Site Plan application 169 Haviland Road
Queensbury, NY 12804
Hutchins Engineering Phone: (518)745-0307
Fax: (518)745-0308
January 15, 2018
Town of Queensbury Planning Board
742 Bay Road
Queensbury NY 12804
Re: Parker Hammond Development, LLC - Clearing/Revegetation Project
Silver Circle, Tax Map ID: 309.17-1-18.4
Dear Planning Board Members:
This office represents Parker Hammond Development, LLC with respect to a selective clearing
and revegetation project upon their vacant 7.86-acre parcel at the end of Silver Circle Industrial
Park.
It is the applicant's desire to clear the interior of the parcel of vegetation and underbrush, in
order to show the parcel for industrial development. The goal is to make the parcel more
attractive and marketable for potential commercial/industrial occupants.
At this time, there are no plans for any buildings or infrastructure to be constructed upon the
parcel.
We respectfully request that this application be placed upon the Board's agenda for one of the
February meetings. Please contact this office if you have any questions or if you require
additional information.
Best Regards,
G. Thomas Hutchins, P.E.
Cc: Kevin Hammond, Parker Hammond Development, LLC
G.Thomas Hutchins,P.E. thutchins@hutchinsengineering.com
General Information
Tax Parcel ID Number: 309.17-1-18.4
Zoning District: CLI
..._.�........
Lot size: 7.86 Acres
Detailed Description of Project [includes current&proposed use]:
Location of project:
Silver Circle,adjacent to and west of 24 Silver Circle
Applicant Name: Parker Hammond Development Address: 24 Silver Circle
LLC Queensbury NY 12804
Home Phone Cell:
Work Phone Fax
(518)793-3226
E-Mail: kevin@parkerhammond.com
Agent's Name: Address: 169 Haviland Road
Hutchins Engineering Queensbury NY 12804
Home Phone Cell:
Work Phone Fax
(518)745-0307 (518)745-0308
E-mail _. _._ ....._u
......... .. _ ....... ........
............_.. ._.. ...............
Owner's Name Address
...... .........
_ ____._.M........ ......_ __�._.......�.._........
Home Phone Cell
Work Phone Fax
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........ .................
E-mail
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Site Plan Review application—Revised October 2016
Town of Queensbury Planning Office-742 Bay Road,Queensbury,NY 12804
Site Development Data.
Area/Type Existing sq.ft. Proposed Total sq. ft.
Additions .ft.
A. Building footprint
c 0 0 0
B. Detached Garage 0 0 0
C. Accessory Structure(s)
0 0 0
D. Paved,gravel or other hard surfaced area o 0 0
....... ..... __...... _......... .......
E. Porches/Decks
0 0 0
F. Other -
0 0 0
G. Total Non-Permeable [Add A-F] 0 0 0
H. Parcel Area [43,560 sq. ft./acre] 342,208 0 342,208
I. Percentage of Impermeable Area of Site [I=G/H]
0% 0% 0%
Setback Requirements
Area Required Existing Proposed
.......... ��_ ........_u_
Front[1]
50' 0 0
Front[2]
Shoreline
Side Yard[1]
30' 0 0
Side Yard[2]
30' 0 0
Rear Yard[1]
30' 0 0
Rear Yard[2]
Travel Corridor
Height[max]
60' 0 0
a ..... ............ ............................................�
Permeability
i
30% 100% 100%
....... .. ..........
No. of parking spaces
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Site Plan Review application—Revised October 2016
Town of Queensbury Planning Office-742 Bay Road,Queensbury,NY 12804
Additional Project Information
1. Will the proposal require a Septic Variance from the Town Board of Health? No
2. If the parcel has previous approvals, list application number(s) N/A
3. Does this project require coverage under the New York State Pollutant Discharge Elimination System
(SPDES)Permit Program . Yes
4. Estimated project duration: Start Date 04/2018 End Date 05/2018
t
5. Estimated total cost of project:
& Total area of land disturbance for project: 6.4 Acres
Floor Area Ratio Worksheet
FLOORA:RATIO (FAR) -- The relationship of building size to lot size, derived by d" ding the total
building floor by the lot size in square feet, yielding a percentage.
Zoning District Symbol Floor Area Rat' [FAR]
Waterfront Residential WR 0.22
Commercial Moderate/Intensi CM/CI 0.3
A. The combined area of all square fo ge, as measure from ex for walls of all structures on the property,
including all floors of the structures, g gcs, basements a attics with more than five (5) feet of ceiling
height and covered porches. Building squa footage does iot include: Open deck, docks and that portion of
covered docks extending over water and one , orage , ed of one hundred twenty (120) square feet or less,
Any additional sheds will be included. (See"FL AREA RATIO").
B. Commercial or industrial: the total area in squa feet: measured from the exterior of the outside walls of a
building or structure, and when applicable,, c sum to of all floor areas of the principal and accessory
buildings or structures on the project site.
A. Parcel Area SQ. ft.
..._ __ ....... .... ------
B. Existing Floor Area s see above definition
C. Proposed AdditionoMoor Area sq. ft.
D. Proposed Tot Floor Area sq. ft.
i,
E. Total AL16wable Floor Area (Area x see a ve table
*If D " larges than E. a variance or revisions to your plan may be needed. Consult with Staff.
4
Site Plan Review application—Revised October 2016
Town of Queensbury Planning Office-742 Bay Road,Queensbury,NY 12804
§ 179-9-080 .fie g uuirem nts for Site Plan Approval.
The Planning Board shall not approve a Site Plan unless it first determines that such site plan meets the
following Standards. Please prepare responses to each of the following topics:
STANDARDS
.._. __. ............................... ......
A The proposed project furthers or is consistent with the policies of the Town's Comprehensive Plan.
._.—-------- .................
B The proposed project complies with all other requirements of this Chapter,including the site plan review standards as set forth in Paragraph
F of this section,the dimensional,bulk and density regulations of the zoning district in which it is proposed to be located(Article 3 and
Table 1),the applicable requirements of all other Articles that apply.
C, The site plan encourages pedestrian activity internally and,if practicable,to and from the site with pedestrian paths or sidewalks connected
to adjacent areas.
D. The site plan must conform to Chapter 136 Sewage and Sewage Disposal,Chapter 147 Stormwater Management Local Law,and other
applicable local laws.
E. The proposed use shall be in harmony with the general purpose or intent of this Chapter,specifically taking into account the location,
character and size of the proposed use and the description and purpose of the district in which such use is proposed,the nature and intensity
of the activities to be involved in or conducted in connection with the proposed use and the nature and rate of any increase in the burden on
supporting public services and facilities which will follow the approval of the proposed use.
............. ............ ........ .._
K The establishment,maintenance and operation of the proposed use will not create public hazards from traffic,traffic congestion or the
parking of vehicles and/or equipment or be otherwise detrimental to the health,safety or general welfare of persons residing or working in
the neighborhood or to the general welfare of the town. Traffic access and circulation,road intersections.,road and driveway widths and
traffic controls will be adequate.
G. Off-street parking and l9oading facilities will be appropriately located and arranged and sufficient to meet traffic anticipated 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 curb cuts and reducing congestion. A twenty-foot wide connection is required. If adjacent properties are either
undeveloped or previously developed without having made provision 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 time arises. The Planning Board may require proof that the
applicant has made contact with adjacent property owners for purposes of coordinating linkages with adjacent properties.
H. The project shall not have an undue adverse impact upon the natural,scenic,aesthetic,ecological,wildlife,historic,recreational or open
space resources of the town or the Adirondack Park or upon the adequate provision of supporting facilities and services made necessary by
the project,taking into account the commercial,industrial,residential,recreational or other benefits that might be derived from the project.
In making the determination hereunder,the Planning Board shall consider those factors pertinent to the project contained in the
development considerations set forth herein under§ 179-9-080 of this Chapter,and in so doing,the Planning Board shall make a net overall
evaluation of the project in relation to the development objectives and general guidelines set forth in§ 179-9-080 of this Article.
j The provision for and arrangement of pedestrian traffic access and circulation,walkway structures,control of intersections with vehicular
traffic and overall pedestrian convenience shall be safe and adequate for pedestrian movement. Pedestrian connections between adjacent
sites shall be provided to encourage pedestrian use.
J, Stormwater drainage facilities will prevent an increase of post development drainage flows as compared to pre-development drainage flows.
Drainage of the site shall recharge ground water to the extent practical. Surface waters flowing off-site shall not degrade any streams or
adversely affect drainage on adjacent properties or public roads. Facilities shall be in conformance with the drainage standards of Chapter
147 of the Town Code and the Town of Queensbury Subdivision Regulations where applicable.
K. The water supply and sewage disposal facilities will be adequate and will meet all applicable and current requirements set forth by
Department of Health regulations and Chapter 136 of the Town Code.
L. The adequacy,type and arrangement of trees,shrubs and other suitable plantings,landscaping and screening shall effectively provide a
visual and/or noise buffer between the applicants and adjoining lands,including the maximum retention of existing vegetation and
maintenance,including replacement of dead or deceased plants.
M Fire lanes,emergency zones and fire hydrants will be adequate and meet the needs and requirements of emergency service providers.
N. The design of structures,roadways and landscaping in areas susceptible to ponding,flooding and/or erosion will minimize or avoid such
impacts to the maximum extent practicable.
.........
0. The site plan conforms to the design standards,landscaping standards and performance standards of this chapter„
5
Site Plan Review application—Revised October 2016
Town of Queensbury Planning Office-742 Bay Road,Queensbury,NY 12804
Applicant/Owner: Parker& Hammond Dev., LLC
Responses to standards questions A-O
A. The proposed project to improve the site is consistent with the policies of the Town's
Comprehensive Plan.
B. The proposed project complies with all other requirements of this chapter.
C. The proposed selective clearing project does not propose any structures or
infrastructure at this time and does not propose any internal pedestrian activities.
D. The proposed selective clearing project does not propose any structures or
infrastructure at this time, therefore Chapters 136 and Chapters 147 are not
applicable.
E. The proposed selective clearing project does not propose any structures or
infrastructure at this time and will not create any burden upon public services.
F. The proposed selective clearing project does not propose any structures or
infrastructure at this time and will not create any increases in traffic upon project
completion.
G. The proposed selective clearing project does not propose any structures or
infrastructure and will not require any parking facilities.
H. The proposed selective clearing project has been designed to not impact natural,
scenic, aesthetic ecological, wildlife, historic, recreational or open space resources of
the Town.
1. The proposed selective clearing project does not propose any structures or
infrastructure and will not generate any internal pedestrian activities.
J. The proposed selective clearing project does not require post-construction
stormwater management practices and the native sandy soils promote on-site
infiltration of stormwater.
K. The proposed selective clearing project does not propose any structures or
infrastructure and will not require any water or wastewater facilities.
L. Native wooded buffers are proposed along the property lines where the parcel
adjoins properties that are under separate ownership.
M. The proposed selective clearing project does not propose any structures or
infrastructure and will not require any emergency services.
N, TheP roP osed selective clearing project q ro'ect does not require post-construction
stormwater management practices and the native sandy soils promote on-site
infiltration of stormwater.
O. The site has been designed with the intent of conforming to the design standards
and performance standards of this Chapter.
§ 179-9-050 Checklist-Application for Site Plan Review.
Application materials and site plan shall include sufficient information for the Board to review and provide a
decision. The applicant is to provide a site plan drawing and all attachments that address items A-V. The
applicant may request a waiver from A-V and is to provide reasons for waiver(s)requested. Please label
information to be submitted.
REQUIREMENTS
Sheet#
A. A vicinity map drawn at the scale that shows the relationship of the proposal to existing community facilities which affect
or serve it,such as roads,shopping areas,schools,etc. The map shall also show all properties,identify owners, S1
subdivisions,streets and easements within 500 feet of the property. Such a sketch may be superimposed on a United States
Geological Survey map of the area.
B The site plan shall be drawn at a scale of forty feet to the inch(1"=40 feet)or such other scale as the Planning Board may
deem appropriate,on standard 24"x 36"sheets,with continuation on 8 1/2"x 11"sheets as necessary for written S2
information. The information listed below shall be shown on the site lan and continuation sheets.
C Name of the project,boundaries,date,north arrow,and scale of the plan. ALL
D Name and address of the owner of record,developer,and seal of the engineer,architect or landscape architect. If the Sl,S2
applicant is not the record owner,a letter of authorization shall be required from the owner.
E. The location and use of all existing and proposed structures within the property,including all dimensions of height and N/A
floor area,all exterior entrances,and all anticipated future additions and alterations.
F The location of all present and proposed public and private ways,off-street parking areas,driveways,outdoor storage areas,
sidewalks,ramps,curbs,paths,landscaping,walls and fences. Location,type and screening details for all waste disposal S1
containers shall also be shown.
G The location,height,intensity and bulb type(sodium,incandescent,etc.)of all external lighting fixtures. The direction of N/A
illumination and methods to eliminate glare onto adjoining properties must also be shown in corn liance with§ 179-6-020.
H. The location,height,size,materials and design of all proposed signs. N/A
j The location of all present and proposed utility systems including:
1. Sewage or septic system;
2. Water supply system;
3. Telephone,cable and electrical systems;and N/A
4. Storm drainage system including existing and proposed drain lines,culverts,catch basins,headwalls,endwalls,
hydrants,manholes and drainage swales.
....... _. _.....
J„ Plans to prevent the pollution of surface or groundwater,erosion of soil both during and after construction,excessive runoff
and flooding of other properties,as applicable. A Stormwater Pollution Prevention Plan(SWPPP)for all land development
activities(excluding agricultural activities)on the site that results in land disturbance of one acre or more. A SWPPP shall
comply with the requirements of the DEC SPDES MS-4 General Permit and Chapter 147 of the Town of Queensbury SWPPP,S2
Code. It shall be at the discretion of the Planning Board as to whether a SWPPP or an erosion and control plan shall be
required for a site plan review project land disturbance of less than one acre.
K. Existing and proposed topography at two-foot contour intervals,or such other contour interval as the Planning Board shall
allow. All elevations shall refer to the nearest United States Coastal and Geodetic Bench Mark. If any portion of the parcel
is within the 100-year floodplain,the area will be shown and base flood elevations given. Areas shall be indicated within S1-S2
the proposed site and within 50 feet of the proposed site where soil removal or filling is required,showing the approximate
volume in cubic yards.
L. A landscape plan showing all existing natural land features than may influence the design of the proposed use such as rock
outcrops,stands of trees,single trees eight or more inches in diameter,forest cover and water sources and all proposed
changes to these features,including sizes and types of plants. Water sources include ponds,lakes,wetlands and WAIVER
watercourses,aquifers,floodplains and drainage retention areas.
M. Land Use District boundaries within 500 feet of the site's perimeter shall be drawn and identified on the site plan,as well
as any Overlay Districts that apply to the property. N/A
6
Site Plan Review application—Revised October 2016
Town of Queensbury Planning Office-742 Bay Road,Queensbury,NY 12804
REQUIREMENTS (CONTINUED) Sheet#
N. Traffic flow patterns within the site,entrances and exits,loading and unloading areas,as well as curb cuts on the site and
within 100 feet of the site. The Planning Board may,at its discretion,require a detailed traffic study for large developments or
for those in heavy traffic areas,which shall include:
1. The projected number of motor vehicle trips to enter or leave the site,estimated for weekly and
annual peak hour traffic levels;
t
2. The projected traffic flow pattern including vehicular movements at all major intersections likely N/A
to be affected 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 and annual peak hour traffic levels and road capacity
levels shall also be given.
O. For new construction or alterations to any structure,a table containing the following information shall be included:
1. Estimated area of structure to be used for particular purposes such as retain operation,office,
Storage,etc.;
2. Estimated maximum number of employees; N/A
3. Maximum seating capacity,where applicable;and
4. Number of parking spaces existing and required for the intended use.
P 1. Floor Plans.
2. Elevations at a scale of one-quarter inch equals one foot(1/4"=1 foot)for all exterior facades of the proposed structure(s)
and/or alterations to or expansions of existing facades,showing design features and indicating the type and color of materials N/A
to be used.
Q, Soil logs,water supply well and percolation test results,and storm water runoff calculations as needed to determine and
mitigate project impacts. N/A
R. Plans for disposal of construction and demolition waste,either on-site or at an approved disposal facility„ N/A
S Plans for snow removal,including location(s)of on-site snow storage. N/A
Z An Environmental Assessment Form("EAF")as required by the SEQRA regulations,with Part 1 completed by the Applicant
shall be submitted as part of the application. If the proposed project requires a special use permit and an EAF has been
submitted in conjunction with a special use permit application,a duplicate EAF is not required for the site plan application. APP
U, If an application is for a parcel or parcels on which more than one use is proposed,the applicant may submit a single
application for all such uses,provided the proposed uses are accurately delineated on a site plan drawn pursuant to the
requirements set forth above. The Planning Board may grant the application with respect to some proposed uses and not
others. For purposes of reviewing an application(and for SEQRA compliance)all proposed uses on a single parcel or on APP
contiguous parcels shall be considered together.
`/w A brief narrative statement on how the project proposed for review furthers or is consistent with the vision,goals and policies
in the Town's Comprehensive Plan. COVER
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Site Plan Review application—Revised October 2016
Town of Queensbury Planning Office-742 Bay Road,Queensbury,NY 12804
Town of Queensbury Site Plan Pre-Submission Conference Form/ Section 179-9-040
1. Applicant Name: Parker Hammond Dev.LLC
2. Tax Map ID 309.17-1-18.4 Location: Silver Circle
r,
3. Zoning Classification CLI
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4. Reason for Review: ITe etatiorm Clearign
r 5. Zoning Section#:
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6. Pre-Submission Meeting Notes: Provided Outstanding; Please provide by
Deed c/
General Information complete
Site Development Data Complete ✓
Setback Requirements Complete
Additional Project Information Complete
FAR addressed
Requirements for Site Plan-Standards
Checklist items addressed ✓ _ -W__Wv_Wv
Environmental Form completed
Signature Page completed
jf.. Me t k. —u L) tL G C,e.y
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�� � A e.0''"'A k�]bM.�JC.�. "`".," . C.�.n b�,.,� 4�7"C 14 0 A--1
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Staff Representative: "
Applicant/Agent: Date:
8
Site Plan Review application—Revised October 2016
Town of Queensbury Planning Office-742 Bay Road,Queensbury,NY 12804
Signature Page
This page includes the 1.) Authorization to Act as Agent Form: 2.) Engineering Fee Disclosure; 3.)Authorization for Site Visits;4.)
Other Permit Responsibilities; 5.)Official Meeting Disclosure and 6.)Agreement to provide documentation required.
f
OWNER'S AGENT FORM:
i
Complete the following if the OWNER of the property is not the same as the applicant
Owner:
Designates:.
As agent regarding: Variance Site Plan Subdivision
For Tax Map No.: Section Block _.. ..M Lot
Deed Reference: Book Page ,Date
OWNER SIGNATURE: _......_. _.. _ DATE: WWWW............_.....
APPLICANT'S AGENT FORM:
Complete the following if the APPLICANT is unable to attend the meeting or wishes to be represented by another party:
Owner: Parker Hammond Dev.LLC
..............................
_. _
Designates: Hutchins Engineering
As agent regarding: Variance ITITIT✓ Site Plan Subdivision
For Tax Map No, 9.17 Section 1 Block 18.4 Lot
Deed Refere II85 Book 186 Page 12/12/14 Date
OWNER SIGNATURE: DATE: 1 15'18
2.1 EN!gINI«ERING FEF RJCLQSURE: Applications may be referred to the Town consulting engineer for review of septic design, storm
drainage,etc.as determined by the Zoning or Planning Department. Fees for engineering review services will be charged directly to the applicant.
Fees for engineering review will not exceed$ 1,000 without notification to the applicant.
A1J I IIORIZA IONI SITE VISITS By signing this page and submitting the application materials attached herein,the Owner,Applicant,
and his/her/their agent(s)hereby authorize the Zoning Board or Planning Board and Town Staff to enter the subject properties for the purpose of
reviewing the application submitted.
4. (yrHER PERMIT E P tri 1BILITIE : Other permits may be required for construction or alteration activity subsequent to approval by the
Zoning Board or Planning Board. It is the applicant's responsibility to obtain any additional permits.
5.) OFFICIAL MEETINg MIN 'TES DISCLOSURE: It is the practice of the Community Development Department to have a designated
stenographer tape record the proceedings of meetings resulting from application, and minutes transcribed from those tapes constitutes the official
record of all proceedings.
6, A RE IIMIIEi'l TQ APiiC1 `ID I))C MEN"I I' REQUIRED: I,the undersigned,have thoroughly read and understand the instructions
for submission and agree to the submission requirements, I acknowledge no construction activities shall be commenced prior to issuance of a valid
permit. I certify that the application,plans and supporting materials are a true and complete statement/description of the existing conditions and the
work proposed, and that all work will be performed in accordance with the approved plans and in conformance with local zoning regulations. I
acknowledge that prior to occupying the facilities proposed,I or my agents,will obtain a certificate of occupancy as necessary. I also understand that
I/we may be required to provide an as-built survey by a licensed land surveyor of all newly constructed facilities prior to issuance of a certificate of
occupancy
I h ve ad tnd agre t the above. ' 1
�v�n �dt yYtvnvno� 1'15 I8
.... ....... ....
Si attl L]� -. Print Name[Applicant] Date signed
t u ] Print Name [Agent] Date signed
9
Site Plan Review application—Revised October 2016
Town of Queensbury Planning Office-742 Bay Road,Queensbury,NY 12804
Short Environmental Assessment Form
Part 1 -Project Information
I nstructiops for Completin
Part 1-Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses
become part of the application for approval or funding,are subject to public review,and may be subject to further verification.
Complete Part 1 based on information currently available. If additional research or investigation would be needed to fully
r respond to any item,please answer as thoroughly as possible based on current information.
Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful
to the lead agency;attach additional pages as necessary to supplement any item.
Part 1-Project and Sponsor Information
Name of Action or Project:
Parker&Hammond Development LLC Selective Clearing Project
Project Location(describe,and attach a location map):
Silver Circle,Town of Queensbury,Warren County
Brief Description of Proposed Action:
Selectively clear 7.0 acres of existing 7.86-acre parcel in northwest corner of Silver Circle Industrial Park
Name of Applicant or Sponsor: Telephone: (518)793-3226
Parker Hammond Development LLC E-Mail: kevin@parkerhammond.com
......................
Address:
24 Silver Circle
City/PO: State: Zip Code:
Queensbury NY 12804
1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES
administrative rule,or regulation?
If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that Z F
may be affected in the municipality and proceed to Part 2. If no,continue to question 2.
2. Does the proposed action require a permit,approval or funding from any other governmental Agency? NO YES
If Yes,list agency(s)name and permit or approval:
3.a.Total acreage of the site of the proposed action? 7.86 acres
b.Total acreage to be physically disturbed? 7.00 acres
c.Total acreage(project site and any contiguous properties)owned
or controlled by the applicant or project sponsor? 10.35 acres
4. Check all land uses that occur on,adjoining and near the proposed action.
r ❑Urban [:]Rural(non-agriculture) [Z]Industrial mCommercial ❑Residential(suburban)
❑Forest ❑Agriculture El Aquatic ❑Other(specify): ..
❑Parkland
Page 1 of 3
5. Is the proposed action, NO YES N/A
a.Aermitted use under the zoning regulations? 11
LDLDp g
Z El
b. Consistent with the adopted comprehensive plan? ✓
6. Is the proposed action consistent with the predominant character of the existing 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 YES
' If Yes,identify:
8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES
i
b.Are public transportation service(s)available at or near the site of the proposed action?
c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? Z 1-1
9.Does the proposed action meet or exceed the state energy code requirements? NO YES
design technologies:
If the proposed action will exceed requirements describe features and technol ❑
10. Will the proposed action connect to an existing public/private water suPpP1Y
? NO YES
If No,describe method for providing potable water: needed for clearing project �--ry
No water ne .. .� �r ...ww..._ I�J
11.Will the proposed action connect to existing wastewater utilities? NO YES
wastewater generated for clearing
If No,describe method for providing wastewater treatment: No„ w_
Z El
_,.,... Project.......
12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES
Places? W1 1:1
b.Is the proposed action located in an archeological sensitive area?
13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES
wetlands or other waterbodies regulated by a federal,state or local agency? ✓
b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? ❑✓ El
If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres:
14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply:
❑Shoreline m Forest ❑Agricultural/grasslands ❑Early mid-successional
❑ Wetland ❑Urban ❑Suburban
15.Does the site of the proposed action contain any species of animal,or associated habitats,listed NO YES
by the State or Federal government as threatened or endangered? ❑
16.Is the project site located in the 100 year flood plain? NO YES
p17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES
If Yes,
a.Will storm water discharges flow to adjacent properties? ❑NO ❑YES
b.Will storm water discharges be directed to established conveyance systems runoff and storm drains)?
If Yes,briefly describe: NO ❑YES
Page 2 of 3
18.Does the proposed action include construction or other activities that result in the impoundment of NO I YES
water or other liquids(e.g.retention pond,waste lagoon,dam)?
If Yes,explain purpose and size
�...�...—,...m...... ... .... ...... __ ......................... ...... ✓
19.Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES
solid waste management facility?
If Yes,describe: ........ .. .. ................................. ... Z El
......... ...wawa _....
20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES
9 completed)for hazardous waste?
If Yes,describe:......_ .... .......... ............................... Z El
I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY
KNOWLEDGE
Applicant/sponso 'a ae: Date:
Signature:
N
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