) Daa the proposal lie within a 100—ynr floodplain? If so, note lontion on the site �NO CD►�S'�'✓�JG`f'/Or` <br /> p1an. �0 1'l0�-�1/� ' . '. <br /> ����� ; <br /> Prej� cs+� � <br /> U � <br /> 6) Doa che proposal imolve any diacharges of wsste ma:aials to surface watas? [f so, W�0��d �L <br /> dncibe the type of wuu and antiapated volume of dixharge.� -/��, T�"¢— <br /> ���ar�p <br /> Zi�st�I�F�a-Q-' <br /> . �rOq✓e►rw t1�i�►s.r�y�j <br /> b. Ground: �� - <br /> 1) Will ground wata be withdnwn. or will water ba discharged tq,g*ound wacer? Give <br /> genen! dacripeon, purposG and appro:imatc quantitia if knawn.'nV <br /> 2) pqcribe wasu ma.erial that will be diuhargad into the ground From sepuc tanks or <br /> other sourea, if any (for exampla Domatic se+vagr, industrial, containing the following <br /> cdemials . . .: agrieulmral: etc.). Dncribe the gmeral s�r, of the system, the num6er of <br /> such sysums, the number of housa to be served (iF applirable), or the number of animals or <br /> humaro the system(s) are apccted to serva ��� <br /> 4. <br /> _ - ' _ <br /> ,... '` . � � - . .-'- '�r ! . _' ... ; <br /> {�.�,.�� rc�: � t � :..* .v�ut - �:. -.. �ro i <br /> '�':.'„�� . �Y.�/� ��' ,��i.�^s-_jyf.Pr."�'4.-..lw�..`�itn n�'i�X'vJiS�iMK� ,, Lv . .� <br />