Tab D r-�
General Information
Tax Parcel ID: 2�$-1- a 2� " - I-'12 L-71 -l 4
Zoning District:
Lot size: _iC2. 13 '" % , 7. 2 1,: R ' 1
1
Mcv%e G W��ed, '. �'-t.� tc-L� L ist ��'rc;►.�
Current Use: h
V 0,gao7lE La j,A-
Proposed Use: COW- SLA l cxkAAq- anual 0eVA'+t!h& UU I tc'S
Project Location: _L) V- iwk
Applicant Name Address: cis
CA,
Home Phone Cell:
Work Phone Fax _
k U " y -
E-Mail: ..
G � �
i
Agent's Name: Address V e- .�k Sy-"r
Home Phone Cell:
542
i Work Phone Fax
i ,32.- tc �1 � �`�� C) i
E-mail
Owner's Name: Address
j Home Phone Cell
ll
Work Phone Fax i I
23
E-mail `
Site Plan Review Revised June 2016
Town of Queensbury Planning Office-742 Bay Road Queensbury, NY 12804.518-761-8220
Additional Proiect Information
�., Will the proposal require a Septic Variance from the Town Board of Health?
2. if the parcel has previous approvals, list application number(s): 116 -
3.
F6e3. Does this project require coverage under the New York State Pollutant Discharge Elimination System
(SPDES) Permit Program? . W�P- fit" r-1? Lt(a,+'RA �),J Mk�bG
4. Estimated project duration: Start Date- '2,%1 — End Date OhLhcWhl
5. Estimated total cost of project:___ _ :,1 U.,
6. Total area of land disturbance for project: 0 S #�
Floor Area Ratio Worksheet : �
FLOOR AREA RA\ins
The relationship of building size to lot lze, derived by dividing the total building
floor area by the lote feet,yielding a percentage.
Zoning District Symbol Floor Area Ratio[FAR)
Waterfront Residential WR 0.22
i
commercial Moderate/Commercial Inte iv e CM I CI 0.3
Main Street MS 0.3
i
A. The combined area of all square footage, as mkua
exterior walls of all structures on the property, including
all floors of the structures, garages, basemttics with more than five (5) feet of ceiling height and
covered porches. Building square footage doee Open deck, docks and that porion of covered docks
extending over water and one storage sheddred twenty (120) square feet or less. Any additional
sheds will be included (See"FLOOR AREA
B, Commercial or industrial: the total area i sqs asured from the exterior of the outside walls of a
building or structure, and when applicabl the f all flo r areas of the principal and accessory buildings or
structures on the project site.
A. Parcel Area sq. ft.
B. Existing Floor Area sq.ft. (see definition above)
C. Proposed Additional FI r Area 50. ft.
D, Proposed Total Floa Area . ft,
E. Total Allowable FI or Area (Area x ) (see above table)
If D is larger than E, variance or revisions to your plan may be needed. Please consult wlstaff.
r—�
Site Plan Review Revised June 2016
Town of Queensbury Planning Office.742 Bay Road-Queensbury. NY 12804.51&761-8220
�. Site Development Data
Area J Type Existing sq. ft. Proposed Total sq. ft.
Additions . ft.
A. Build*n footprint t4G �u'O a kvwl�
r Sire t ? C) Ilk
z0
etached Garage
tA 1A N A
C. Accessory Structure(s) _
int'. AAA_ 5 CiO-Pe" r A `�L
D. Paved, gravel or other hard surfaced area 1Jn 1(a•( lr� (�) �yy
V V•'V � �W V ��V
f. Parches 1 Decks
Ilk N
F. Other
G. Total Non-Permeable [Add A-F]
44 (ot
H. Parcel Area [43,560 sq.ft. 1 acre]
I. Percentage of Impermeable Area of Site [i=GIH]
COO+ 00-4
Mack_Reguirements
r•
Area Reg4ed Existing Proposed
Front[1]
'Z
+ . '
I Front[2] IAN
Shoreline
Side Yard [I] +
Side Yard [2]
Rear Yard [1] l
Rear Yard [2]
r
Travel Corridor
Height[max]
t >s &P&
Permeability
i
No. of parking spaces NA
Site Plan Review Revised June 2016
Town of Queensbury Planning office 742 Bay Road-Queensbury, NY 12804.51&761-8220
'--"9-9-080 Re uirements for Site Plan Approval. The Planning Board shall not approve a Site Plan unless it
I..'t 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 les
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 Se ge and Sewage Disposal,Chapter 147 Stormwater Management Local Law,and other
applicable local laws. A 1 Ai Ll,' S �� �p� 'S S S
) The proposed use shall be in liarmony with the general purpose or intent o 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. h 1, `L U J1 I (eg
) The establishment,maintenance and operation of the proposed use will not create public hazards from traffic,traffic tong stion 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. W0 S U 'r I wl Lzctl; OS o,& /�ivA ��
C Off-street parking and 19oading facilities be appropriately located and arranged and fficient to meet traffic anticipate to be eo IkO
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 Boazd may require
proof that the applicant has made contact with adjacent property owners for purposes of coordinating linkages with adjacent properties. Wo
'Be 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 right 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§ I79-9-080 of this Chapter,and in so doing,the Planting 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. 11�.$
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. r 2 d (6,(n a cte_Ss u k, k0-t, ,eS
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
wn 6�
of Chapter 147 of the ToCode and the Town of Queensbury Subdivision Regulations where applicable. 140 1 W Vel V oL
K The water supply and sewage disposal facilities will be adequate and will meet all applicable and current requirements set forth by -�6tdt
Department of Health regulations and Chapter 136 of the Town Code. t-40 PutQ�ke Waw V,-_�AeA- 4 es
L The adequacy,type and arrangement of trees,shrubs and other suitable plantings, landscaping and screening shall effectively provide a
visual andior noise buffer between the applicants and adjoining lands,including tie`maximum relent qn pf existing vegetation and
maintenance,including replacement of dead or deceased plants. Sf,kt;I. IM V:i<f`�e4_ W(I1 OE the Gat j U�2. cA+-
�� Fire lanes,emergency zones and fire hydrants will be adequate and eet t e e s an requirements f emergency serytc_e eiders
N• The design of structures,roadways and landscaping in areas susceptible to ponding,flooding and/or erosion will minimize or avoid such
impacts�oaxextent practicable. w at0. 0 yirt ��� >(E t,31 $The sitthe design standards,landscaping star ands and performance standards of this hapten,
e�
Site Plan Review Revised Tune 2016
Town of Queensbury Planning Office•742 Bay Road,Queensbury,NY 12804• 518-?61-8220
�''9-8.050 A 1'cation far Site Plate Review
Absent any waiver or waivers, an application for Site Plan Review shall include the follokving:
REQUIREMENTS Sheet #
A A vicinity map drawn at the scale that shows the relationship of the proposal to existing community facilities which affect Yf C
or serve it,such as roads,shopping areas,schools,etc The map shall also show all properties,identify owners, L3,
subdivisions,streets and easements within 500 feet of the property. Such a sketch may be superimposed on a United States C- ac
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 3�Q
deem appropriate,on standard 24"x 36"sheets,with continuation on 8 112"x 11"sheets as necessary for written
information. The information listed below shall be shown on the site vlan and continuation sheets
C Name of the project,boundaries,date,north arrow,and scale of the plan.
D Name and address of the owner of record,developer,and seal of the engineer,architect or landscape architect- If the p pt Eft y�,k
applicant is not the record owner,a letter of authorization shall be required from the owner I l
E. The location and use of all existing and proposed structures within the property,including all dimensions of height and �Se
floor area,all exterior entrances,and all anticipated future additions and alterations �c U6
The location of all present and proposed public and private ways,off-street parking areas,driveways,outdoor storage areas, v
sidewalks,ramps,curbs,paths,landscaping,wails and fences. Location,type and screening details for all waste disposal �x tK�j
containers shall also be shown.
Ci The location,height,intensity and bulb type(sodium,incandescent,etc.)of all external fighting fixtures The direction of Lt
illumination and methods to eliminate late onto ad oinin properties must also be shown in com liance with 179-6.020.
The location,height;size,materials and design of all proposed signs.
� 14
The location of all present and proposed utility systems including
1. Sewage or septic system, 1- A
2. Water supply system. `.�f.��� tifG� U 4-Og-t .5"tt1�
3. Telephone,cable and electrical systems,and W •A
4. Storm drainage system including existing attd proposed drain lines,culverts,catch basins;headwalls;endwalls,
hydrants,manholes and drainage swales. A , ej} t5lc- �-f-Umi A-
j. Plans to prevent the pollution of surface or groundwater,erosion of soil both during and after construction,excessive runoff tj
and flooding of other properties,as applicable. A Stormwater Pollution Prevention Plan(SWPPP)for all land development 1 ` 1
activities(excluding agricultural activities)on the site that results in land disturbance of one acre or more. A SWPPP shall l - 0.,Lt
comply with the requirements of the DEC.SPDES MS-4 General Permit and Chapter 147 of the Town of Queensbury ( Ali
Code. It shall be at the discretion of the Planning Board as to whether a SWPPP or an erosion and control plan shall be r"ga f(
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 �J A
allow. All elevations shall refer to the nearest United States Coastal and Geodetic Bench Mark If any portion of the parcel 1
is within the 100-year floodplain,the area will be shown and base flood elevations given. Areas shall be indicated within CA: L
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
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 a d.
watercourses,aquifers;floodplain and drainage retention areas. k'oIYAAA
p L
M. Land Use District boundaries within 500 feet of the site's perimeter shallbe drawn and identified the site plan,as well
as any Overlay Districts that apply to the property. 5
Site Plan Review Revised June 2016
Town of Queensbury Planning Office• 742 Bay Road, Queensbury,NY 12804 • 518-761-8220
r-�
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: I
low
1. The projected number Of Motor vehicle trips to enter or leave the site,estimated for weekly and 1 7—
annual peak hour traffic levels; W 1
2. The projected traffic flow pattern including vehicular movements at all major intersections likely
to be affected by the proposed use of the site; 3i 1
3. The impact of this traffic on levels of service on abutting public streets and at affectedj k
intersections. Existing and proposed weekly and annual peak hour traffic levels and road capacity 7v4--(4tp W t'
levels shall also be given. t Y� � "+ tkczir L"l:�11 ,. kgLc_t1t
Q For new construction or alterations to any structure,a table containing the following informations all 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;
3 Maximum seating capacity,where applicable,and 7
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) Nq t Vk4L
andlot alterations to or expansions of existing facades,showing design features and indicating the type and color of materials
r� i 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
R Plans for disposal ofconstruction and demolition waste,either on-site or at an approved disposal facility_ 144 !, k _ �.
S Plans for snow removal,including iocation(s)of on-site snow storage. t T h �
T An Environmental Assessment Forrn("EAF")as required by the SEQRA regulations,with Part 1 completed by the A plicant C ( �j
shall be submitted as part of the application. Ifthe proposed project requires a special use permit and an EAF has been see C Gyp J
submitted in conjunction with a special use permit application,a duplicate EAF is not required for the site plan application
LT 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 U V111,ly
others For purposes of reviewing an application(and for SEQRA compliance)all proposed uses on a single parcel or on {
contiguous parcels shall be considered together.
V. 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,
4 4to«+. porn[ �A S � �t� I hLV,iv Wq—Avc. ire ,� ei-
{ << . - . -�c�c+ -u: k.�,e ,x( r cL t+q %_L Ju o aL, c LA
l i► Ll�' l`� 101A 41 i(`Q. TI�.� b tJ 1" }ci+rC 1�+1 L . '� l [ -�' � }.�L i w�� t.4 +�
Z.c>\V�&_ U') l 'lam 4 S f Qr_(_ 0 W
Site Plan Review Revised June 2016
Town of Queensbury Planning Office•742 Bay Road,Queensbury,NY 12804 •518-761-8220
7
Pre-Submission Conference Form [179-4-0401
7. Tax Map ID - /-
557- � !r �( - /c) �/ �GI
2. Zoning Classification ] A
3. Table of Allowed Uses a/, � �� /� subjecttoSite Plan Review
4. Ordinance Section# ( ! C� - 3 O Wu�+ ) q /'7/- /0-0 7[�
5. Pre-Submission Meeting Notes; Outstanding Items To Beressed Include
Deed No
General Information complete Ye No
Site Development Data Complete Yes No
AAd
Setback Requirements Complete es No
Additional Project Information Complete No
'Cove rape under DEC fik prQaram k s No
FAR Worksheet complete / No
Standards addressed No
Checklist items addressed Y No
Environmental Form completed Yes No
Signature Page completed es No
Si.2 OnCd ivVV) C n 4 0�ZC
Dr Dean r1e Q.0 M G P LtG-
�k-eL c. Lcnd rJ U;,0A-j CUSS. t,%
_TA V & P
t C C, Ai 0
v
[Yct Vt ,mac f ciP C-p—
�C an c Ajt
c
AnnlicaT nt must p[Qvide o fLo_M&.r12tire of Intent(NOi):SWPPP Acceptance Form. DEC letter issuing perrrt't<t
un mber: Notice of Termination-M 10l�Staff Representative: 4 � A6�_
n Applicant !Agent: 9��— M aA4P�
Date: 1
Site Plan Review Revised June 2016
Town of Queensbury Planning Office•742 Bay Road•Queensbury, NY 12804.518-761-8220
Signature Page
This page Includes the 1:)Authorization to Act as Agent form:2.)Engineering Fee Disclosure; 3,)Authorization.for Site
veils, 4.) tither Permit Responsibdiilies; 5.) Official Meeting Disclosure and b:)Agreement to provide documentation t
required.
4�1
OWNER'S AGENT FORM:
a
i
Completethe following Me OWNER of the property is notthe sante as the applicant
Owner. _
Designates:
As agent regarding: Variance Site Plan Subdivision
For Tax Map No-: Section Block Lot '
Deed Reference: Book Page Date j
l �
OWNER SIGNATURE: DATE:
APPLICANT'S AGENT FORM-
k i
Complete the following if the APPLICANT is unable to attend the meeting or wishes to be represented by another party
Owner:
Designates: 7
As agent regarding: Variance Site Plan Subdivision
For Tax Map No.: Section Block Lot
Deed Reference: Book Page Date
APPLICANT SIGNATURE: BATE:
2.) ENGINEERING FEE DISCLOSURE: 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
3.)AUTNORIZATtON FOR SITE VISITS: By signing this page and submitting the application materials attached herein, the Owner,
Applicant, and hlslher/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.)OTHER PERMIT RESPONSIBILITIES: Other permits may be required for construction or alteration activity subsequent to approve)
by the Zoning Board or Planning Board. It lathe applicant's responsibility to obtain any additional permits.
5.f OFFICIAL MEETING MINUTES DISCLOSURE: it isthe practice of the Community.Development Department to have a designated .
stenographer tape record the proceedings of meetings resuhingfrom application,and minutes transcribed from those tepee constitutes
the ofFiidol reoord of all proceedings.
6.) AGREEMENT TO PROVIDE DOCUMENTATION REOUIRI=D: 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 csrtify that the application, pians and supporting materials are a true and complete
statemenWescription of the existing conditions and the work proposed., and that all work will be performed In accordance with the
approved plans and inconformance with local zoning regulations.I acknowledge that prior to occupying the facilities proposed, f or my
agents.,will obtain'a certificate of occupancy as necessary. I also understand that llwe 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 have read and agree t4 the above.
`
idalure[Applicant] Print Marne[Applicant] Datd signed
o,a I_Aplfc Arm td'
ignature[ gent] Print Name [Agent] Date signed
s
Of
Ske Plan Review Revised June 2018
Tooww'of Qu sbury Planning Office,742 Bay Road •Queensbury, NY 12804 518-761-822 f
/�
9
r-. Short Environmental Assessment Form
Part I -Project Information
Instructions for Completing
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
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.
r
Part I -Project and Sponsor Information o- t-T
Name of Action or Project "
�M A
Project Location(describe,and attach a location map)
Brief Description of Proposed Action:.
-Tip V 0 V'0&4 k -kD c�b+kt,v. 4., S ��c►at� L11 � �0_V-V'AkJ -�Dw>.
10 LAJv 0-f' 4"A— races tk'i
v-� S ntiC nc. L]eft G iTa.�i�e ii eC31h+� �f,.� Y-`°e-+t rv'A�-C �M-(-4s AIS.
W%A\ kA& \rti'�tL\c� iL0. 4'�Dv\l-ko V .'_ o"VN
,.Name of Applicant or Sponsor: Telephone: L. _ sw 0
k�e_ Fa CT N� t k44L Co - S
F r� tl Y' ct` E-Mail: � �:; : t;_o/.\
Address:
City/PO: State Zip Code:
1.Does the pro osed action orAy 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 off the proposed action and the environmental resources that
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: J lY S OVSD�C 1''�-it- Ak+
_F
-'5,0 V,
09L
3.a. Total acreage of the site of the proposed action? acres
b. Total acreage to be physically disturbed? �acres
c.Total acreage(project site and any contiguous properties)owned
or controlled by the applicant or project sponsor? '2_Z4,± acres
4. Check all land uses that occur on,adjoining and near the proposed action.
❑Urban %Rural(non-agriculture) ❑Industrial ❑Commercial CgResidentiai(suburban)
Forest ❑Agriculture El Aquatic ❑Other(speciffyy):% Cy-Lcmc 5�'XkA1� CkiN glrOt
❑Parkland
Y 0.
Page 1 of 3
�. Is the proposed action. N4 YES N1A
a.A permitted use under the zoning regulations?
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? S � ra
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: so Q.rt. it, 6— +'
rNAA^r V� ' J,-e ❑ ILEI
8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES
t7 r� a v a,,As pe;` W,-k ete_CLC f � NC W Lek ad ® ❑
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? ® ❑
4.Does the proposed action meet or exceed the state energy code requirements? NO YES
If the proposed action will exceed requirements,describe design features and technologies:
10. Will the proposed action connect to an existing public'private water supply? NO YES
If No, describe method for providing potable water: UaE � ' ❑
11. Will the proposed action connect to existing wastewater utilities? NO YES
If No describe.methoO for providing wastewater treatment: G L. �cd l ® ❑
�� t!' # 06 S re'�im NS 4lll W�-t' .yt
12 a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES
Places? � ❑
i
b. is the proposed action located in an archeological sensitive area?
1 . 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? C❑
If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: L�
14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply:
❑Shoreline [AForest ❑Agri culturallgrass]ands ❑Early mid-successional
❑ Wetland El 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? 1, d; D b MswC.
J� *Ae t� trOCESS ❑ ❑
16. is the project site located in the 100 year flood plain? NO YES
17.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 [LYES
_!�e,c±% . --2j
Page 2 of 3
18.Does the proposed action include construction or other activities that result in the impoundment of NO YES
water or other liquids(e.g. retention pond,waste lagoon,dam)?
If Yes,explain purpose and size: al(e
- 4
J� 1aCR-• I
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: ® ❑
20.Has the site of the proposed action or an adjoining property been the subject of rernediation(ongoing or NO YES
completed)for hazardous waste?
If Yes,describe: ❑
I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY
KNOWLEDGE
Applicant/sponsor name: CO �Q� Date
Signature:
r1
PRINT FORM Page 3 of 3