HomeMy WebLinkAboutChecklist - SEP Application - 1/31/1991 For non-project actions, the references in the checklist to the vords "project",
"applicant", and "property or site" should be read as "proposal', "proposer",
and "affected geographic area , respectively.
A. BACKGROUND
1. Name of proposed project, if applicable:
2. Name of applicant: Q� L, ,tD (-�p�rs.�
3. Address and phone n mber of applicant and contact person:
4. Date checklist prepared: /j,_61q
5. Agency requesting checklist: yGj S O,,L) CI-0
6. Proposed timing or schedule !including phasing, if applicable):
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7. Do you ha e any plans for future expansion, or further activity
related to or connected vith this proposal? If yes explain.
8. List any environmental information you knov about that has been
prepared, or vill be prepared, directly related to this proposal.
9. Do you knov vhether applications are pending for governmental
approvals of other proposals directly affecting the property covered
by your proposal? If yes, explain.
10 List any government approvals or permits that rill be needed for
your proposal, if knovn.
11. Give a brief, complete description of your proposal, including the
proposed uses and the size of the project and site. There are
several questions later in this checklist that ask you to describe
certain aspects of your proposal. You do not need to repeat those
answers on this page. (Lead agencies way modify this form to
include additional specific information on project description. )
12. What is the location of the proposal. Give sufficient information
for a person to understand the precise location of your proposed
project, Including a street address, if any, and section, township,
and range, if known. If a proposal would occur over a range of
area, provide the range or boundaries of the site(s). Provide a
legal description, site plan, vicinity sap, and topographic map, if
reasonably available. While you should submit any plans required
by the agency, you are not required to duplicate maps or detailed
plans submitted with any permit applications related to this
checklist.
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TO BE COMPLETED BY APPLICANT: EVALUA TION FOR
AGENCY USE ONLY
B. ENVIRONMENTAL ELEMENTS
1. EARM:
a. Gen_er description of the site (circle one): Flat, rolling, hilly,
steep slope mountainous, other
b. What is the steepest slope on the site (approximate percent slope)?
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TO BE COMPLETED BY APPLICANT: EVALUATION FOR
AGENCY USE ONLY
c. What general types of soils are found on the site (for example,
clay, sand, gravel, peat, muck)? If you know the classification of
agricultural soils, specify them and note any prime farmland.
TO BE COMPLETED BY APPLICANT: EVALUATION FOR
AGENCY USE ONLY
d. Are there surface indications or history of unstable soils in the
immediate vicinity? If so, describe.
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e. Describe the purpose, type, and approximate quantities of any
filling or grading proposed. Indicate source of fill.
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f. Could erosion occur as a result of clearing, construction, or use?
If so, generally describe.
g. About vhat percent of the site vill be covered vith impervious
surfaces after project constructions (for example, asphalt or
buildings)?
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h. Proposed measures to reduce or control erosion, or other impacts to
the earth, if any:
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2. AIR:
a. What types of emissions to the air would result from the proposal
(i.e. dust, automobile, odors, industrial rood smoke) during
construction and vhen the project is completed? If any, generally
describe and give approximate quantities, if knovn.
A'14-
b. Are there any off-site sources of emissions or odor that may affect
your proposal? If so, generally _describe.
N/A
C. Proposed measures to reduce or control emissions or other impacts
to air, if any:
N/A
TO BE COMPLETED BY APPLICANT: EVALUATION FOR
AGENCY USE ONLY
3. WATER:
a. Surface:
1) Is there any surface water body on or in the immediate vicinity
of the site (including year-round and seasonal streams, saltwater,
lakes, ponds, wetlands)? If yes, describe type and provide names.
If appropriate, state what stream or river it flows into.
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2) Will the project require any work over, in, or adjacent to
(within 200 feet) the described waters? If yes, please describe and
attach available plans.
3) Estimate the amount of fill and dredge material that .would be
place in or removed from surface water or wetlands and indicate the
area of the site that would be affected. Indicate the source of
fill material.
4) Will the proposal require surface water withdrawals or
diversions? Give general description, purpose, and approximate
quantities if known.
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5) Does the proposal lie within a 100-year floodplain? If so, note
location on the site plan.
6) Does the proposal involve any discharges of waste materials to
surface waters? If so, describe the type of waste and anticipated
volume of discharge.
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TO BE COMPLETED BY APPLICANT: EVALUATION FOR
AGENCY USE ONLY
b. Ground:
1) Will ground rater be withdrawn, or will rater be discharged to
ground water? Give general description, purpose, and approximate
quantities, if known.
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2) Describe waste material that will be discharged into the ground
from septic tanks or other sources, If any lfor example, Domestic
sewage: Industrial, containing the following chemicals . . . ;
agricultural, etc. ). Describe the general size of the system, the
number of such systems, the number of houses to be served (if
applicable), or the number of animals or humans the system(s) are
expected to serve.
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C. Water Runoff (including storm water):
1) Describe the source of runoff (including storm water) and method
of collection and disposal, if an (include quantities, If known).
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Where will this water flow? Will this rater flow into other waters?
If so, describe.
2) Could waste materials enter ground or surface waters? If so,
generally describe.
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d. Proposed measures to reduce or control surface, ground, and runoff
rater impacts, if any:
TO BE COMPLETED BY APPLICANT: EVALUATION FOR
AGENCY USE ONLY
4. PLANTS:
a. Check or circle types of vegetation found on the site:
_K deciduous tree: alder, maple, aspen, other
5_ evergreen tree: fir, cedar, pine, other
shrubs
grass
pasture
crop or grain
yet soil plants: cattail, buttercup, bullrush, skunk cabbage, other
water plants: rater lily, eelgrass, milfoil, other
other types of vegetation
b. What kind and amount of vegetation will be removed or altered?
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C. List threatened or endangered species known to be on or near the
site.
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d. Proposed landscaping, use of native plants, or other measures to
preserve or enhance vegetation on the site, if any:
5. ANIMAL
a. Circle any birds and animals which have been observed on or near the
site or are known to be on or near the site:
birds: hawk, heron, eagle, ngbird , other . . . . . . . . . . .
mammals: deer, bear, a beaver, other . . . . . . . . . . . . .
fish: bass, salmon rout ' herring, shellfish, other . . . . . .
b. List any threatened or endangered species known to be on or near the
site.
TO BE COMPLETED BY APPLICANT: EVALUATION FOR
AGENCY USE ONLY
C. Is the site part of a migration route? If so, explain.
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d. Proposed measures to preserved or enhance vildlife, if any:
6. ENERGY AND NATURAL RESOURCES:
a. What kinds of energy (electric, natural gas, oil, wood stove, solar)
vill be used to meet the completed project's energy needs? Describe
whether it vill be used for heating, manufacturing, etc.
N/A
b. Would your project affect the potential use of solar energy by
adjacent properties? If so, generally describe.
N/A
C. What kinds of energy conservation features are included in the plans
of this proposal? List other proposed measures to reduce or control
energy impacts, if any:
N/A
7. ENVIRONMENTAL HEALTH:
a. Are there any environmental health hazards, including exposure to
toxic chemicals, risk of fire and explosion, spill, or hazardous
vaste, that could occur as a result of this proposal? If so,
describe.
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1) Describe special emergency services that might be required.
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TO BE COMPLETED BY APPLICANT: EVALUATION FOR
AGENCY USE ONLY
2) Proposed measures to reduce or control environmental health
hazards, if any:
b. Noise.
1) What types of noise exist in the area vhich say affect your
project (for example: traffic, equipment, operation, other)?
N/A
2) What types and levels of noise could be created by or associated
with the project on a short-tern or a long-term basis (.for example:
traffic, construction, operation, other)? Indicate what hours noise
would come from the site
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3) Proposed measures to reduce or control noise impacts, if any:
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8. LAND AND SHORELINE USE:
a. What is the current use of the site and adjacent properties?
b. Has the site been used for agriculture? If so, describe.
C. Describe any structures on the site.
d. Will any structures be demolished? If so, vhat?
e. What is the current zoning classification of the site?
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TO BE COMPLETED BY APPLICANT: EVALUATION FOR
AGENCY USE ONLY
Y. What is the current comprehensive plan designation of the site?
g. If applicable, what is the current shoreline master program
designation of the site?
h. Has any part of the site been classified as an •environmentally
sensitive" area? If so, specify.
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i. Approximately how many people would reside or, work in the completed
project?
N/A
J. Approximately how many people would the completed project displace?
N/A
k. Proposed measures to avoid or reduce displacement impacts, if any:
N/A
1. Proposed measures to ensure the proposal is compatible with existing
and projected land uses and plans, if any:
9. HOUSING:
a. Approximately how many units would be provided, if any? Indicate
whether high, middle, or low-income housing.
N/A
b. Approximately how many units, if any, would be eliminated? Indicate
whether high, middle, or low-income housing.
N/A
C. Proposed measures to reduce or control housing impacts, if any:
N/A
TO BE FILLED OUT BY APPLICANT: EVALUATION FOR
AGENCY USE ONLY
10. AESTHETICS:
a. What is the tallest height of any proposed structure(s), not
Including antennas; vhat is the principal exterior building
material(s) proposed?
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b. What vievs in the immediate vicinity vould be altered or obstructed?
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C. Proposed measures to reduce or control aesthetic impacts, if any:
11. LIGHT AND GLARE
a. What type of light or glare vill the proposal produce? What time
of day vould it mainly occur?
N/A
b. Could light or glare from the finished project be a safety hazard
or interfere vith viers?
N/A
C. What existing off-site sources of light or glare may affect your
proposal:
N/A
d. Proposed measures to reduce or control light and glare impacts, if
any:
N/A
12. RECREA TION:
a. What designated and informal recreational opportunities are in the
immediate ,vicinity?
TO BE FILLED OUT BY APPLICANT: EVALUATION FOR
AGENCY USE ONLY
b. Would the proposed project displace any existing recreational uses?
If so, describe.
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C. Proposed measures to reduce or control impacts on recreation,
including recreation opportunities to be provided by the project or
applicant, if any:
13. HISTORIC AND CULTURAL PRESERVATION:
a. Are there any places or objects listed on, or proposed for,
national, state, or local preservation registers known to be on or
next to the site? If so, generally describe.
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b. Generally describe any landmarks or evidence of historic,
archaeological, scientific, or cultural importance known to be on
or next to the site.
C. Proposed measures to reduce or control impacts, if any:
14. TRANSPORTATION:
a. Identify public streets and highvays serving the site and describe
proposed access to the existing street system. Shov on site plans,
if any.
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TO BE FILLED OUT BY APPLICANT: EVALUATION FOR
AGENCY USE ONLY
b. Is site currently served by public transit? If not, what is the
approximate distance to the existing street system. Show on site
plans, if any.
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C. Nov many parking spaces would the completed project have? Nov many
would the project eliminate?
N/A
d. Will the proposal require any new roads or streets, or improvements
to existing roads or streets, not including driveways? If so,
generally describe (indicate whether public or private).
N/A
e. Will the project use for occur in the immediate vicinity of) water,
rail, or air transportation? If so, generally describe.
N/A
f. Nov many vehicular trips per day would be generated by the completed
project? If known, indicate when peak volumes would occur.
N/A
g. Proposed measures to reduce or control transportation impacts, if
any:
N/A
15. PUBLIC SERVICES:
a. Would the project result in an increased need for public service
(for exasple. fire_ protection,_- police__protection,_ _-health _care,
schools, other)? If so, generally describe:
N/A
TO BE FILLED OUT BY APPLICANT: EVALUATION FOR
AGENCY USE ONLY
b. Proposed measures to reduce or control direct impacts on public
services, if any:
N/A
16. UTILITIES:
a. Circle utilities currently _.avai.lahle at ..the site: elegy ric
nata vate`' refuse service , epho , sani a
`ptic syst a, other:
b. Describe the utilities that are proposed for the project, the
utility providing the service, and the general construction
activities on the site or in the immediate vicinity which Aright be
needed:
c. S39 nature:
The above ansrers are true and cowplete to the best of
my knowledge. I understand that the lead agency Is
relying on thew to wake .its deciad on.
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$I[,jlJa t tlI'e:
Date SubwItted.- l