Siskiyou — Environmental Questionnaire, Handwritten

Source: https://www.siskiyoucounty.gov/sites/default/files/fileattachments/community_development/page/2431/pln-20110726_environmentalquestionnairehandwritten.pdf

ENVIRONMENTAL QUESTIONNAIRE

SISKIYOU COUNTY PLANNING DIVISION 806 South Main Street, Yreka CA 96097 Phone: (530) 841-2100 / Fax: (530) 841-4076

Answer all questions that are applicable.

Please note: If you are applying for a Conditional Use Permit, Subdivision over 4 lots, General Plan amendment, Specific Plan and/or Rezoning, it is advised that you schedule a pre-development meeting before filling out this Environmental Questionnaire. Please contact the Planning Department at 530-841-2100 for scheduling.

I. GENERAL

a) Project Title (same as on application):___________________________________________________

b) List All Related Applications: _________________________________________________________

c) Property Owner:

Name (Pls. Print): ______Telephone:

Company: ___________________________________ E-mail:________________________________

Address: _________________________________City: _____________________ Zip: ___________

d) Applicant (if different than owner):

Name (Pls. Print): ______Telephone:

Company: ___________________________________ E-mail:________________________________

Address: _________________________________City: ____________________ Zip: ____________

e) Address or Location of Property: ______________________________________________________

f) Assessor’s Parcel Number(s): ________________________________________________________

g) Site Area (acres/sq. ft.): _____________________________________________________________

h) Current Zoning: __________________________ Proposed Zoning: ___________________________

i) Existing Use of Property: ____________________________________________________________

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j) Describe existing uses and facilities onsite (buildings, wells, septic systems, parking, etc):_____________

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k) Description of Proposal:

l) Description of Surroundings:

m) Indicate all historic uses of the property to its first known use and show areas of such use on site plan (ie. animal enclosures, livestock dipping areas, carcass burial locations, chemical mixing structures, clandestine drug labs or dumpsites, fuel tanks, crop areas, mining shafts, buildings, processing areas, storage, hazardous waste, spoils piles, etc.):

1. Residential uses? yes no

If yes, describe uses: ______________________________________________________________________

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2. Commercial uses? yes no

If yes, describe uses: ______________________________________________________________________

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3. Mining uses? yes no

If yes, describe uses:______________________________________________________________________

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4. Physical hazards (i.e. mine audit, air shaft, etc)? yes no

If yes, describe uses: ______________________________________________________________________

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5. Is any portion of the site under a Williamson Act contract? yes no

If yes, indicate contract name and number:_____________________________________________________

II. AESTHETICS -- Would the project:

a) Create a change to the existing condition of land (including, but not limited to altering views of
existing trees, topographic features, or existing buildings) or add new structures which could impact
existing scenic views? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

b) Create a new source of substantial light or glare, which would adversely affect day or nighttime
views in the area? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

III. AGRICULTURE AND FOREST RESOURCES -- Would the project:

a) Convert or Result in the conversion of Prime Farmland, Unique Farmland, or Farmland of
Statewide Importance to non-agricultural use? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

b) Conflict with existing zoning for agricultural use, or a Williamson Act contract? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

IV. AIR QUALITY – Specific air quality and/or greenhouse gas emission studies may be required in order to fully evaluate your projects potential air quality impacts. It is suggested that applicants with residential projects containing 20 or more units, industrial, or commercial projects discuss this requirement with the Planning Department prior to filing a formal application.

a) Are there any sources of air pollution within the vicinity of the project? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

b) During the construction or at implementation of the project, would there be sources of air pollutants in terms of vehicle, mobile, a n d stationary sources present? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

c) Would the project expose sensitive receptors to pollutant concentrations (list all sensitive receptors
within one quarter mile of the project - ie. schools, hospitals, etc)? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

d) Would the project create objectionable odors affecting a substantial number of people?
yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

e) Would the project generate greenhouse gas emissions, either directly or indirectly, that may have a
significant impact on the environment?? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

f) Would the project conflict with an applicable plan, policy or regulation adopted for the purpose of
reducing the emissions of greenhouse gases? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

V. VEGETATION AND WILDLIFE: All projects disturbing wetlands and streams may require consultation or permits from the U.S. Army Corps of Engineers, California Department of Fish and Game, U.S. Fish and Wildlife Service, National Marine Fisheries Service, and/or the Central Valley Regional Water Quality Control Board.

a) Please estimate the percentage of all existing trees that would be removed by the project as proposed

b) Have any biological surveys been conducted on the property? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

c) Are you aware of any known endangered species of plants or animals found on the project site or in the near vicinity of the project area? yes no

If yes, describe: _________________________________________________________________________

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d) Describe what changes to the existing vegetative communities the project will cause as proposed: ______

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VI. ARCHAEOLOGY/CULTURAL RESOURCES

a) Are there any historical, archaeological or culturally significant features on the site (i.e. old
foundations, structures, Native American habitation sites, etc.)? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

b) Are any changes proposed to any existing structure that is over 50 years old? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

VII. GEOLOGY & SOILS

a) Does the property have or have you observed any building or soil settlement, landslides, slumps, faults,
steep areas, rock falls, mud flows, avalanches or other natural hazards on this property or in the nearby
surrounding area? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

b) How many cubic yards of material will be moved onsite?___________________________________

c) How many cubic yards of material will be imported?_______________________________________

d) How many cubic yards of material will be exported?_______________________________________

e) Describe material sources or disposal sites, transport methods and haul routes___________________

____________________________________________________________________________________

f) What is the maximum proposed height and slope of any excavation/cut? ___________________________

g) What is the maximum proposed height and slope of any fill?

h) Are retaining walls proposed? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

i) Is there a potential for any blasting during construction? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

j) How much of the area is to be disturbed by grading activities?

VIII. HAZARDOUS MATERIALS - “Hazardous materials” include, but are not limited to, hazardous substances, hazardous waste, or any material which a handler or the administering agency has a reasonable basis for believing that it would be injurious to the health and safety of persons or harmful to the environment if released into the workplace or the environment (i.e. oils, lubricants, and fuels).

a) Has the site ever stored or used hazardous materials, including pesticides and herbicides? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

b) Are these materials stored in underground tanks? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

c.) Will the proposed project involve the handling, storage or transportation of hazardous materials?
yes no. If yes, will it involve the handling, storage, or transportation at any one time of more
than 55 gallons, 500 pounds, or 200 cubic feet (at standard temperature and pressure) of a product or
formulation containing hazardous materials? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

a) Is there a body of water (lake, pond, stream, canal, etc.) within, on, or near the boundaries of the property? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

b) If yes, would water be diverted from or into this water body? yes no

If yes, does applicant have an appropriative or riparian water right? yes no

c) Would any run-off or other water discharge from the project enter any offsite canal/stream or watershed
drainage? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

d.) Would the project result in the physical alteration of a body of water, drainage channel or drainage
pattern? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

e.) Are any areas of the property within the 100-year flood plain or subject to flooding or inundation?
yes no

If yes, describe and accurately identify the location on the site plan:________________________________

______________________________________________________________________________________

f) Are any improvements (streets, building sites, earthwork, etc) proposed within the limits of the 100-year
floodplain? yes no

If yes, accurately identify the location of the future, fully developed, unmitigated 100-year floodplain on the
site plan: ______________________________________________________________________________

______________________________________________________________________________________

g) Are any Best Management Practices (BMPs) proposed yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

a) Would the project physically divide an established community? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

b) Would the project conflict with any applicable land use plan, policy, or regulation of an agency with
jurisdiction over the project (including, but not limited to the general plan, specific plan, local coastal
program, or zoning ordinance) adopted for the purpose of avoiding or mitigating an environmental effect?
yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

c) Would the project Conflict with any applicable habitat conservation plan or natural community
conservation plan? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

d) Would the project create job opportunities? yes no

Please describe: _________________________________________________________________________

______________________________________________________________________________________

e) Would the project destroy job opportunities? yes no

Please describe: _________________________________________________________________________

______________________________________________________________________________________

f) Will the proposed development displace any currently productive use, including agricultural livestock
grazing? yes no

Please describe: _________________________________________________________________________

______________________________________________________________________________________

a) Will the project result in the loss of availability of a known mineral resource that would be of value to the region and the residents of the state? Does the property have or have you observed any building or soil settlement, landslides, slumps, faults, steep areas, rock falls, mud flows, avalanches or other natural hazards on this property or in the nearby surrounding area? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

b) Will the project result in the loss of availability of a locally-important mineral resource recovery site
delineated on a local general plan, specific plan or other land use plan? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

XII. NOISE: Project sites near a major source of noise, and projects which will result in increased noise, may require a detailed noise study prior to environmental determination. Please contact the Planning Department for more information.

a) Is the project near a major source of noise? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

b) What noise would result from this project, both during and after construction?

Please describe: _________________________________________________________________________

______________________________________________________________________________________

c) If noise attenuation measures (ie. berms, walls, special construction) are proposed, please attach noise
study, describe measures and include on the site plan and in cross-sectional details.

Please describe: _________________________________________________________________________

______________________________________________________________________________________

XIII. POPULATION AND HOUSING

a) Will the project cause a substantial population growth in an area, either directly (for example, by
proposing new homes and businesses) or indirectly (for example, through extension of roads or other
infrastructure)? yes no

If yes, describe: _________________________________________________________________________

______________________________________________________________________________________

b) Will the project cause the removal of existing homes or the displacement of people? yes no

If yes, describe: _________________________________________________________________________

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XIV. FIRE PROTECTION

a) How distant are the nearest fire protection facilities?

b) Describe the source and location of the nearest emergency source of water for fire protection:

c) Are there offsite access limitations that might limit fire truck accessibility (ie. steep grades, poor road
alignment or surfacing, substandard bridges, etc.)? yes no

Please describe: _________________________________________________________________________

______________________________________________________________________________________

XV. PARKS & RECREATION (for residential projects)

a) How close is the project to the nearest public park or recreation area? ____________________________

Name the area:_________________________________________________________________________

b) Describe any onsite recreational facilities proposed as part of the project:________________________

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XVI. TRANSPORTATION/CIRCULATION

a) Does the proposed project front on a County road or State Highway? yes no

Please describe: _________________________________________________________________________

______________________________________________________________________________________

If no, what is the name of the private access road and nearest cross-street?

b) Would any permanent non-auto traffic result from the project (trucks, trains, etc.)? yes no

If yes, please describe:_____________________________________________________________________

_______________________________________________________________________________________

c) Are any new roads proposed? yes no

If yes, please describe the typical street section(s):_______________________________________________

_______________________________________________________________________________________

d) Will new roadway/driveway access onto County roads be constructed with the project? yes no

If yes, please describe _____________________________________________________________________

_______________________________________________________________________________________

e) Describe any proposed improvements to County roads and/or State Highways (i.e. frontage
improvements, bike lanes, curb, sidewalk): ____________________________________________________

_______________________________________________________________________________________

f) How much additional traffic is the project expected to generate? What are the expected peak
hours of traffic to be caused by the development (i.e. Churches on Sundays, 8:00am-1:00pm;
Offices on Mondays through Fridays, 8:00-9:00am, and 4:00-6:00pm)?

_______________________________________________________________________________

_______________________________________________________________________________

XVII. WATER SUPPLY

a) Define existing water source and its location on-site:___________________________________________

_______________________________________________________________________________________

b) Define any new water source :_____________________________________________________________

_______________________________________________________________________________________

c) Will there be public water supply for domestic use? yes no

If yes, please describe _____________________________________________________________________

_______________________________________________________________________________________

d) Will the project potentially impact the surrounding area’s use of agricultural water? yes no

If yes, please describe _____________________________________________________________________

_______________________________________________________________________________________

a) How is sewage presently disposed of at the site?______________________________________________

_______________________________________________________________________________________

b) Are there any changes to or new sewage disposal proposed? ____________________________________

_______________________________________________________________________________________

c) Is there a public sewage disposal system? yes no

If yes, please describe _____________________________________________________________________

_______________________________________________________________________________________

d) During the wettest time of the year, is the groundwater level less than 8 feet below the surface of the
ground onsite? yes no

If yes, please describe _____________________________________________________________________

_______________________________________________________________________________________

XIX. SOLID WASTE

a) What types of solid waste will be produced?________________________________________________

b) How much? _________________________________________________________________________

c) How will it be disposed of?_____________________________________________________________

XX. CERTIFICATION

I hereby certify that the statements furnished above and in the attached exhibits present the data and
information required for this initial evaluation to the best of my ability, and that the facts, statements, and
information presented are true and correct to the best of my knowledge and belief.

First Name:______________________________________ Last Name:_____________________________

Signature:_______________________________________ Date:________________________________

Work Phone:( )__Cell Phone:( )

Email Address:__________________________________________________________________________