HomeMy WebLinkAboutDOC-2000-Environmental Checklist Form - G "
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ENVIRONMENTAL CHECKLIST FORM
A. BACKGROUND
1. Name of pro osed project, if applicable:
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2. Name of applicant:
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3. Address and phone number of applicant and contact person:
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4. Date checklist prepared:
9 a 9-99
5. Agency requesting checklist:�/
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6. Proposed timing or schedule(including phasing, if applicable):
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7. Do you have any plan for future additions, expansion, or further activity related to or
connected with this proposal? If yes, explain.
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8. List any environmental information you know that has been prepared, or will be prepared,
directly related to this project.
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9. Do you know whether applications are pending for government approvals of other
proposals directly affecting the affected geographic area covered by your proposal? If yes,
explain. /V 1
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10. List any government approvals or permits that will be needed for your proposal, if known.
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11. Give brief, complete description of your proposal, including the proposed uses and the size
of the project and site. There are several questions in this checklist that ask you to describe
certain aspects of your proposal. You do not need to repeat these answers on this page.
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12. 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. Provide a legal description, site plan, vicinity map, 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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B. ENVIRONMENTAL ELEMENTS
1. Earth
a. General description of the affected geographic area(circle one). Flat, ollin hilly,
steep slopes, mountainous, other
b. What is the steepest slope on the site(approximate percent slope)?
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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 s them and
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note any prime farmland./
d. Are there any 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 arg ding
proposed. Indicate source of fill.
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f. Could erosion occur as a result of clearing, cons con r use. f so, generally n
describe. (an jScc f))% O-J'J SohtP �eQ re.1.1oo0j i S '?re f0
g. About what percent of the site will be covered by impervious surfaces after
proposal construction(for example, asphalt or buildings)?
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h. Proposed measures to reduce or control I 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 wood smoke) during construction and when the
project is completed? If any, generally describe and give approximate quantities if
known.
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b. Are there any off-site sources of emissions or odors that may affect your proposal?
If so, generally describe. N D
C. Proposed measures to reduce or control emissions or other impacts to air, if any:
3. Water
a. Surface
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(1) Is there any surface water body or on 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.
(2) Will the project require any work over, in, or adjacent to (within 200 feet)
the described waters? If yes, describe and attach available plans.
(3) Estimate the amount of fill and dredge material that would be pi aced in or
removed from surface water or wetlands and indicate the area of the site that
would be
affected. Indic
ate to the source of
fill material. _
(4) Will the proposal require surface water withdrawals or diversions? Give
general description,purpose and approximate quantities if known.
(5) Does the proposal lie within a 100-year floodplain? If so, note location on
the affected geographic area plan.
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(6) Does the proposal involve any discharge of waste materials to surface
waters? If so, describe the type of waste and anticipated volume of
discharge. /00
b. Ground
(1) Will ground water be withdrawn, or will water be discharged.to ground
water? Give general description, purpose and approximate quantities if
known.
(2) Describe waste material that will be discharged into the ground from septic
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tanks or other sources, if any (for 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
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houses to be served (if applicable), or the number of animals or humans the
system(s) are expected to serve.
C. Water Runoff(including storm water):
(1) Describe the source of runoff(including storm water) and method of
collection and disposal, if any(include quantities, if known). Where will
this water flow? Will this water flow into other waters? If so, describe.
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(2) Could waste materials enter ground or surface waters? If so, generally
describe.
d. Proposed measures to reduce or control surface, ground and runoff water impacts, if
any: moss Ica iqP Ssfe�q t�
4. Plants
a. Check or circle types of vegetation found on the site:
deciduous trees: alder, maple, aspen, other
!/ evergreen trees: fir, cedar, pine, other
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grass
pasture
crop or grain
wet soil plants: cattail, buttercup,bulrush, skunk cabbage,
other
water plants: water 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 affected
geographic area.
d. Proposed landscaping, use of native plants, or other measures to preserve or
enhance vegetation on the affected geographic are`a�,, if any:
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5. Animals
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a. List any birds or animals which have been observed on or near the affected
geographic area or are known to be on or near the affected geographic area:
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Birds:
Mammals:
Fish:
b. List any threatened or endangered species known to be on or near the affected
geographic area: 11/n
C. Is the affected geographic area part of a migration route? If so, explain.
d. Proposed measures to preserve or enhance wildlife, if any:
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6. Energy and Natural Resources
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a. What kinds of energy(electric,natural gas, oil, wood, stove, solar) will be used to
meet the completed project's energy needs? Describe whether it will be used for
heating, manufacturing,etc. -y
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b. Would your project affect the potential use of solar energy by adjacent properties?
If so, generally describe. NC)
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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:
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7. Environmental Health
a. Are there any environmental health hazards, including exposure to toxic chemicals,
risk of fire and explosion, spill,or hazardous waste that could occur as a result of
this proposal? List other proposed measures to reduce or control energy impacts, if
any:
(1) Describe special emergency services that might be required.
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(2) Proposed measures to reduce or control environmental health hazards, if
any:
b. Noise
(1) What types of noise exist in the area which may affect your project(for
example: traffic, equipment, operation, other)?
(2) What types and levels of noise would be created by or associated with the
project on a short-term 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:
8. Land and Shoreline Use
a. What is the current use of the site and adjacent properties?
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b. Has the site been used for agriculture? If so, describe.
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C. Describe any structures on the site. ��
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d. Will any structures be demolished? If so, what? U
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e. What is the current zoning classification of the site? _
f. What is the current comprehensive plan designation of the site?
g. If applicable, what is the current shoreline master program designation of the site?
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h. Has any part of the site been classified an"environmentally sensitive" area? If so,
specify. tu-�y�„�y�}
i. Approximately how many people would reside or work in the completed project?
j. Approximately how
��m77 any people would the completed project displace?
k. Proposed measures to avoid or reduce displacement impacts, if any?
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1. Proposed measures to ensure the proposal is compatible with existing and projected
land uses and plans, if any:
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9. Housin
a. Approximat how many units would be provided, if any? Indicate whether high,
middle or low-income housin .
b. Approximately how many units, if any, would be eliminated? Indicate.whether
high,middle, or low-income housing.
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C. Proposed measures to reduce or control housing impacts, if any: _
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10. Aesthetics
a. What is the tallest height of any proposed structure(s), not including antennas; what
is the principal building material(s)proposed?
b. What views in the immediate vicinity would be altered or obstructed?
C. Proposed measures to reduce or control aesthetic impacts, if any:
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11. bight and Glare
a. What type of light or glare will the proposal produce? What time of day would it
mainly occur? NOA)JE
b. Could light or glare from the finished project be a safety hazard or interfere with
views?
C. What existing off-site sources of light or glare may affect your proposal?
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d. Proposed measures to reduce or control light and glare impacts, if any?
12. Recreation
a. What designated and informal recreational opportunities are in the immediate
vicinity?
b. Would the proposed proposal displace any existing recreational uses? If so,
describe?
C. Proposed measures to reduce or control impacts on recreation, including recreation
opportunities to be provided by the proposal or applicant, if any?
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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 highways serving the site and describe proposed access
to the existing street system. Show on site plans, if any.
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b. Is site currently served by public transit? If not, what is the approximate distance to
the nearest transit stop?
C. How many parking spaces would the completed project have? How many would
the project eliminate?
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). �U
e. Will the project use(or occur in the immediate vicinity of) water, rail, or air
transportation? If so, generally describe.
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f. How many vehicular trips per day would be generated by the completed proposal?
If know, indicate when peak volumes would occur.
g. Proposed measures to reduce or control transportation impacts, if any:
15. Public Services
a. Would the proposal result in an increased need for public services (for example:
fire protection, police protection,health care, schools, other)? If so, generally
describe. N O
b. Proposed measures to reduce or control direct impacts on public services, if any.
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16. Utilities
a. Circle utilities currently available at the site: a trici atural water refuse
ervic�n sanitary sewe eptic system, other.
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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 might be needed.
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C. SIGNATURE
The above answers are true and complete to the best of my knowledge. I understand that the lead
agency is relying on them to make its decision.
9^�0 -99
Si Date Submitted
D. SUPPLEMENTAL SHEET FOR NONPROJECT ACTIONS
I. How would the proposal be likely to increase discharge to water, emissions to air,
production, storage or release of toxic of hazardous substances or production of noise?
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Proposed measures to avoid or reduce such increases are:
2. How would the proposal be likely to affect plants, animals, fish or marine life?
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Proposed measures to protect or conserve plants, animals, fish or marine life are:
3. How would the proposal be likely to deplete energy or natural resources?
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Proposed measures to protect or conserve energy and natural resources are:
4. How would the proposal be likely to use or affect environmentally sensitive areas or areas
designated(or eligible under study) for governmental protection; such as parks,wilderness,
wild and scenic rivers,threatened or endangered species habitat, historic or cultural sites,
wetlands, floodplains or prime farmlands?
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Proposed measures to protect such resources or to avoid or reduce impacts are:
5. How would the proposal be likely to affect land and shoreline use, including whether it
would allow or encourage land or shoreline uses incompatible with existing plans?
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Proposed measures to avoid or reduce shoreline and land use impacts are:
6. How would the proposal be likely to increase demands on transportation or public services
and utilities?
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Proposed measures to reduce or respond to such demand(s) are:
7. Identify, if possible, whether the proposal may conflict with local, state or federal laws or
requirements for the protection of the envir nment.
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