Loading...
HomeMy WebLinkAboutSHX2008-00017; SEP2008-00026;; JARPA - SHX Permit / Conditions STA MASON COUNTY �P C DEPARTMENT OF COMMUNITY DEVELOPMENT o a U r= Planning Division o T z P O Box 279, Shelton,WA 98584 Z�of N Y ti (360)427-9670 1864 Exemption from Shoreline Management Act Case No.: SHX2008-00017 Substantial Development Permit Requirement The Proposal By: MIKE&JULI PAVLIK TO BE KEPT IN THE 5015 E VIA NONTAYA DRIVE DESERT RIDGE,AZ 85054 PARCEL FILE To undertake the following development: Shoreline exemption for ATF bulkhead and concrete beach access stairs repair i i Within Hood Canal and/or its associated wetlands is exempt from the requirement of substantial development because the development is categorized under WAC 173-27-040(2)as being category li B-normal maintenance Please contact Tammi Wright at ext 295 if you have any questions. Issued: 3/24/2008 ���' Expires: 3/24/2010 Authorized Local Government Official i �I cc: APPLICANT WDFW USACOE WDOE TRIBAL COUNCIL M�rglc. Sc�.ro..4-� 2 1889 STATE OF WASHINGTON DEPARTMENT OF ECOLOGY PO Box 47775 • Olympia, Washington 98504-7775 • (360) 407-6300 March 24,2008 TO BE KEPT IN THE PARCEL FILEZ�0i- -0o6 +� Ms.Grace Miller Your address Mason County is in the Department of Community Development Planning Division Skokomish- PO Box 279 Dosewallips Shelton,WA 98584 watershed Dear Ms.Miller: Thank you for the opportunity to comment on the mitigated determination of nonsignificance for the Pavlik(after-the-fact)Bulkhead and Stairs Repair project(SEP2008-00026)located at 25680 North US Highway 101 in Hoodsport as proposed by Mike and Julie Pavlik. The Department of Ecology(Ecology) reviewed the environmental checklist and has the following comment(s): WATER QUALITY: Roberta Woods(360)407-6269 Any discharge of sediment-laden runoff or other pollutants to waters of the state is in violation of Chapter 90.48 RCW,Water Pollution Control,and WAC 173-201A,Water Quality Standards for Surface Waters of the State of Washington, and is subject to enforcement action. Erosion control measures must be in place prior to any clearing, grading,or construction. These control measures must be effective to prevent stormwater runoff from carrying soil and other pollutants into surface water or storm drains that lead to waters of the state. Sand, silt,clay particles, and soil will damage aquatic habitat and are considered to be pollutants. Proper disposal of construction debris must be on land in such a manner that debris cannot enter the Hood Canal or cause water quality degradation of state waters. Fresh uncured concrete in direct contact with the water is toxic to aquatic life. All concrete shall be poured in the dry and allowed to cure a minimum of seven(7)days before contact with water. Ecology's comments are based upon information provided by the lead agency. As such,they do not constitute an exhaustive list of the various authorizations that must be obtained or legal requirements that must be fulfilled in order to carry out the proposed action. If you have any questions or would like to respond to these comments please contact the appropriate reviewing staff listed above. Department of Ecology Southwest Regional Office (AW: 08-1674) cc: Neil Caudill,WQ Roberta Woods,WQ Mike and Julie Pavlik(Applicant) Steve Merrill,Jesfield Construction Company(Contact) e 10 I 1 � , r I 4 I i � I t I • t t C0rJ42 L 1 �• - 1 _. 9'7(14+T: .: S1",i u Z4t -, ipt-4 Les - I d r 1 I -v j I , • 1 ' n� - tt .... APPROVED I : MASON COUNTY-ROD PLANNING SITE PLAN REQUIkED TO SE ON SI$E - CTTO ; - ` � ��Ia�v�ES s��J� �3�bva Tr LJ fate1310 I/ y-H, CAD " leg►` ip..a 9 4 t T , I e FR i N.u i - A # - :- , : I r d y � Y }• S i, f .r-*, A I� Y • i • 1 L lik � l r a - 1 • u+� .#. - , �•: 7vik' Qiv- 'fir ��"r • ,'��. '• i' �' alp � ��� w,.�' ,� "��•. __ 't n Z-_ ill '.1 � t . ~ 1 � ` s. y• _ a r �J- x i Tt l iY ` t K d � i i• 'V I T_3 Rlow 1 IrA,4. �r�` Ali .srAv MASON COUNTY BPS c DEPARTMENT OF COMMUNITY DEVELOPMENT o n°u �= Planning Division y N T �? P O Box 279, Shelton, WA 98584 Y (360)427-9670 1864 MITIGATED DETERMINATION OF NONSIGNIFICANCE (WAC 197-11-350) SEP2008-00026 Description of Proposal: SEPA for ATF bulkhead and concrete stairs to beach repair Proponent: MIKE & JULIE PAVLIK TRUSTEES Site Address(If Assigned): 25680 N US HIGHWAY 101 HOODSPORT Directions to Site: North 101 to address E KEPT INTHE �: Parcel Number: 422015200014 A R C E L FILE Legal Description: CANAL BEACH TRACTS TR 1 Lead Agency: Mason County The Lead Agency for this proposal has determined that it does not have a probable significant adverse impact on the environment. An Environmental Impact Statement (EIS) is not required under RCW 43.21 C.030(2)(c). This decision was made after review of a completed Environmental Checklist and other information on file with the Lead Agency. This information is available to the public upon request. MITIGATED MEASURES ARE ATTACHED. Please contact Tammi Wright at ext. 295 with any questions. This DNS is issued under WAC 197-11-340(2). The Lead Agency will not act on this proposal for 14 days from the date shown below, when the determination is final. Comments must be submitted to Dept. of Community Development, P.O. Box 279, Shelton WA 98584 by 3/24/2008. Appeal of this determination must be filed within a 14-day period following this final determination date, per Mason County i Code Chapter 15.11 Appeals. i. ll,M) Authorized Local Government Official Date ii p { I 1 's 9i 1 9 MASON CO. ENVIROMENTAL CHECKLIST A. BACKGROUND 1 Q-ZZD� )2000 ) y- 1. Name of proposed project, if applicable: IVEU L S va-t IL YZ - BELFAIR .O flCE 2. Name of applicant: : , >�t 4 J Pq ,J LA K 3. Address and phone number of applicant and contact person: 0 i Kt 4 St/w t PEA V Li K t?�+.17J�c;— s;-�vC r✓�E�R��� ,5- 015' F WA ►-10r/TAYA aziatr -3r,t,-Lp Cowsr.. Co, Pf"56-1 —, laig>&E7 1 A-*a $Sos,+ PO Box 15'y-0 4. Date c ecklist prepared: LtVo - 2-4tt - y..,S,6 ,vk 7- o INL4-Yni, . 19W5y- Z1l fo-00 360 • Z75. 6 b% 5. Agency requesting checklist: WlR-S��l Ca��1-rY 6. Proposed timing or schedule (including.phasing, if applicable): A%i Uv,�-i- Z L b 7. Do you have any plans for.future expansion; or further activity related to or connected with this proposal: If yes, explain. 8. List any environmental information you know about that has been prepared, or will be prepared, directly related to this proposal. I I 9. Do you know whether applications are pending for governmental approvals of other proposals directly affecting the property covered by your proposal? If yes, explain. i 10. List any government approvals or permits that will be needed for your proposal, if known. WI��� C�,1.Ti C— �koR.�'t.+�.1� G,c r�n�i1J,J '� i3v 1 L� ✓� t�tXw�l i H PA i e. Describe the purpose, type, and approximate quantities of any filling or grading proposed. Indicate source of fill rE f. Could erosion occur as a result of clearing, construction, or use: If so, generally describe. Yv � g. About what percent of the site will be covered with impervious surfaces after project constructions (for example, asphalt or buildings)? /✓� C It4Prr/Cr1:-� h. Proposed measures to reduce or control erosion, or other impacts to the earth, if any: 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. A/ () riF b. Are there any off-site sources of emissions or odor that may affect your proposal? If so, generally describe. Mason County Environmental Checklist Page 3 . 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. 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. tj0 2) Describe waste material that will be discharged into the ground from septic 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 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 flow into other waters? If so, describe. �Jo rJl= 2) Could waste materials enter ground or surface waters: If so, generally describe. t�t7 Page 5 Mason County Enviromnental Checklist 5. ANIMALS 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: er a on_gbi� other Mammals: deer, bear, elk, beaver, other Fish: bass, al o, t ou erring, a Ifis other b. List any threatened or endangered species known to be on or near the site. PJ& -TJ CH tj0 off. C. Is the site part of a migration route? if so, explain. N0T- 4--- d 0,-J10 d. Proposed measures to preserve or enhance wildlife, if any: 6. ENERGY AND NATURAL RESOURCES: 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. b. Would your project affect the potential use of solar energy by adjacent properties: If so, generally describe. W � t , 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: A)0rJc Mason County Environmental Checklist Page 7 b. Has the Jsite been used for agriculture? If so, describe. C. Describe any structures on the site. `jV n1(rt..r= 6AM I L-%,` H oM L d. Will any structures be demolished? If so, what? Ivy 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? l��l�rJ 12t�1�t1+✓T I �t-- h. Has any part of the site been classified as an "environmentally sensitive" area? If so, specify. N LTI— Ic n/oLj YJ i. Approximately how many people would reside or work in the completed project? ICJ C11 A d&- j. Approximately how many people would the completed project displace? NO CMA rv(,t / O✓o,) k. Proposed measures to avoid or reduce displacement impacts, if any: Mason County Environmental Checklist Page 9 11. LIGHT AND GLARE a. What type of light or glare will the proposal produce? What time of day would it mainly occur? FJ 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: N0rJC d. Proposed measures to reduce or control light and glare impacts, if any:. A/LD dL 12. RECREATION: a. What designated and informal recreational opportunities are in the immediate vicinity? tv A-T�--Yt- (LtZ(Z t'N" 6MA-L " A•cTi ✓i T- c-- b. Would the proposed project displace any existing recreational uses? If so, describe. Ivy C. Proposed measures to reduce or control impacts on recreation, including recreation opportunities to be provided by the project or applicant, if any: Mason County Environmental Checklist Page 11 e. Will the project use (or occur in the immediate vicinity of)water, rail, or air transportation? If so, generally describe. In/AIICi2- 7Y21 AJ5-?O can i ,J o,J k D o iJ CA b)41 f. How many vehicular trips per day would be generated by the completdd project: If known, indicate when peak volumes would occur. 1�J0 CN/i L/GE-S g. Proposed measures to reduce or control transportation impacts, if any: NO AI l� 15. PUBLIC SERVICES: a. Would the project result in an increased need for public service (for example: fire protection, police protection, health care, schools, other)? If so, generally describe: b. Proposed measures to reduce or control direct impacts on public services, if any: �L) Mason County Environmental Checklist Page 13 ESA LISTED SALMONIDS CHECKLIST Applicant Information Project Information Name MIKE I. Sv La E- IAA VL-)K Name PA-,)uK BUt.IGH L-Yw- P-6l'A i 2 Phone "D — 2.5y- - +6-1y 0 Location ULSO US, NooAVa.4k i,wA Description 9�bS Ex,sr,.J C- Ro c 13�L-K H eve 4, Co.JC Qa i�E' STAB►tt S This worksheet was designed to help project proponents, and government agencies, identify when a project needs further analysis regarding adverse effects on ESA (Endangered Species Act) listed salmonids. Salmonids are salmon, trout and chars, e.g. bull trout. For our purposes, "ESA Listed Salmonids" is defined as fish species listed as endangered, threatened or being considered for listing. If ESA listed species are present or ever were present in the water shed where your project will be located, your project has the potential for affecting them, and you need to comply with the ESA. The questions in this section will help determine if the ESA listings will impact your project. The Fish Program Manager at the appropriate Department of Fish and Wildlife (DFW) regional office can provide information for the following two questions. 1. Are ESA listed salmo ids currently present in the watershed in which your project will be located? YES NO Please describe. 2. Has the e ever been an ESA listed salmonid stock present in this watershed? YES NO Uncertain Please describe. If you answered "yes"to either of the above questions, you should complete the remainder of this checklist. April 2003 - 1 - t FISH MIGRATION: The following questions will help determine if this project could interfere with migration of adult and juvenile fish. Both increases and decreases in water flows can affect fish migration. 1. Does the project require the withdrawal of a. Surface water? YES NO Amount Name of surface water body b. Ground water? YES NO Amount From where Depth of well 2. Will any water be rerouted: YES NO If yes, will this require a channel change? 3. Will there be retention or detention ponds? YES NO If yes, will this be an infiltration pond or a surface discharge to either a municipal storm water system or a surface water body? If to a surface water discharge,please give the name of the waterbody. 4. Will this project require the building of new roads?. YES NO Increased road mileage may affect the timing of water reaching a stream and may impact fish habitat. 5. Are culverts proposed as part of this project? YES NO X\ 6. Will topography ch ges affect the duration/direction of runoff flows? YES NO If yes, describe the changes. 7. Will the project involve any reduction of the floodway or floodplain by filling or other partial blockage of flows? YES NO If yes, how will the loss of flood storage be mitigated by your project? -3 - VEGETATION: The following questions are designed to determine if the project will affect riparian vegetation,thereby, adversely impacting salmon. 1. Will the project involve the r moval of any vegetation from the stream banks: YES NO If yes, please describe the existing conditions, and the amount and type of vegetation to be removed. 2. If any vegetation is removed,do you plan to re-plant? YES NO If yes,what types of plants will you use? -5- Cob 1-1 AGENCY USE ONLY, Agency Reference#: Date Received: Circulated by: (local govL or agency),< JOINT AQUATIC RESOURCES PERMIT APPLICATION FOR JARPA) (for use in Washington State) FEB 2 8 2008 M PLEASE TYPE OR PRINT IN BLACK INK. T FAIR OFFICE O FILL IN ELECTRONICALLY, USE F11 TO MOVE THROUGH THE F01� ❑ Application for a Fish Habitat Enhancement Project per requirements of RCW 77..55.290. You must submit a copy of this completed JARPA application form and the(Fish Habitat Enhancement JARPA Addition)to your local Government Planning Department and Washington Department of Fish &Wildlife Area Habitat Biologist on the same day. NOTE: LOCAL GOVERNMENTS—You must submit any comments on these projects to WDFW within 15 working days. Based on the instructions provided, 1 am sending copies of this application to the following: (check all that apply) �( Local Government for shoreline:[]Substantial Development []Conditional Use []Variance %Exemption ❑Revision ❑Floodplain Management []Critical Areas Ordinance Washington Department of Fish.and Wildlife for HPA(Submit 3 copies to WDFW Region) Washington Department of Ecology for 401 Water Quality Certification(to Regional Office-Federal Permit Unit) ❑ Washington Department of Natural Resources for Aquatic Resources Use Authorization Notification 0 Corps of Engineers for: ❑ Section 404 ❑ Section 10 permit Coast Guard for: ❑ General Bridge Act Permit ❑ Private Aids to Navigation(for non-bridge projects) ❑ For Department of Transportation projects only: This project will be designed to meet conditions of the most current Ecology/Department of Transportation Water Quality Implementing Agreement SECTION A-Use for all permits covered by this application. Be sure to ALSO complete Section C(Signature Block)for all permit applications. 1.APPLICANT /A I KE 4- 7VL4 t PA%,t_I k MAILING ADDRESS 0 15- EE VIA MOO IAA/ A DV-t yr .Drrs�- 2 I D(rc , A:6 4 5-0,5 {- WORK PHONE7"'L ADDRESS HOME PHONE FAX# +10-7-1%+ - 4-6-so +ip - Z56L+ - Lwscl If an agent is acting for the applicant during the permit process,complete#2. Be sure agent signs Section C(Signature Block) for all permit applications 2.AUTHORIZED AGENT �ESF� t,p C�rJS (Lv c;t0� CO. PA kn1Y MAILING ADDRESS M &Y 1 S L-LYtJ , WA a C6524 WORK PHONE V 1J E-MAIL ADDRESS HOME PHONE FAX# 360 -Z75- 66S4 11;tAiFIZtt11-L LE RC-IT .00r► 3(x�_Z7S-3�SJ 3. Relationship of applicant to property: OWNER ❑ PURCHASER ❑ LESSEE ❑ I f 4. Name, address and phone number of property owner(s)if other than applicant: 5. Location (street address,including city,county and zip code,where proposed activity exists or will occur) 2-5-6-so fj- Nic-"WNq 101 H0oD5i?o2T %WA 155+5 Local government with jurisdiction(city or county) M A 5o y d C O J,N l y Waterbody you are working in VJP—1 Ai. 1(0 lM A R I Ali. Tributary of WRIA# / Is this waterbody on the 303(d)List" YES NO )400 D CIS rJA I— If YES,what parameter(s)? "For 303d List, Shoreline designation UQ bA i\) h_tti)://www.ecv.wa.gov/programstwq/303d/index html Zoning designation . Y,Secron Section Township Range Government Lot SL D 22 y- DNR stream type if known Latitude and Longitude: E+7- t}Z 3 b Z 1J 1 Z3, 1 Z 0126 to Fax Parcel Number �- ECY 070-15(Rev. 11104) JARPA Contact the State of Washington Office of Regulatory Assistance for latest version or call 3601407-7037 or 800/917-0043 1 6. 'Describe the current use of the property,and structures existing on the property. Have you completed any portion of the proposed activity on this property? YES ❑ NO For any portion of the proposed activity already completed on this property,indicate month and year of completion. r-'- 015-OW 4 t_ V 56, Lai T7-I A s/A/&-LE Fro w►I t.Y H O A I E o 1J WOZK Is the property agricultural land? ❑ YES NO Are you a USDA program participant? ❑ YES NO 7a. Describe the proposed work that needs aquatic permits: Complete plans and specifications should be provided for all work waterward of the ordinary high water mark or line,including types of equipment to be used. If applying for a shoreline permit,describe all work within and beyond 200 feet of the ordinary high water mark. If you have provided attached materials to describe your project,you still must summarize the proposed work here. Attach a separate sheet if additional space is needed. �P1�t12-�5r'A$t��2� �Xt sr►in/6- IzocK bvf...Kk E/�a g`( Pu w�P.tr�G- t^��J�c.1r1�;rE brlwEE-N THE ACK5 A#JA O-E-? riQ FX ISTI t✓!r edNtfLE7E" Sf-141t'L5 -m 1146 U4CH ovt( c-.AY1N4- TH6WI w1-rtl NEW, PREPARATION OF DRAWINGS: See sample drawings and guidance for completing the drawings. ONE SET OF ORIGINAL OR GOOD QUALITY REPRODUCIBLE DRAWINGS MUST BE ATr''ACHED. NOTE: Applicants are encouraged to submit photographs of the project site,but these DO NOT substitute for drawings. THE CORPS OF ENGINEERS AND COAST GUARD REQUIRE DRAWINGS ON 8-112 X 11 INCH SHEETS. LARGER DRAWINGS MAYBE REQUIRED BY OTHER AGENCIES. 7b. Describe the purpose of the proposed work and why you want or need to perform it at the site. Please explain any specific needs that have influenced the design. R A-12 t X STr n/G ��K L.t<MIF" 2F CphJC 2ETe S'�t� T'© 7c. Describe the potential impacts to characteristic uses of the water body. These uses may include fish and aquatic life,water quality, water supply,recreation and aesthetics. identify proposed actions to avoid,minimize,and mitigate detrimental impacts and provide proper protection of fish and aquatic life. Identify which guidance documents you have used. Attach a separate sheet if additional space is needed. 1%4l rJlr'A L. -Tv-A PAR c7S. NJ Eo j I t'wt t o/r i jA5 t,S ty Ox) 1-h F OtE:*c f 4 . +L.L- Co IJC 02-eiF W65! 0 J 2.t'D AT- LO L-7 "V 6- 4, WO W c"'r �C o Jc t2E'We W/}-S A-L.L_Jw t-D TO .C nJ7t`(L 7H t WATtYL_ 7)j 1 S wO 2&� C 6,S Ev No Fans I o iJ 04 S I L-F I N If OF `i}4E l.v 4Tt-2 7d. For in water construction work,will your project be in compliance with the State of Washington water quality standards for turbidity WAC 173.201A-110? YES NO (See USEFUL DEFINITIONS AND INSTRUCTIONS) 8. Will the project be constructed in stages? YES ❑ NO JN Proposed starting date: COMPLE-M'D Iw1 A-J&45; 7-0o6. L wem aUQpo,J OF GorJS?dL•IclJ�r� Estimated duration of activity: �2oX 9. Check if any temporary or permanent structures will be placed: ❑ Waterward of the ordinary high water mark or line for fresh or tidal waters AND/OR Waterward of the mean higher high water for tidal waters? 10.Will fill material(rock,fill,bulkhead,or other material)be placed: ❑ Waterward of the ordinary high water mark or line for fresh waters? If YES,VOLUME(cubic yards) /AREA (acres) ❑ Waterward of the mean higher high water for tidal waters? If YES,VOLUME(cubic yards) /AREA (acres) ECY 070-15(Rev. 11/04) JARPA Contact the State of Washington Office of Regulatory Assistance for latest version or call 360/407-7037 or 800/917-0043 2 I. Will material be placed in wetlands? ❑ YES NO It YES: A. Impacted area in acres: B. Has a delineation been completed? If YES, please submit with application. ❑ YES ❑ NO C. Has a wetland report been prepared? If YES,please submit with application ❑ YES ❑ NO D. Type and composition of fill material(e.g.,sand,etc.) E. Material source: F. List all soil series(type of soil)located at the project site,and indicate if they are on the county's list of hydric soils. Soils information can be obtained from the natural Resources Conservation Service(NRCS). G. WILL PROPOSED ACTIVITY CAUSE FLOODING OR DRAINING OF WETLANDS? ❑ YES ❑ NO If YES, IMPACTED AREA IS ACRES OF DRAINED WETLANDS. NOTE:If your project will impact greater than''/:of an acre of wetland,submit a mitigation plan to the Corps and Ecology for approval along with the JARPA form. NOTE:A 401 water quality certification will be required from Ecology in addition to an approved mitigation plan if your project impacts wetlands that are: a)greater than%acre in size, or b)tidal wetlands or wetlands adjacent to tidal water. Please submit the JARPA form and mitigation plan to Ecology for an individual 401 certification'If a)or b)applies. 12. Stormwater Compliance for Nationwide Permits Only: This project is(or will be)designed to meet ecology's most current stormwater manual,or an Ecology approved local stormwater manual. ❑ YES ❑ NO If YES-Which manual will your project be designed to meet? If NO-For clean water act Section 401 and 404 permits only-Please submit to Ecology for approval, along with this JARPA application,documentation that demonstrates the stormwater runoff from your project or activity will comply with the water quality standards,WAC 173.201(A) 13.Will excavation or dredging be required in water or wetlands? Q YES NO If YES: A. Volume: (cubic yards)/area (acre) B. Composition of material to be removed: C. Disposal site for excavated material: D. Method of dredging: 14. Has the State Environmental Policy Act(SEPA)been completed ❑ YES ❑ NO A f rc.ttA-Tor1 7sa--4i7M-P SEPA Lead Agency: M145or,) COJrJTe SEPA Decision: DNS,MDNS,EIS,Adoption,Exemption Decision Date(end of comment period) SUBMIT A COPY OF YOUR SEPA DECISION LETTER TO WDFW AS REQUIRED FOR A COMPLETE APPLICATION 15. List other Applications,approvals or certifications from other federal,state or local agencies for any structures,construction discharges or other activities described in the application(i.e.preliminary plat approval,health district approval,building permit,SEPA review, federal energy regulatory commission license(FERC),Forest practices application,etc.). Also,indicate whether work has been completed and indicate all existing work on drawings. NOTE:For use with Corps Nationwide Permits,identify whether your project has or will need an NPDES permit for discharging wastewater and/or stormwater. TYPE OF APPROVAL ISSUING AGENCY IDENTIFICATION DATE OF APPLICATION DATE APPROVED COMPLETED? NO. .11Wfnl(. EemIT' MMoo CooaT{ HPAW D F tnl 16. Has any agency denied approval for the activity you're applying for or for any activity directly related to the activity described herein? ❑ YES NO If YES,explain: ECY 070-15(Rev. 11/04) JARPA Contact the State of Washington Office of Regulatory Assistance for latest version or call 360/407-7037 or 800/917-0043 3 ai�1Y111111M i� Y���l 71IY... ,. J:. SECTION B - Use for Shoreline and Corps of Engineers permits only; 'I 7a.Total cost of project. This means the fair market value of the project,including materials,labor,machine rentals,etc. DOD 17b. if a project or any portion of a project receives funding from a federal agency,that agency is responsible for ESA consultation. Please indicate if you will receive federal funds and what federal agency is providing those funds. See instructions for information on ESA.` FEDERAL FUNDING ❑ YES NO If YES, please list the federal agency. 18.Local government with jurisdiction: Mt4.5p y.) COO 19. For Corps, Coast Guard and DNR permits,provide names,addresses and telephone numbers of adjoining property owners,lessees, etc. - Please note: Shoreline Management Compliance may require additional notice—consult your local govemment. I NAME ADDRESS PHONE NUMBER SECTION C-This section MUST be completed for any permit covered by this application 0. Application is hereby made for a permit or permits to authorize the activities described herein. I certify that I am familiar with the information contained in this application,and that to the best of my knowledge and belief,such information is true,complete,and accurate. I further certify that I possess the authority to undertake the proposed activities. I hereby grant to the agencies to which this application is made,the right to enter the above-described location to inspect the proposed,in-progress or completed work. I agree to start wo ONLY all necess permits have been received. I&WIIJ DATE q SIG A E OF AP LICANT 1 2Q�18 • DATE 7vt�_ ::3 tz i� C0gs-AVGJ70.,/ Co. 2 „ I o 8 SIGNATURE OF AUTHORIZED AGENT '7 I HEREBY DESIGNATESE 1511 La" CD„Ii!. C 0• TO ACT AS MY AGENT IN MATTERS RELATED TO THIS APPLICATION FOR PERMITS) 1 U ERST6NV7IAT IF A DERAL PERMIT IS ISSUED,I MUST SIGN THE PERMIT. ��gg • O SIGN RE O APP CAT DATE SI E C F LA O NER(EXCEPT PUBLIC ENTITY LANDOWNERS,E.G.DNR) THIS APPLICATION MUST BE SIGNED BY THE APPLICANT AND THE AGENT,IF AN AUTHORIZED AGENT IS DESIGNATED. 18 U.S.0§1001 provides that: Whoever,in any manner within the jurisdiction of any department or agency of the United States knowingly falsifies,conceals,or covers up by any trick,scheme,or device a material fact or makes any false,fictitious,or fraudulent statements or representations or makes or uses any false writing or document knowing same to contain any false,fictitious,or fraudulent statement or entry,shall be fined not more than$10,000 or imprisoned not more than 5 years or both. IROMPLL,T9-0 IBY L.OG�jL.OPFIAJ. k, A. Nature oft agoonmas p rsp 'bt � vitr(�3 flood plain;floodway,daita,type of och, r as accret►on,erosion,high bank;low Link,or eke,matenal aucf t1 , r`aivg�; frfad,,olay. rock;riprap anti e>tenf and fyp�5 o#;tt�lkheamg,:if"any) B, In the event that any o#the pro4pastrd buildings;or structures will;exceed a fight of lttirty five feet above the aylgre:grade level, indicate.the approximate location of and nl tii,ber of:fesidential units,exiljng 0tt(t,jofegal that will have:an;dsfitl:t itew C. If:the:application involves a conditional.use or variance,set forth in full.hotpgrdon of the master prpgrafn yvhich provides that the proposed SiSs may be a conditional use,or,.in the case of a variance,irorti-whlstt the variance is being sought: These Agencies are Equal Opportunity and Affirmative Action employers. For special accommodation needs,please contact the appropriate agency in the instructions ECY 070-15(Rev. 11/04) JARPA Contact the State of Washington Office of Regulatory Assistance for latest version or call 360/407-7037 or 800/917-0043 4 MASON COUNTY DCD Sent SEPA-S' M Q00,22 to(check all that apply)on Skokomish Tribal Nation j2T WA Department of Ecology Natural Resources Dept. Environmental Review Section ATTN:Marty Ereth PO BOX 47703 N 541 Tribal Center Rd. Olympia,WA 98504-7703 Shelton,WA 98584 Quinault Indian Nation 10\ U.S.Army Corps of Engineers ATTN: Mark Mobbs SEPA Reviewer PO Box 189 PO Box C-3755 Tahola,WA 98587 Seattle,WA 98124 Squaxin Tribal Nation WA Dept.of Fish and Wildlife Natural Resources Dept. ATTN: Margie Schirato(saltwater) 2952 SE Old Olympic Highway 2391 W Deegan Rd. Shelton,WA 98584 Shelton,WA 98584 The Confederated Tribe of the Chehalis a WA Dept.of Fish&Wildlife ATTN:SEPA Reviewer ATTN:Gloria Rogers(freshwater) 420 Howanut Rd. PO Box 695 Oakville,WA 98568 Elma,WA 98541 Shannon Soto WA Dept.of Transportation WA DNR,South Puget Sound Region Alana Hess, Development Review Engineer 950 Farman Avenue North P.O. Box 47440 Enumclaw,WA 98022-9282 Olympia,WA 98504-7440 Elizabeth Ellis a City of Shelton WA DNR,Aquatic Resources 525 West Cota St. PO BOX 47027 Shelton,WA 98584 Olympia,WA 98504-7027 Office of Archeaology&Historic Preservation Boyd Powers ATTN:Stephanie Kramer WA DNR,SEPA Center P.O. Box 48343 PO BOX 47015 Olympia, OI is WA 98504-8343 Olympia,WA 98504-7015 School District: Olympic Region Clean Air Agency 2940-B Limited Ln.NW Mason Cty Public Works ATTN: Olympia,WA 98502 Mason Cty Env. Health ATTN: Mason County Transit PO Box 1880 Mason Cty Building ATTN: RIGS baAdtvskn Shelton,WA 98584 Applicant: Agent: H Ju-1a PavIrk je5� cld &nsfmc-h �015 Via PO N 1 0 $GOS4 01I t, Arf fn :