HomeMy WebLinkAboutJARPA - SHX Application M y
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AGENCY USE ONLY
Agency Reference#: Date Received:- /
Circulated by: (local govt.or agency) I"C C i -,1 2
JOINT AQUATIC RESOURCES PERMIT APPLICATION FORM (DARPA)
(for use in Washington State)
M
PLEASE TYPE OR PRINT IN BLACK INK
❑ I am applying for a Fish Habitat Enhancement Project per requirements of RCW 75.20.350. 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,I am sending copies of this application to the following: (check all that apply)
Local Government for shoreline:❑Substantial Development ❑Conditional Use ❑Variance AExemption ❑ 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 Nationwide Permits(to Regional office-Federal Permit Unit)
❑ Washington Department of Natural Resources for Aquatic Resources Use Authorization Notification
❑ Corps of Engineers for: ❑Section 404 ❑Section 10 permit
❑ Coast Guard for Section 9 Bridge Permit
❑ US Fish&Wildlife Service or National Marine Fisheries Service for Endangered Species Act(ESA)Consultation
SECTION A - Use for all permits covered by this application. Be sure to ALSO complete Section C (Signature Block)
for all permit applications.
t.APPLICANT�Ogff
MAILING ADDRESS
�1 4�F J� �4
WORK PHONE E-MAIL ADDRESS HOME PHONE FAX#
Naas ��35'. �
Xf an agent is acting for the applicant during the permit process, complete #2.
2.AUTHORIZED AGENT /A 14.e
MAILING ADDRESS /V -47
WO K PHON E-MAIL ADDRESS HOME PHONE F
3.RELATIONSHIP OF APPLICANT TO PROPERTY: OWNER ❑PURCHASER ❑LESSEE ❑OTHER:
4.NAME,ADDRESS,AND PHONE NUMBER OF PROPERTY OWNER(S),IF OTHER THAN APPLICANT:
5.LOCATION(STREET ADORE S,INCLUDING CITY CO NTY PND ZIP CODE,WHERE PROPOSED ACTIVITY EXISTS OR WILL O 1
CUR)
3_2 /
LOCAL GOVERNMENT WITH JURISDICTION(CITY OR COUNTY) ,(�' 0/ i Cl Ll 2 7
WATERBODY TRIBUTARY OF RIA#
'/.SECTION I SECTION TQWNSHIP RANGE GOVERNMENT LOT SHORELINE DESIGNATION
�o a3 1,t-2�A,v e s,gE�V�•EI C.
LATITUDE S LONGITUDE ry / /► ZONING DESIGNATION
IF KNOWN: (�(J J�
TAX PARCEL NO: DNR STREAM TYPE,IF KNOWN
A.;?,330 - 646. 1,4 T //r,
JARPA, Revised 12/98, contact Ecology's Permit Assistance Center for latest version, 360/407-7037 Page 1 of 4
6.DESCRIBE THE CURRENT USE OF THE PROPERTY,AND STRUCTURES EXISTING ON THE PROPERTY. IF ANY PORTION OF THE PROPOSED ACTIVITY IS ALREADY COMPLETED ON
THIS PROPERTY,INDICATE MONTH AND YEAR OF COMPLETION.
V x z7y
IS THE PROPERTY AGRICULTURAL LAND? ❑YES ARE YOU A USDA PROGRAM PARTICIPANT? ❑YES N0
7a. DESCRIBE THE PROPOSED CONSTRUCTION AND/OR FILL WORK FOR THE PROJECT THAT YOU WANT TO BUILD 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.ATTACH A SEPARATE SHEET IF ADDITIONAL SPACE IS
NEEDED.
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.
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. ATTACH A SEPARATE SHEET IF ADDITIONAL SPACE IS NEEDED.
141 GUE
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PREPARATION Or DRAWINGS: SEE SAMPLE DRAWINGS AND GUIDANCE FOR COMPLETING THE DRAWINGS. ONE SET or ORIGINAL OR GOOD QUALITY REPRODUCIBLE DRAWINGS MUST
BE ATTACHED. NOTE:APPLICANTS ARE ENCOURAGED TO SUBMIT PHOTOGRAPHS OF THE PROJECT SITE,BUT THESE DO NOT SUBSTITUTE FOR DRAWINGS. THE CORPS or
ENGINEERS AND COAST GUARD REQUIRE DRAWINGS ON 8-112 R 11 INCH SHEETS. LARGER DRAWINGS MAY BE REQUIRED BY OTHER AGENCIES.
8.WILL THE PROJECT BE CONSTRUCTED IN STAGES? ❑YES NO
PROPOSED STARTING DATE: 14-�'/aP
ESTIMATED DURATION OF ACTIVITY: �!"' /l�� � / ,it �- d 1
9.CHECK IF ANY STRUCTURES WILL BE PLACED: �•1 J 4:. iV 'U
ATERWARD OF THE ORDINARY HIGH WATER MARK OR LINE FOR FRESH OR TIDAL WATERS;AND/OR
❑WATERWARD OF MEAN HIGH WATER LINE IN 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)
DARPA,Revised 12/98, contact Ecology's Permit Assistance Center for latest version, 360/407-7037 Page 2 of 4
11.WILL MATERIAL BE PLACED IN WETLANDS? ❑YES O
IF 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,&INDICATE IF THEY ARE ON THE COUNTY'S LIST OF HYDRIC SOILS.SOILS INFORMATION CAN BE OBTAINED
FROM THE NATURAL RESOURCES CONSERVATION SERVICE(NRCS):
12.WILL PROPOSED ACTIVITY CAUSE FLOODING OR DRAINING OF WETLANDS? ❑YES 1,❑"NO
IF YES,IMPACTED AREA IS_ACRES. K
13.WILL EXCAVATION OR DREDGING BE REQUIRED IN WATER OR WETLANDS? ❑YES O
IF YES:
A VOLUME: (CUBIC YARDS)/AREA (ACRES)
B.COMPOSITION OF MATERIAL TO BE REMOVED:
C. DISPOSAL SITE FOR EXCAVATED MATERIAL:
D. METHOD OF DREDGING:
n
14.HAS THE STATE ENVIRONMENTAL POLICY ACT(SEPA)BEEN COMPLETED? ❑YES ❑NO
SEPA LEAD AGENCY: SEPA DECISION: DNS,MONS,EIS,ADOPTION,EXEMPTION DECISION DATE(END OF PERIOD):
SUBMIT A COPY OF YOUR SEPA DECISION LETTER TO W DFW 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.
TYPE OF APPROVAL ISSUING AGENCY IDENTIFICATION DATE OF APPLICATION DATE APPROVED COMPLETED?
NO.
HIJA
4916
16.HAS ANY AGENCY D IED APPROVAL FOR THE ACTIVITY DESCRIBED HEREIN OR FOR ANY ACTIVITY DIRECTLY RELATED TO THE ACTIVITY DESCRIBED
HEREIN? [IYES NO IF YES,EXPLAIN:
SECTION B - Use for Shoreline and Corps of Engineers permits only:
17.TOTAL COST OF PROJECT. THIS MBANS TVE FAIR MARKET VALUE OF THE PROJECT,INCLUDING MATERIALS,LABOR,MACHINE RENTALS,ETC.
18.LOCAL GOVERNMENT "WITH JU}i�ISDTr+T
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 GOVERNMENT.
NAME ADDRESS PHONE NUMBER
J•
DARPA, Revised 12/98,contact Ecology's Permit Assistance Center for latest version,360/407-7037 Page 3 of 4
SkCTION 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
CCURATE. I FURTHER CERTIFY THAT I POSSESS THE AUTHORITY TO UNDERTAKE THE PROPOSED ACTIVITIES. I HEREBY GRANT TO THE AGENCIES TO WHICH
HIS APPLICATION IS MADE,THE RIGHT TO ENTER THE ABOVE-DESCRIBED LOCATION TO INSPECT THE PROPOSED,IN-PROGRESS OR COMPLETED WORK. I
AGREE TO START WORK ONLY AFTER ALL NECESSARY PERMITS HAVE BEEN RECEIVED.
SIGNAT E OF APPLICANT OR AUTHO A _I 11 ATE
I HEREBY DESIGNATE t
TO ACT S MY AGENT IN MATTERS RELATED TO THIS APPLICATION FOR PERMIT(S). I UNDERSTAND THAT IF A FEDERAL PERMIT IS ISSUED,
1 MUS SI N THE PER .
SIGNATU OF APPLICANT DATE
SIGNATURE OF LANDOWNER PUBLIC ENTITY LANDOWNERS,E.G.DNR) DATE
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.
COMPLETED BY LOCAL OFFICIAL
A. Nature of the existing shoreline. (Describe type of shoreline,such as marine,stream, lake,lagoon,marsh,bog,swamp,flood
plain,floodway,delta;type of beach,such as accretion,erosion, high bank, low bank,or dike;material such as sand,gravel,
mud,clay,rock,riprap;and extent and type of bulkheading,if any:)
B. In the event that any of the proposed buildings or structures will exceed a height of thirty-five feet above the average grade
level, indicate the approximate location of and number of residential units,existing and potential,that will have an obstructed
view:
C. If the application involves a conditional use or variance,set forth in full that portion of the master program which provides that
the proposed use may be a conditional use,or, in the case of a variance,from which 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.
JARPA,Revised 12/98,contact Ecology's Permit Assistance Center for latest version, 360/407-7037 Page 4 of 4
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'MKPLETED BY APPLICANT �� , Cam, ICF� ;?( C `p EVALUATION FOR
c j __ c, I AGENCY USE ONLY
C'D 2�
A. -BACKGROUND:
1. Name of proposed project, if applicable: t
(� �� 7-
/�
Z. Name of applicant: �&d0E, RA�tM(�9v�! 02ERT� - T'1_ C�ILE96-477,
3. Address & phone number of applicant b contact person: /.UOA Gl�=cL h i,Q
4. Date checklist prepared:
5. Agency requesting checklist:
6. Proposed timing or schedule (including phasing, if applicable) :
7. Do you have any plans for future expansion, or further activity
related to or connected with this proposal? If yes, explain.
/vL/)
8. List any environmental information you know about that has been
prepared, or will be prepared, directly related to this
proposal.
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.
//0
10. List any government approvals or permits that will be needed
for your proposal, if.known.
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 may modify
this form to include additional specific information on project
description. ) ,
%>!A CT C
1
TO BE CONPLETED BY APPLICANT EVALUATION FOR
AGENCY USE ONLY
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
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.
J7// /U� UL�rt� L.� 'm' /Y`/�i U; /V
Ct� —r,,0 77'v"c G 3 /c. a W
B. ENVIRONMENTAL ELEMENTS:
1. EARTH:
a. General description of the site (circle one) :
Flat, rolling, hilly, steep slopes, mountainous,
other 5772F,P
b. What is the steepest slope on the site (approximate
percent
slope)?
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 not any prime farmland.
d. Are there surface indications or history of
unstable soils in the immediate vicinity? If so,
describe.
2
TO BE COMPLETED BY APPLICANT EVALUATION FOR
AGENCY USE ONLY
e. Describe the purpose, type, and approximate
quantities of any filling or grading proposed.
Indicate source of fill.
f. Could erosion occur as a result of clearing,
construction, or use? If so, generally describe.
g. About what percent of the site will be covered with
impervious surfaces after project constructions
(for example, asphalt or buildings)?
h. Proposed measures to reduce or control erosion, or
other impacts to the earth, if any. :
1-�4
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.
r�u ti�
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
3
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.
2) Will the project require any work over, in, or adjacent to
(within 200 feet) of the described waters? If yes, please
describe and attach available plans.
3) Estimate the amount of fill and dredge material that would
be placed in or removed from surface water or wetlands and
indicate the area of the site that would be affected.
Indicated the source of fill material.
/V'P/U
4) Will the proposal require surface water withdrawals or
diversions? Give general description, purpose, and approximate
quantities if known.
1UJ
5) Does the proposal lie within a 100-year-floodplain? If so,
note location on the site plan.
V e)
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.
/V
4
TO BE CMWLETED BY APPLICANT EVALUATION FOR
AGENCY USE ONLY
b. Ground:
1) Will ground rater be withdrawn, or will rater be discharged
to ground rater? Give general description, purpose, and
approximate quantities, if known.
/M
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 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(e) are expected to serve.
A/
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.
A/0/t/
2) Could waste materials enter ground or surface waters? If so
generally describe.
I/d
d. Proposed measures to reduce or control surface; ground, and
runoff water impacts, if any:
,60A)z7r--- ,?I,�
4. PLAHTS:
a. Check or circle types of vegetation found on the
site:
✓deciduous tree: lder�anv%l� aspen, other
evergreen tree: , ir, ine, other
shrubs k OLA1v,4
_—L,—grass GtpG.A w C!
pasture
crop or grain
wet soil plants: cattail, buttercup, bullrush, skunk cabbage,
others
water plants: water lily, eelgrass, milfoil, other ,,1?,U6r-
5
TO BE COUPLE'= BY APPLICANT EVALUATION FOR
AGENCY USE ONLY
b. What kind and amount of vegetation will be removed
or altered?
C. List threatened or endangered species known to be
on or near the site.
d. Proposed landscaping, use of native plants, or
other measures to preserve or enhance vegetation on
the site, if any:
QJo-v�
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: ark heron, eagle, ongbirds, ther
mammals: deer bear, elk, beaver, other
fish: bass, salmon, trout, herring, shellfish, other `lfeA4
b. List any threatened or endangered species known to
be on or near the site.
C. Is the site part of a migration route? If so,
explain.
i(/U
d. Proposed measures to preserve or enhance wildlife,
if any:
1Ua1U,E_— /Uv /.tfT?_�X1L 2A/UC�
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'a energy needs? Describe whether
it will be used for heating, manufacturing, etc.
N/A
6
TO BE COMPLETED BY APPLICANT EVIALUATION FOR
_ AGENCY USE ONLY
b. Would you 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--seasures 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 waste, that
could occur as a result of this proposal? If so,
describe.
1) describe special emergency services that might
be required.
w N/A
2) Proposed measures to reduce or control
environmental health hazards, if any:
b. Noise.
1) What types of noise exists in the area which may
affect your project (for example: traffic,
equipment operation, other)?
N/A
2) What types of-_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.
7
TO BE COMPLETED B7 APPLICANT E1IALUATIOB F08
AGENCY USE ONLY
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?
S iNU_/
b. Has the site been used for agriculture? If so,
describe.
/U O
C. Describe any structures on the site.
d. Will any structures be demolished? If so, what?
tiU
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?
h. Has any part of the site been classified as an
'environmentally sensitive' area? If so, specify.
�0
i. Approximately how many people would reside or work
in the completed project?
N/A
J. Approximately how may people would the completed
project displace?
N/A
6
TO BE COMPLETED BY APPLICANT EVALUATION FOR
AGENCY USE ONLY
k. Proposed measures to avoid or reduce displacement
impacts, if any:
H/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 may units, if any, would be
provided? Indicate whether high, middle, or low-
income housing.
H/A -
b. Approximately how many units, if any, would be
eliminated? Indicate whether high, middle, or low-
income housing.
H/A
C. Proposed measures to reduce or control housing
impacts, if any:
H/A
10. AESTHETICS:
a. What is the tallest height of any proposed
structure(s), not including antennas; what is the
principal exterior building material(s) proposed?
b. What views in the immediate vicinity would be
altered or obstructed?
AJ&/tjc
c. Proposed measures to reduce or control aesthetic
impacts, if any:
h
11. LIGHT AHD GLARE:
a. What type of light or glare will the proposal
produce? What time of day would it mainly occur?
N/A
9
TO BE COMPLETED BY APPLICANT EVALUATION FOR
AGENCY USE ONLY
-b. Could light or glare from the finished project be a
safety hazard or interfere with 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. RECREATION:
a. What designated and informal recreational -
opportunities are in the immediate vicinity?
b. Would the proposed project displace any existing
recreational uses? If so, describe.
/VO
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.
b. Generally describe any landmark or evidence of
historic, archaeological, scientific, or cultural
importance known to be on or next to the site.
lueIU67
C. Proposed measures to reduce or control impacts, if
any:
AJ/A
10
TO BE (ORPLETED BY APPLICAST E9ALUATIQB FOR
AMMCY USE ONLY
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.
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.
H/A
C. How many parking spaces would the completed project
have? How many would the project eliminate?
H/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).
H/A
e. Will the project use (or occur in the immediate
vicinity of) water, rail, or air transportation?
If so generally describe.
N/A
f. How many vehicular trips per day would be generated
by the completed project? If known, indicate when
peak volumes would occur.
H/A
g. Proposed measures to reduce or control
transportation impacts, if any:
H/A
11
TO BE COMPLETED BY APPLICANT EVALUATION FOR
AGENCY USE ONLY
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.
H/A
b. Proposed measures to reduce or control direct
impacts on public services, if any:
N/A
16. UTILITIES:
a. Circl utilities currently evailablewa.t._.th'site:
electricity, natural gas, `'at r_„refuse service\
e ephone sanitary serer,_--septic system, ther.
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 vhich might be needed.
17. SIGNATURE:
The above ansvers are true and complete to the best of my
knorledge. I understand that the lead agency is relying on
them to make its decision.
Signature:
Date Submitted:
12
ESA LISTED SALMONIDS CHECKLIST
Applicant Information Project Information _
Name �lGB ,a Ted Name
Phoney/a4 !9 7- �F�o i Location�=�7 / EAU iU G,1c Ile
-
Description /14/J4� AJ LAk
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 watershed 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 salmonids currently present in the watershed
in which Yonr project will be located?
Yes No /
Please describe.
2 . Has there 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.
September 1999 1
PROJECT SPECIFICS: The questions in this section are specific to •
the project and vicinity.
1. Name of watershed: �UEiIJ
2 . Name of nearest waterbody:
3 . What is the distance from this project to the nearest body of
water?
Often a buffer between the project and a stream can reduce the chance of a
negative impact to fish.
4 . What is the current land use between the project and the
potentially affected water body (parking lots, farmland,-etc) ?
5 . Is the project above a:
• natural permanent barrier (waterfall) Yes No
• natural temporary barrier (beaver pond) Yes No
man-made barrier (culvert, dam) Yes
No
• other (explain) :
6. If yes, are there any resident salmonid populations above the
blockage? Yes No ✓ Don' t know
7 . What percent of the project will be impervious surface
(including pavement & roof area) ?
tin,u4F-
September 1999 "
2
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 withd awal of:
i . Surface water? Yes No
Amount
Name of surface water body
ii . Ground water? Yes Nox-
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 r ject require the building of new roads?
Yes Nod' Increased road mileage may affect the timin of reaching a stream and may impact fish habitat. 9 water
5 . Are culverts proposed as part of this project? Yes No
6 . Will topography changes 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 b i1ling or other partial blockage of flows?
Yes No
If yes, how ill the loss of flood storage be mitigated by
your project?
September 1999
3
WATER QUALITY: The £ollowing' questions will help determine if
this project could adversely impact water quality. Such impacts
can cause problems for listed species.
Water quality can be made Morse by runoff from
in cont impervious surfaces, aiteriag water
temperature, discharging Q contaminants, etc.
1. Do you know of any problems with water quali
streams within this watershed? Yes NoY in any of the
If yes, describe.
2 . Will your project either reduce or increase shade -along or
over a waterbody? Yes No
Removal of shading vegetation or the building of structures such as docks or
floats often result in a change in shade.
3 . Will the project increase nutrient loading or have the
Potential to increase nutrient loading or contaminants
(fertilizers, other waste discharges, or runoff) to the
waterbody? Yes No�L
4 . Will turbidity be increased because of construction of the
project or during operation of the project? Yesv No
In-water or
,/
or near water work will often increase turbidity.h
5 . Will your project require long term maintenance, i .e. bridge
cleaning, highway salting, chemical sprays for vegetation
management, learing of parking lots?
Yes Noy-__ If yes, please describe .
September 1999
4
VEGETATION: The following questions are designed
if the to determine ,
project will affect riparian vegetation, thereby,
adversely impacting salmon.
1. Will the project involve the removal of any vegetation from
the stream banks? * Yes No X.
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?
F
September 1999 -_
5
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DA.STAI- GARY YANDO,DIRECTOR
A U DEPARTMENT OF COMMUNITY DEVELOPMENT S N ENT
N Y �? PLANNING -SOLID WASTE - UTILITIES
o boy BLDG. I - 411 N. 5T11 ST. • P.O. BOX 578
1864 SHELTON, WA 98584 • (360) 427-9670
DISCLAIMER/WAIVER OF COUNTY LIABILITY: PERMITS ON EXISTING LEGAL LOTS OF RECORD,
LAND DIVISION APPROVALS, SHORELINE PERMITS, VARIANCES, AND SPECIAL USE PERMITS:
The undersigned property owner is aware of the uncertainty regarding Mason County's development regulations created
by the Growth Management Hearings Board's Order of September 6, 1996, and in consideration of Mason County's
willingness to proceed with processing of applications which might be affected by that Order, the undersigned property
owner hereby agrees to waive any lawsuit, action, or claim for damages against Mason County which may arise out of
Mason County's actions in acceptance, processing and/or issuance of such permits or approvals (hereinafter"permitting
actions'), which damages are attributable to the County's decision to take permitting actions despite the risk that changes
to the County's development regulations might later make the County's permitting actions invalid.
r-) r3 Date t)
(Parcel No. or pt.Legal Description)
g )
S
Property ner's signature(Notarized)
(or the County may accept the signature of the owner's authorized agent upon proper proof of authorization)
ACKNOWLEDGEMENT CERTIFICATE (INDIVIDUAL)
STATE OF
COUNTY OF
On this day of , in the year , before me
Notary Public,
Personally appeared personally known to me to be the person whose name is
subscribed to this instrument, and acknowledged that he/she executed it.
WTI'NESS my hand and official seal.
- For County use only-
• Reviewed by applicant on
Notary's signature (Date).
My Commission Expires: Staff Initial:
co .O -
9� LAID TITLE COMPANY OF MASON COUNTY
tt �.. '< 930 W RAILROAD AVE. P.O. BOX 327
31 � SHELTON, WASHINGTON 98534
(360) 426-32E3 (300) 955-0852
o _ Qo- AND /l r
�Q"y ��' L TITL-E CO2!PAPft ORDa NO. �// U Z7' S7
,
THIS SXrTCH IS FURNISHED FOR INFOF4ATION PURPOSES ONLY TO ASSIST IN PROPE.1-
LOCATION WITH TO STP.=ETS AND OTHF._? PARCELS. NO R�-R—l7s ..tLAT;Ctt IS
MADE AS TO ACCURACY AND THE Mm-ANY ASSiJ2•SES NO LIABILITY FOR ANY LOSS OCCiRING
BY REASON OF RELIANCr T'r.2 t::ON.
IAIJ
HAVEN LAKE
SECT10N 30, TWF. 23N, R 2W, WM. I. tk
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MASON COUNTY WASHINGTON
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