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City of Portage, Wisconsin
Environmental Assessment Checklist
Ref. Sec. 70-3(2)(c) Code of Ordinances
Part 1 - Project Information. The applicant 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 City; attach additional pages as necessary to supplement any item.
Part 1 - Project and Sponsor Information
Name of Action or Project:
Project Location (describe, and attach a location map):
Brief Description of Proposed Action:
Name of Applicant or Sponsor:
Telephone:
E-Mail:
Address:
City/PO:
State:
Zip Code:
1. Does the proposed action require a permit, approval or funding from any other governmental Agency?
If Yes, list agency(s) name and permit or approval:
YES
2.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?
acres
3. Check all land uses that occur on, adjoining and near the proposed action.
Urban
Forest
Parkland
Rural (non-agriculture)
Agriculture
Industrial
Aquatic
Commercial
Other
(specify):_____________
Residential (suburban)
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4. Is the proposed action,
a. A permitted use under the zoning regulations?
b. Consistent with the adopted comprehensive plan?
NO
YES
N/A
5. Is the proposed action consistent with the predominant character of the existing built or natural
landscape?
NO
YES
6. Is the site of the proposed action located in, or does it adjoin, a sensitive area?
If Yes, identify:
NO
YES
7. a. Will the proposed action result in a substantial increase in traffic above present levels?
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?
NO
YES
8. Will the proposed action connect to an existing public/private water supply?
If No, describe method for providing potable water:
NO
YES
9. Will the proposed action connect to existing wastewater utilities?
If No, describe method for providing wastewater treatment:
NO
YES
10. a. Does the site contain a structure that is listed on either the State or National Register of Historic
Places?
b. Is the proposed action located in an archeological sensitive area?
NO
YES
11. a. Does any portion of the site of the proposed action, or lands adjoining the proposed action, contain
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?
If Yes, identify the wetland or waterbody and extent of alterations in square feet or acres:
_______________________________________________________________________________________
NO
YES
12. Identify the typical habitat types that occur on, or are likely to be found on the project site. Check all that apply:
Shoreline Forest Agricultural/grasslands Early mid-successional
Wetland Urban Suburban
13. Does the site of the proposed action contain any species of animal, or associated habitats, listed
by the State or Federal government as threatened or endangered?
NO
YES
14. Is the project site located in the 100 year flood plain?
NO
YES
15. Will the proposed action create storm water discharge, either from point or non-point sources?
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)?
NO YES
If Yes, briefly describe:
_________________________________________________________________________________________
_____________________________________________________________________________
____________
NO
YES
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16. Does the proposed action include construction or other activities that result in the impoundment of
water or other liquids (e.g. retention pond, waste lagoon, dam)?
If Yes, explain purpose and size:
NO
YES
17. Has the site of the proposed action or an adjoining property been the location of an active or closed
solid waste management facility?
If Yes, describe:
NO
YES
18. Has the site of the proposed action or an adjoining property been the subject of remediation (ongoing or
completed) for hazardous waste?
If Yes, describe:
NO
YES
I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY
KNOWLEDGE
Applicant/sponsor name: Date:
Signature:
Part 2 - Impact Assessment. The City is responsible for the completion of Part 2. Answer all of the following questions
in Part 2 using the information contained in Part 1 and other materials submitted by the applicant or otherwise available to
the reviewer. When answering the questions the reviewer should be guided by the concept “Have my responses been
reasonable considering the scale and context of the proposed action?
No, or
small
impact
may
occur
Moderate
to large
impact
may
occur
1. Will the proposed action create a material conflict with an adopted land use plan or zoning
regulations?
2. Will the proposed action result in a change in the use or intensity of use of land?
3. Will the proposed action impair the character or quality of the existing community?
4. Will the proposed action have an impact on the environmental characteristics of a sensitive
environmental area?
5. Will the proposed action result in an adverse change in the existing level of traffic or
affect existing infrastructure for mass transit, biking or walkway?
6. Will the proposed action impact existing:
a. public / private water supplies?
b. public / private wastewater treatment utilities?
7. Will the proposed action impair the character or quality of important historic, archaeological,
architectural or aesthetic resources?
8. Will the proposed action result in an adverse change to natural resources (e.g., wetlands,
waterbodies, groundwater, air quality, flora and fauna)?
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No, or
small
impact
may
occur
Moderate
to large
impact
may
occur
9. Will the proposed action result in an increase in the potential for erosion, flooding or drainage
problems?
10. Will the proposed action create a hazard to environmental resources or human health?
Part 3 - Determination of significance. The City is responsible for the completion of Part 3. For every question in Part
2 that was answered “moderate to large impact may occur”, or if there is a need to explain why a particular element of the
proposed action may or will not result in a significant adverse environmental impact, please complete Part 3. Part 3 should,
in sufficient detail, identify the impact, including any measures or design elements that have been included by applicant to
avoid or reduce impacts. Part 3 should also explain how the City determined that the impact may or will not be significant.
Each potential impact should be assessed considering its setting, probability of occurring, duration, irreversibility,
geographic scope and magnitude. Also consider the potential for short-term, long-term and cumulative impacts.
Check this box if you have determined, based on the information and analysis above, and any supporting documentation,
that the proposed action may result in one or more potentially large or significant adverse impacts and a public hearing is
required.
Check this box if you have determined, based on the information and analysis above, and any supporting documentation,
that the proposed action will not result in any significant adverse environmental impacts.
City Engineer
Date
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