Adir. Rehab. Site Plan Application Ke Plan Review Revised J une,2009
gngr iI Information
fion
Tex Parcel Ifs Number. 309.11-2-11
Zoning District.- I" (Main Str o
Deta fled Description of Project [include current& proposed a see:
The proposal is to add on to the existing ph can refiabillitation offices to add additional matment:rooms,offices and
_Wz4zaiclamamas Addition,
treatment areas
Location f project:
A0,111c0intName. Adirondack Rehabilitation dl;lres :, 17 Malo Street
Medicine a nsbg Ph[Y 12804
OrkPh P 18-798-0767'
VVVjackson@adirondackrehab.com
40ht" Nam'61.1 Ethan P. Deli—Rurinski h°ilall 134 Dix Aire
Architecture � �� l !nis Falls, NY 11801
VAI game'WPlIbn& 51.8-260-2888
d 518-74,168 Fax 51 - 1- 7
E-rnail, eph[ail nyra .rr.co rq "
m
RPS Pro pler r Holdings, LILA d�� MIaiinru Street
u ensbru y NY �12804
Hbrhe' 6 li6n V
VVOrK:Phd�e,",", 518-798-0767 Fay
18-798-015
jack..s n@adirrndac �rh ab.corrw
MAR 2016
IN F
,
Town of Queenabliury Planning Office, 742 Bay Road ° Queensbury, NY 12804, 518-7,611-8220
Site Plan Review Revised June 200,9
Area:I Ty qw , Total sl. fL
Addi
ill aq.
., Building footprint, 3,457 SF 2,0315'n= 5,4 8 SF
B. [Detached Garage
C. Accessory Structure(s)
D. Fayed, gravel or other hard surfaced area 5.,73 .5'F 7,194 SF 12,925 SF
E Porches/ Decks
F. Other
.
Total Non-Permeable [Add A-171 9,188SF 9,225 5F 18,413 SF
H. Parcel Area [43,560 sq. . I acre] 15,795 SI* U14 5Imm 23,809 5F i
I Perc entageI mpermeable Area of Site [l= /l-l] 5,8.17% '734
bask ggguiLeMM,
Area ROquired Existing Pt po d
Front [11 Bldg. IL,In, _2" 4P-2"
Front Rj ®r
horeli 50101, Nib
Sade Yarn [11 01—W 40. " a:M
Rear'hard ( ]
Travel Corridor
Height [max] sq-0", 16'-T 2"- "'
Permeability 10 41.83% 2Z66%
No., of p r ang speces
Town of QueensWry Planning Office, x`42 Bey Road - Queensbury., ' 128N , 518-7611-8220
Site Plan Review Revised' June 20D9
11. Will the propo6a I require a ~peptic Variance from the Town Boardl of Health? No, .,
. It the parcel haus previous approvals, list application number(s):
& Does this project require coverage under the NYS DECtormwater Pollution Prevention
Program? No
Vii. Estimated project duration Start Date M2101 6 End Date 12'x016
5. Estimated total crust of project: $401,0.,0001
l3. Total area of Eared disturbance for project: 14,000 S
FloorArea Ratio Wor h+9
FLOOD, AREA RATIO (FAR) — The relationship of bui�lding size to lot size, derived by dividing the total
building floor area by the lot size in square fest„ yielding a percentage.
Zoning District ymb l� � �IF or ee � � [FARC .
ate fr �tesideu i ..
all ' 0.22
Commercial Moderate CM 0.3
Commercial ial irnten ive l 0.31
A. The cornb1ned area of all square footage, as rrneuasuure from exterior walls of all structures on the Property,
including all tldors of the structures, garages, basements arndl attic w th more than five (5)feet f ceiling height
used wed prnr hes, I uildling square footage does not include: Open duck, docks and that portlon of aged
docks extending over water and one storage shed of, one hundred twenty ("i ii) square feet or lliess. Any
additional sheds+ ill] be lin6lod4ed, (See'FLOOR RE RATIO"').
B., Commercial or Jrnd'ustrlal the til area in square feet as measured from the exterior of the outs1de walls of a
buuildiirng or structure, and when applicable, the sear totalof all floor areas of the principal and accessory
buuild"nrugs or structures on the project site.
Parcel Amas tt.
Existing Fleur Area sq. ft. Isee above defiruitinarti
P'repeised Additional Floor Area
P"rwa n end Total! Floor Area s ft.,
Total Allowable Floor Area urea x I aee above table
Town of Queensbury Planniin gi Once- 74 Say Il oad Queensbury, NY 12804 5 18-761-8220
Mite Plan Review IRevi d June 2,009
79-9 w The Planning Board shall not approve a Site Plan
unless it fitst determines that such site,plan meets, the FoRo in ' Stani Please r pat ' responses to each of
the flowing toplii
STANDARDS -
✓p,. The proposed Project furthers or its consistent with,the polViciues,of the Town's.Comprehensive Plan.
S. The proposed project commpoles with all other requirements of this Chapter', including the site plan review standards.. as set forth lira
Paragraph F of this section, the dimensional, bulla, alndl density,regulations o1 the zoming district in which in is proposed) to,be located)
(Article 3 and Table 1)„the applllicehle requirements of all otherArficliea'that apply-
C. The sums Iplan encourages pedestrian activity internally and, if practicable, to and from the site with pedestrtan paths or sidewalks
connected to adjacent areas.
D. The sft plan must conform to Chapter 136 Sewage and Sewage Disposal, Chapter 147 Storrnwmater Management Local Lawn„ and;
other applicable Vocal laws.
E. the proposed use shall be irm hanmomy with the general purpose or hent of this,ChapWir, spedffeally''takdng auto iocount the location,
character and size of the proposed use and the desclrlipation and purpose o1'the distrlot In which such use Is proposed, the nature and
intensity of the activities to be Involved)In or conducted in,conneWon with the'proposed use and the nature and rats-of any Increase In
the burden on supp+art irrg!pulbile seMcea and facifrbas which vA!ll Wow the approwal of the plropose,dl use,
F... The establishment,maintenance and operation of the proposed use will not create Public haaaurds from traffic,traffic congesfion or the
parking) of vehiicles alnftr equipment or be otherwise detufinerrtal to the health, sdfety or general welfare of Persians residing or
working to the neighborhood or to the general welfare of the town. Traffic amass and circulation„ mad intersections, road and
driveway widths, and traffic contrails will be adequate-
. Off-street partying and loiadii ii will be appropi lately located and arranged aund su dent to meat traffic sunfidipatad to, be,
generated by the, new, use. The establishment of vehicle links between parking areas of adjacent properties are provided where
feasible. This furthers the Town's,goal of reducing cone, rants :and reducing congestion.. A twv rrtyWfoot v*le connection is required, 11
adjacent properties are either undeveloped or Previously developed without having made prowislom for future linkage., then a future
connection must be identified and provided: for In the site plan under review for such future linkage when the done anises. The
Planning Board may require proof that the applicant has made owtact wwi hu adjacent property owners,for Purposes of coordinating
Vinkages'wwtth adjacent properties.
1f,, The project shag not have an undue adverse rntipact upon the natural, scam„ aesthetic, ecological, wrlldllfe'„ hristodo, recreatiuonat or
ripen space resources of the tom or this Adirondack Park or'upon the adequate provision of sulpportiilg faciliftles and semwices made
necessary by the project,taking Into account the conmrmelrodal'i, industrial, residerrtiaV, recreational or other benefits that might be derived
flora the project. 4n making the determination, hereunder, the: (Planning Board) OWE 'consider those factors pertinent to the project
contained In,the develo"at oo iderattons set forth Iherekn under§ 179-M801 of this chapter, and In so doing, the Planning Board
shall make a not mmrall evaluation of thio project In rellation to the development objectives and general guidelines,set forth in,§ 179-9-
M of this Ari
L The provision fay and arrarugernent of pedestrian traffic amass and circulation, walkway st o1u!r s, control of intersections with
vehicular traffic and coverall pedeestrian ocinvienience shall be safe and; adequate for pedestrian movement, Pedestrian oonni.
between adjacent sites shad be pro,4ded to encourage pedestrian use.
I Stournwwater drairiaage facilities will prevent sin increase of post development direinegie ftom as tompared to plre-development drainage
flowws. Drainage of the site shell recharge ground water to the extent para i!call, Surface waters flowing;offOei shall not degrade any
streams our adversely affect drainage on adjacent plropedies or public roads. Facilities shall be In conformnannce with the drainage
standards of Chapter 147 of the Town Code and the Town of Quueensbuury Subdivision Regulations vwhere applicable.
K_ The wearer'suppty and sewage disili facilities will be adequate and will meet all applIcabte and currelnt requirements,set forth by
Department of Health(regulations and Chapter 136 of the Town Code.
L, The adequacyr, type and arrangement of trees, shrubs and other sultable phantin s, lands popg wird screening shall effectively
provide a visual amda'orr noise buffer between the applicants and adjoinfinig lends, including the nmaAmum[retention of, existing.
viagetation and maintenance,Including replacement of deed or deceased)ptants-
w'V. Fire lanes, emergency zones and fire hydrants will be aderduate, and meet the needs and requirements of ernergency service
providers.
N. The design of stmOvres, roadways and IsndscapUng ni areas luso ntib4e lou poinding„"f aardiri anchor erosion wilC minilnroiaa or avoid
such impactsto,the maxlnri a lent pracHicable.
O. The'silte plan cori rms to the design standards, Iamdsoaping standardls,shot performance standards of thus chap r.
Town of QueensibuTy Planning Off ice- 7"42.Bray Road • Queensbury,NY 1213041° :518-761-0 220
Site Plan Review Revised June,2009
Application for site plan approval sh,alli be made to the Planning Board using forms supplied by the Board]. Application materials
and the site plan shall inl sufficlent information for the Id,oward to make Its finding's under§ 179-M70 and 17"-080 below,.
In deterrninling the content of the site plan and surpporhgi documentation, the Planning Board may waive certain requirements if
The Planning Boeird deems such requirements or information unnecessary for the type of (project proposed. Any such wuwraiwrer
shall tae made in writing, and shall contain statemarfs of the reasons why this waived Mrrmation ragpuiremenis are not
necessary for an informed review under the citcurnstanrpes,. The Planning Board may grains such waivers on its own lnlflatiiviue or
at the wrWen request of an aplptfcaunt. Such request shall set forth the speciAc requirements,that ere requested to be waived and
the reasons for the requested waiver, Absent any wrraiwrwer or waivers, an applliccatien for Site Plain Review shall include the
t'billcwwil
REQUiFt'ImENTS bn S,hell
vicinity reap dram at the scale that shows,the relationship of flue proposal two eadsdng cornrmuumiuty faclli as which amt or _
sense it such a's roads, shoppingi ares;, schools. etc. Thai map shail also show,all IpinVerfies, identify owners,, subdivisions,
streets,, and easements within 500 feet of the property. Such a sketch may the suullpemirnposed an a I lrntlead $tatn Geological
Survey map of the area.
8 The sinus plan shall be ud alt a scene of forty feat to,the inch I"=4mm
It feat)or suuolw other scale as the Planning Boarrl may All
deem appropriate, on standard W's 36"s'heell with r rifinuuatiiom on OW x 11"sheets as ftecessary for written information,.
The lnforrmetfon liistedl(below,shall]be shown om the site plan and continnuation sheets.
Narne of the p ect, boundaries,,da h a"nl;��, and scale of the plan. All
0, Name andl anddmma of the owner of record"developer,and seal of the engineer,architect or landscape airotrfftect. If the Alll
applicant is not the rewo rd owner,a letter of authorization shall be required iredl from the owner
The location and use of all existing and proposed1structuras within the property„ Iin urdieng all,diirnensions of height and floor Cal
area,all exterior entrances,and all a'dntidpaeted future additions and atceratdons.
F The(location of all present and,proposed public and private ways, aff treeot parking areas„dri aysre ouatdoor storage 'areas,, C_
siideww!al",, raurwps, curbs., paths, landscaping, wells, and fenow Umation, type, and screening details for all waste disposal
containers shall also be showwn.
The location„ height, intensity, and bulb type tsodllurru, Incandescent, eto,f of all extsmnal lighting Wures, The direction of C-3
lNuminationi and methodis to eliminate glare onto awdjolningi propedim mugalso be'shown,In compliance with§17 .,
Ht The location,heighC$ie,nnatenriiallsd andl dlesign of sM proposed]signs.
I The location of all present and proposed]utillit r systerns inrJurdhng, C-;
1„ Serge or w0c syrstern;, Th ru
2. u, watersupplysysternv -4
3.. Telephone,cabte,and eteculoal systems; and
i
4. Storm drainage system including existing ' iwN proposed dram lines, cukverts,, catrah basins, headmil
endwwaalls,ehorants„,manholes.andi dlrainage swales,
dolens to prevent the pollution of Surface or groru'ndwwafar, emision of sold both dluiring and after construction, excessive runoff, _1
and flooding of other pi pees, as appticable.. A StormwateT Pollution Prevention, Man (•�P,P) for atl land development hrlt,n
a wlhedre requirements the DECP MS-4 General Permit and Chapter 147 of the T or more,Qu , ?iuiryt�l� stuai
(excluding g°
Icomply g tnt of gl�ueensb+ulry bode. lit "'°4,
shall be:at the discretion of the Planning Board as to whether a SWPPP or an erosion and control plan sl hill be required for a
Me plan review project land disturbance of less than 1—aare,
l Existing and pfopcsed topography at two-fbot contour intervals, or such other contour faitdrwral as the Plarlining board small
alllaw.All elevations shall (refer to the nearest.United States Qoastal and Geodetic'Bench Dada,. It any portion of the piarmel is -
1
within the tOD-year fl,loodplain,fl, the area vwill be shown, and base flood elevations given,, Areas shall] be indicated rayi'thl the And
proporsed site arpd within ea feet of the proposed site ww here soil r °mowal-or Sting is required,showering the approximate volume -
In cubic yards,
L A landscape plan showing all existing natural Bandl features that may lrnflluenoe the deslgn of the proposed use such as mck Cm3
outcrops, stands of trees, single trees eight or more inches In diameter, forest cover, and waster sources, and all proposed
changes to these features inoluuol ft sizes and types of plants,Water sources include ponds--,lobes„wweUands and watercourses,
agluliers,bloprairns,,and drainage retention areas.
Town of Queensbury Planning Office° 742 Bay] award!° Queensbury,,INY 12804 r 5,18-761-8220
Site Flet Review Revised J u ne 2009
M Land Use District boundaries within 5(10 feet of the afte's perimeter shall be drawn and identified oin the site pWn, as well as C-1
any Overlay Distrids that apply to the proli
N Traffic Ipattems within the site,entrances and exits, and loading aind unloadft areas, as well as curb cuts,on the site and C_,1
within 1100 feet of the sfte. The Planning Board may, at its discretion, require a Mailed traffic study far large developments or And,
for those In heavy traft aireagi which shall incluidw C-2
I,The projected numberof motor vehicle trips to enter or leave the site, estimated for weekly and annual pe*i
traffic lei
2-The projected traffic flow pattem,iincluuding vehicular movements at all major ince ions likely to be aii by the
proposed use of the site;
3-The impact of this traffic on levels of service on abutting public streets and at affected Intersections. Existing and
proposed weekly wid annual peak hour traffic levels and road capacity levels shall also be given.
Foir new--coinstruicUon or alterations to any structure,a table cDnitaining the following inform,ation:shall be Include&
11. Estimated area of structure to be used'i particular puirposes,such as retail operation,ofli storage,etc.;
2. Estimated ma)dmum number of empi!Dyees;�
3. Maximum seating capacity.,where applicable;and
4. Number of Parkin spaces existing and required for the Intended use.
P 1. Floor Plains.
A-1
2. IFllewatirurus at a scale of ono-e juarter inch equals oine foot(14"m 1 foot)for all exterlor facades of the proposed structurefs)
andfor alterations to or expartaii of existing facades,shovAng design features,and indicating the type and color of materials,
to be used.
,Q Sol logs,water suppty vaill aind percolation test results, and storm runoff caRmlatibins, as needed to determine andl mi C-I,
purojewit impacts,
-Tans—6rdisposal of constructionand demallition Was—te,,either on-site or,at an approved disposal facility. C-1
S Plans kr snow rerri inciuding location(s),of on-site snow storage, IC-2
T Ain Environmental Assessment Form (SW), as required by the 51 regulations,with Part 1 oompleted by the Applicant Yes
,sholll The submitted as patt of the application. If the prolposed project: requlires a special use perrn� and an EAF has been
submitted in conjunction with a -W use permit a;0lication,a,duplicate E is not required for the 15fte pLain application.
I If an application is fair a parcel) or Parcels on wWch more than one use is proposed, the applitient may submit a single NA
application for alit such uses provided the proposed uses are ac,curai delineated on a site plan drawn pursuant to the
requirements set for", above. The Plafli,ning Board may,grant the app4hcaii with respect to some proposed uses and not
others. For,purposes, of reviewing an appilleation (and for SEORA compliance) ail proposed uses, on a single, parcel or on
contiguous parcels shall be considered together.
=V A bn
"ef naii statemenit on ,ow the i proposed for review furthers or is consistent wfth,the v1slon,goal's and!,Policies 'Yes
'a :
intha Town's Comprehensive Plan.
Town of Queeinsbury Planning Office- 742 Bay Road - Quieenabuiry. NY 12,804 , 518-761-8220
Site Man Review Revised June 2009
1. fax Map I , , 0 .11-2-11
. Zoning Classification AS Ifillain
3. Reason dorReview: -Alteration&Addition to Office Bt
61 Pre-Submission Meefing Notes;Outstanding IternsToBeI u d Include:
Deed _LL-Yes No
General In' rmalibin cornpl1ete 'Yes —'iso
Site Devellopment Data Complete 7Yee No
Setback Req uireme t omplete Nva
Additional Pirojoct Information CompLete V, Yee
FAR Worksheet complete 'es —iso
Standards addressed =Yes No
Checklist iternis addressed " es — e
Environmental Form carnpleted s ,"'No
Signature nature Page completed Yee e
^ N
12 p
y C
ry" ryp
x� N W 6 �� i (f✓uu 1 ub
. �_.�. , "I �� t �_ u� ., _ ..
Y
y
ry
Staff Representative-
Applicant
epresentative:Applica nt I Agent:
Fete= I N ;
"I°ouarr'n of Queensbury Planning ice• 742 Bay Road ° Queensbury,NY 12 - 518-761i-WJO
Site Plan Review Revilsed June 2009
Signature g
This (page includes the 1.,) Autbojza.fion to Act as Agent Forum: 1) Engineering Fee Disdosur% .) Authorizaton for
SiteVisits; 4.), Other Permit Responsibilities, 6,.) uffieiM iMleeting Disclosure and 6.) Agreement to provide
docuurnuentation required..
OWNER's AGENT,FORM:
Complete the follawing it the WMER of the property is not the same as,'the applicant
Owner.
Designates:
As agent regarding. Variance_ Site Plan—Subdivision For
Tax Map Nlo.,, section-__ Moak Lot
Deed Reference,: Book Page Date
OWNERSIGNATURE. DATE
aPid'P'ucu�4 TSIs GENT FORM:
Donnplete the following if the r p"I"p`�ll -ANT is unable to atteutd the meeting or wishes to be represented I>y another
pert.
Owner: Adirondac Retuab]U i r°n Mgo ng,
Designates. I-uaeiirn lri Hall Architecture ure- Ethan Hili
As agent regarding: " adaunce X Site Plan- ndubdivision For
Tai tang N _09.11 Section Block k 1�1 �Lot
Deed ire � � �Page Dat
OWNE� I RW A. . DATE:
21—EN 3INEEI IN Fr;, 171, L Applications may be referred) to the Town consulting engineer foir review olf sepft
design, storm drainage., etc, as determined by theZoning easing or Planning Department. Fees for engineering review services will be
charged directly to the applicant. gl=ees for engine ing review will not exceed 1,000 Wthotd notificaUon to the applicant.
I AUTHQRt u'TtQN M §11gYJS TS. By signing this page and submitting the application rnatenals attached herein, the
Owner, ,applicant. and luis1heritheiir agent(s) hereby authonLze the Zoning (Boardor Planning Board and Town Staff to enter the
subject properties for the purpose of reviewwiing the application suudbmi
4J, QJH'CE . fi ner permits may be required for construction or alteration activity subsequfent to
approval by the Zoning Hoard'or(planning board, It is the applicant's responsibility to obtain any additional perm ts.
It is the pracfte of the Community Development (Department, to have a
designated stenographer tape record the proceedings of meetings resulting from appilcatdion, andl minutes transcribed from
those tapes constitutes the official record of ail proceedings,
1. the uund mignedl, have thoroughly reed and undersland
the instructions for submission, and agree to time submission regvirernernts, II acknowledge no construction activities siaall be
commenced) prior to Issuance of a valid permit, I certify that thie application„ plans and supporting materials are a true and
complete staterneWdescription of the existing contiftions and the work proposed,, and that all work will be perfoir ned In
accordance with the approved plans and in conformance luta to Cal zoning regulations, II acknowledge that, phor to occupying
the facilities proposed. II or my agents„ will obtain a certificate of occupancy as necessary. I also understand that l ere may be
required to provide, an as�buuilt survey by a licensed lamed surveyor of all newly constructed faeillitles prior to issuance of a
certificate of occupancy
q qli7 sit Brad,angree to eallove,
dig [ J& Date grt d
t
l hatu m [Ageh'rlt] Print name [Agint] Cate signed
Town of Queensbury Planning Office742 lay pearl•Cloeensbuury, NY 12804° 5,118-761-8220 t,g22,0
Short Environmental Assessment Form
Part,I -Project Information
J_ustruefions for Complefigg
Part 1.-Project Information, The spolicant or prGilect sponsor is responsible for the completion of Part 1. Respons c
become part of the application for approval or funding,are subject to pitblic review,and may be subject to,further verification
Complete Part I based on information currently available. Ifadditional,research or investigation would be needed to fully
mpond to any item,please answer as thoroughly as,possible based,on current information.
Complete all items in Part 1, You may also Provide any aMitiovnal infon-nation which you believe:will he needed by or Useftil.
to the lead agency;attach additional pages as necessary tosupplement any item.
Part I -11'ro],W and Sponsor Information
Name of Action or Project,
Adirondack IRehabiillita flon MeOcine,
Project Location(dc scribe,and,attach a location map),-
17 Main Street,Queensbury NY
Brief Description of Proposed Action:
Addiffen lo,exIsUng aredilcall latedi office building for addItional exam rooms and office apace
Name of Applicant or Sponsor: Telephone: 51&7-9B-G767
Adirondack Rehabilitation Medicine E-Mail- vja.ekson@adirond,ackrehab.colim
Address
17 Main Street
..........--
City/P tatat Zip Code:
Queenabury N4wYo* '12804
1. Does the proposed action only involve the legislative adoption of a plan,local law,ordinance,
administrative rulo:,or regulation?
If Yes, attach a narrative description of the intent of the proposed action and the environmental resources thatPill
may be affected in the mani6pality and proceed to Part 2., if no,continue to,question 1
�2. Does the pr posed action require a permit,approval or funding fTom any other governmental Agency? NO, YES
If Yes, list agoncy(V name and pernu"t or a val,
Town of QueAsbiury 'lanining,8oara appraivall,TcMwn of QueensIbury BuNdingi Permit
3,a, Total acreage of the site of the proposed action? 01,55 acres
b,Total acreage:to be physically disturbed? Q. acres
c.Total =eage(project site and any contiguous properties)owned
or controlled by the applicant or project sponsar'? 1.42 acres
4. Check all land,uses that ocoar on,adjoining and near the proposed action. . .....
�5ZI Urban. [3 Rural(non-agriculture) []Industrial gCommercial lie idential�suubuu an
El Forest OA.griculturc ClAquatic [3 Other,(specify),
DParkland
Page 1 of 3
Is the proposed action, O 'lu ?
a. Apornuitted use under the zoning reguulationlil? 121
b. consistent with the adopted comprehensive ply? 217—
-11-111111111111 .
- , _ -
., Is the proposed action consisteuat with the predominant character f°the existiuu,pp built or natural. NO YES
landscape?
7.. Is the site of the proposed action located in,or does it adjoin,a state listed.Critical Environmental Area ' NO,
V !YE
If Yes,identify,
r 118, a, Will the proposed action result in.a substantial increase;in traffic above preserit l"cls? __R0_ T
IJI El
b. Are public transportation service(s)available at or near the site ofthe,proposed action
c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action9 -G
9,trues th,eproposed auction met or exceed the state energy code requuirements�' _NO, YES
if tho proposedaction will exceed requirements,describe design features and teehnol pwies;
D FE
10, Will the proposed action connect to an existing pu blie/private water supply? NO, YES
If'No,describe method for providing,potable water;:
I I Will the proposed action connect to existing.wastewateruutilities? O
If No,describe method for providing wastewater treatment:
Li
1. , a..Ices the site contain a structure that is]listed on either the State or National Register of Historic O YES
Places? 0
b. is the proposed action located in an archeological sensitive area?
13.a. foes any portion of the site of the proposed action,cr lands adjoining the proposed action,contain No
wetlandsor other waterbodies regulated by a federal,state,or local agency? u
b.Would the proposed action physically alter,or encroach into.,any existing wedand or waterb od ;?
If Ye%identify the wetland or waterbody and extent of alterations,in square feet or acres. 121 El
14. Identify the typical:habitat t n,or are likely to be found oo the project site, heck all mut apply,
ahoreliuue ❑lorest s fleet occur col ll rasslands DEarly,amid-suuccessionid
EI Wetland OUrban F1 Suburban
15.Does the site of the proposed action contain any species of aninuall,for asseciated h,abita ,listed YES
by tlue Mate or Federal government as threatened or endanerect?
lb,is the proj;ect site located in the: 100 year flood plain? NO YES
S
17, Will the proposed action create storm water discharge, either fuorru point or non-point sources? NO
If Yes,
a,Will storm water dischau ,es flow to adjacent properties'? NO DYES
b, Wil:l storm water discharges be directed to established conveyance s sterns runoff and storm
IfYes, briefly describe:
P'a of 3
1 ,Does the proposed action.include arrusla aucti,ozn or other activities that result in the impoundment of NO YE I
water or other liquids e.g,.rat n d)m pond,waste lagoon,dam)?'
If Yes,explain purpose and s;im
Li
--T9,Has tfu site of the proposed actioln or an adjoining propicaly been the 100ation'n of an active or closed NO YES
olid Wasw Management gemernt f iliit "?
If Yes, descdbeab
2 . Has the site of the proposed action or an adiounnlrng,property laecaa the subject of remediation(on,going or NO E'S
completed)for hazardous este?
If Yes,describe: ��
This answer le prrnwr a y t,>i� E we age,the applicant has no,knowl' a of any eurrent eun- emrng riire i�u�rn yam�
I.AFFIRM THAT THE RMA ION PROWDEDABOVE Is TRUE AND,ACCURATE ATE TO"I°I.IE REST OF MY
KNOWLEDGE
pplicern sp srn Ethan P m- q ent ter a Applicant Mah 12,20,16
Signature: '
i
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Part I J Question 12b, [Archeological Ates) ;'Yes
Part 11 Question 13a [Wetllainds or Other i o
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Part I /Question 20 (Remediation itel Ye�s
Short Environmental Assessment ssment Form - EAF Mapper Summer Report r