HomeMy WebLinkAboutSHR2006-00027 JARPA - SHR Permit / Conditions pN >1, ,, MASON COUNTY
DEPARTMENT OF COMMUNITY DEVELOPMENT
Mo Planning Division
7 N P O Box 279,Shelton,WA 98584
°� (360)427-9670
1
SHR2006-00027 NOTICE OF SHORELINE MANAGEMENT PERMIT
Notice is hereby given that CARTER/LUND,who is the owner of the described property,has filed an
application for a Shoreline Management Permit for the development of:
Sub. Dev.
New pier, ramp and float.
1_��4( (0�91 HE 1�br�rFt SHo Kp.) F3EL �4�tz
Site Address:
m6er: 322245000085
Location of Project: APPROX. 10 MILES WEST OF BELFAIR STATE PARK AND APPROX 6
MILES E OF TAHUYA ON THE N SHORE RD.
Within:SW(quarter section)of Section:24 Township:22 N Range:3 W,W.M.
in ,Mason County Washington.
Said development is proposed within Hood Canal and/or its associated wetlands. Any person desiring to
express their view or to be notified of the action taken on the application should notify:
MASON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT
P O BOX 279
SHELTON,WA 98584
in writing of their interest.The comment period is at least 30 days from the final date of publication given pursuant to WAC
173-14-020. The final date of publication,posting,or mailing of notice is 12/21/2006.
Written comments will be accepted up to the date of the hearing.
A public hearing will be held on this permit request. Contact this office at(360)427-9670,ext.294 for date and time of
hearing.
A Determination of Nonsignificance was issued on 12/8/2006 under WAC 197-11-340. Written comments regarding this
determination must be received by 12/22/2006.
SH R2006-00027
A % r A,'
MASON COUNTY
DEPARTMENT OF COMMUNITY DEVELOPMENT
Courthouse Annex
P.O.Box 279,Shelton,WA 98584
(360)427-9670
SHORELINE PERMIT APPLICATION
PERMIT NO. SHORELINE SUBSTANTIAL DEVELOPMENT �C
SHORELINE VARIANCE
DATE RECEIVED SHORELINE CONDITIONAL USE
SHORELINE EXEMPTION
The Washington State Shoreline Management Act(RCW 90.58)requires that substantial developments within
designated shorelines of the state comply with its administrative procedures(WAC 173-14)and the provisions of the
Mason County Shoreline Management Master Program The purpose of this Act and local program is to protect the
state's shoreline resources. The program requires that substantial development(any development of which the total
cost or fair market value exceeds$5,000,00 or materially interferes with the normal public use of the water or
shorelines of the State be reviewed with the goals,polices,and performance standards established in the Master
Program.
Answer all questions completely. Attach any additional information that my further describe the proposed
development. Incomplete applications will be returned.
APPLICANT: / BI L- .. CART F—C
ADDRESS: _[Q8'b NOR M5MVE tom.
BELFAIR, WI(street) 985a8
(city) (state) (;;P)
TELEPHONE: (ao(e)32a 50LIq
(home) A I (business)
Aa�Y
AUTHORIZED REPRESENTATIVE: LrlrMAt4 (M/ zLrJ S!WVF_V E
ADDRESS: 5a1 5r+AQSrE*D WA1' A SSEssn1 TS�
(a `)ter 1 bwrls—D, WA `7 8 3(a1J
(city) (state) (Zip)
TELEPHONE: _ (3(9
PROPERTY DESCRIPTION:
General location(include property address,water body and associated wetlands—identify the name of the
shoreline):
/0-91-1 v 10 19 1 NOON S )vc Rp,4D R E.% l=A tg+�j
i�iE- �.IOKTH SHe nF HDol� CArtkL
Legal description(include section,township,and range to the nearest quarter,quarter section or latitude and
longitude to the nearest minute. Projects located in open water areas away from land shall provide a longitude
location)—include all parcel numbers:
Su/1/& 1, 57ec gq+ , 7-2.1 rl, , IA W
1-0m&: U/ 230 00. $a1'
OWNERSHIP: Contract
Applicant_Owner Lessee Purchaser (Identify) Othez
Owner: � J E f'r91eY p k*012JJ SW9ZkJ E r
e207 COOF T gM-r PLAC. W
SEkrrLEf t.✓ly(atreet)9'$199'
(city) (state) (Zip)
0N'N� -3 AMA 00N r A4rRtCJA- LtAr D
/0s5/ NO N0leT"5H&2q-PD.89LFt4-l9 WA IT5a8
IiPLANNINGICHARELL&RENEE/SHOREL NEPEtMIT.APP REVISED:06-25-03
DINF.LOPMFNT DESCRIPTON
Development(identify and describe the proposed project,including the type of materials to be used,construction
methods,principle dimensions,and other pertinent information):
Trtf- f33o nc6 6 A 1161 Pi Ex RAMP o FLW 5TRlgclldRE /b de SH9iPE�
t3}'FattRriQoPrcRilFS. J11>c STrdnCntkE l✓1►LIavSISi oF/a !o'YJO'F/XED
Pim 6wxrAAQ-zD Dr" NL*i.45 r-fe; A V'X 3f�WC-.9.+M A!A M,.W4
(tk► e y ArJ D T MEE FLOATS (ALL./o'Y eW) THAT tUM A T Fi!04U
e0f-►1t T DF CLiLW gqe' to Ar/E
WtTA-1'10 i/ZfEfcn! ILe3 J'�3 Le TbSuFt�kr SrRtncM S� 8�F)
Use(identify current use of property with exist improvements:
r
SI NGt. >rPrM1�1' Re 1 eNC r Vl+rAr.Ji A-iJ1�
Reason for requesting development
Jb PROVIDE MORE. OPORTIAN i 7i ES ran/-WAiFwI
RTc�t2F-+9'flowf. - —
ACKOWLEDGEMENT
I hereby declare,to the best of my knowledge and belief,the forgoing information and all attached information is
true and correct.
(applicant "authorize representative) /D G(date) 18�
TO BE COMPLETED BY LOCAL OFFICIAL
Identify and describe existing features of the site and surrounding area:
If proposed stnucmres will exceed a height of J5 feet above the existing grade love],indicate the location of any
residential units that will have an obstructive view:
If a.Conditional Use or Variance is requested,make reference to the appropriate section in the Master Program
I:API.ANNINOICHARELL&RENEPARORELINEPPRMIT.APP REVISED:06-25-01
The Shoreline Permit Application
Page 3 PERMIT NO. 5►+R zoo ao��
ADJACENT PROPERTY OWNERS LIST
Addresses are to be obtained from the Mason County Assessor's Office,Building 1,second floor.
Jeanine Shepherd Garry&Diane Wilson Robert&Donna Tessier
4122 Ashworth Ave.N P.O.Box 1499 1565 Weathervane CT.
Seattle,WA 98103 Allyn,WA 98524 Fircrest,WA 98466
Joseph&Barbara Galando Trse James&Dorice Wolfrom Trste Irwin Mortgage
Joseph Galando Res Trust Wolfrom Family Trust 8435 N Stemmons Freeway
3124 SW 171"St. 26485 8th Ave.S Dallas,TX 75247
Seattle,WA 98166 Des Moines,WA 98198 Laurie Smiley Et Vir
THE SHORELINE PERMIT PROCESS—Page 4
Publication cost is the responsibility of the applicant. Final permit processing will not occur
until advertising fees have been paid to the newspaper by the applicant.The Shelton-Mason
County Journal will bill the applicant directly.
I/WE understand that UWE must sign and date the attached acknowledgement indicating that
UWE understand that is MY/OUR responsibility. UWE must submit the signed page as part of
this application in order for it to be considered as complete.
a'sV,'/. Z04,1r,
O" n.
�dlec�- l2 .4-7.), _
.&PLICANT
/ .., .
AGENCY USE ONLY
,Agency Reference# Date Received.
,Circulated Dy: (iocai govt. o, agencyi
JOINT AQUATIC RESOURCES PERMIT APPLICATION FORM (.3ARPA)
(for use in Washington State)
PLEASE TYPE OR PRINT 1N BLACK INK
Application for a Fish Habitat Enhancement Project per requirements of RCW r 7.55.290. 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, i am sending copies of this application to the following: (check all that apply)
1 54 Local Government for shoreline:U Substantial Development ❑ Conditional Use ❑Variance ❑ Exemption ❑ Revision
❑Fioodplain Management ❑Critical Areas Ordinance
12� 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
Corps of Engineers for: ❑ Section 404 ,Section 10 permit
Coast Guard for General Bridge Act Permit
❑ 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�� '49
MAILING ADDRESS
WORK PHONE _ . � �E-MAIL ADDR1s55�� 'e 1 HOME PHONE �FAX#
ff an agent is acting for the applicant uring the permit process,complete#2. Be sure agent signs Section C(Signature Block)for all permit
applications
2.AUTHORIZED AGENT
A161?1PJe_ i.t�-J� `'S ' / SES�r'1%i� 3 f'lh✓ LE! Irvt✓�r*
MAILING ADDRESS
( fr J (�GE4p/y� i/e/A �7 / z
WORKPHONEI LLm — EE�AQA GL .7( :tG HOi• E C4'3`+` IFAX# 3
�3-RELATIONSHIP OF APPLICANT TO PROPERTY:45 SWNER ❑PURCHASER ❑LESSEE ❑OTHER:
4.NAME.ADDRESS,AND PHONE NUMBER OF PROPERTY OWNER(S),IF OTHER THAN APPLICANT: -
5.LOCATION(STREET ADDRESS,INCLUDING C11',COUNTY AND ZIP CODE,WHERE PROPOSED ACTIVITY EXISTS OR WILL OCCUR) l
fL � � %a �`� /��►2 t� S �t�� r i� jr.LFr'�j�t 1+r`t(�3c1' � s�i i�I
LOCAL GOVERNMENT W]ITH JfURISDICTI ON(CITY OR COUNT:') MA _ICAD J4 c'o"j.J'i r
WATERBJDY YOU AREWORKING IN t eTRIBUTARY OF f WRIA
_ ! D
II-S THIS WATERBODY ON THE 303(d)LIST?YES II NO a—
VIFYFS,)AT1ATPARAMETER4S)'
httD:/(wuv;.eco-.t>a.Qoviprosramslwalli s/imDaireci cr-Lrs.htrn1 vr.B FOR3oSa
i
PST
SECTION i SECTION TOWNSHIP RANGE { GOVERNMENT LOT ;SHOR=LINE D-SIGNATION
ILAT(TUDE&LONGITUDE: % L-✓T! '" i 5 ?` IzONING DESIGNATION
TAX PARCEL NO' ` IDNR SIREAh'TYPE.IF KNOWN
Lf
C.i,V4iT_Cl 'i_"'.
i SCRIBE TFiE CURRElf'USE OF THE PROPER '�,ANC S?'R JRES EX'STING Ot\-=1E?Rv, n i:. HAVE YOU COMP— D ANY PORTION Or T E PRO?OSED ACTIVITY ON 7 f]S
PROPERTY? •'YES 'r,3 FOR AFP'�ORTIOt�0= -i_�ROPCS �ST:V"'"AIR DY COMP' ,ON THIS?R^-ER'" NDI:.ATE MON-'ri AND. .�R OF COMPLETION_
N&-LC t rF%I`ll i I KC-_ lit-"qc 1 ;;TIC Ise r �i�•
i
IS THE PROPERTY AGRICULTURAL LAND? C .ES L"NO ARE YCI'A USDA PROGRAM PARTICIPANT? J YES 2'.'Vf
7a. DESCRIBE THE PROPOSED WORK THAT NEEDS AQUATIC PERMITS: COMP;-c PLANS ANC SPECIFICATIONS SHOULD BE PROVIDED FOR ALL WORK WATERWARD OF THE ORDINARY
H R.HIGH WATER MARK OR LINE,INCLUDING TYPES OF EQUIPMENT TO BE USED. IF APPLYING FOP,A SHORELINE PERMIT,DESCRIBE ALL WORK WITHIN AND BEYOND 200 FEET OF THE
ORDINARY HIGH WAIF,MARK. IF YOU HAVE PROVIDED ATTACHED MATERIALS TO CESCRIBE YOUR PROJECT,YOU STILL MUST SUMMARIZE THE PROPOSED WORK HERE. ATTACH
A SEPARATE SHEET IF ADDITIONAL SPACE IS NEEDED. - 12iZU t f7i /
�c SYfAt�t . � �� Faun Pl�i' r2"T irF�`SJ. YT,4 1'uf� /tt,ftl<i_ CetNSirSTi 1l:Jt- A lcl`X(vo'
FI,k rr D `fit k, DX%16-L,,N� Fig, 5:3`fc off- r�Ro*-wi f,� J�� C-RATUD A
f,��,i J �, A r. ,��,)�nh�NLg oaf' ' A � -REE (ALA- t�' x '�
Tl�'i' i -tM lit " "�` M /�! i�,rl}T,"?Vv'A'?0 �3�f1� C"' )rJ gk;iC-L4/�� FLCat�'13 CUi�5 j 3 j Lr-
t-t.�l-t."i; E ice}C_i 5 � r( E k i �b �� ;% .j f� �'1. � , fl&Uy5-jyRE44 F— r-Lcfi-i 4-7 tcyj,
t-r-t-D AL- H AV 2' TWC- t=-IrT vv i row� C-RNT)NC ��>w-t.t T��� ��� -7 rapt �i i S Avb
1 � SJ�"3 f�1Lr �Sr'i(.L f�j� 1�1*-+`y' tZ ✓�� LFd J '�%ulee Y� J
Z A C C,r4 C.i✓fv,4 i d t- t
t� 3 Ma�anii�.p , �+�� t� � U+OP H-ft, tAF- — (5c.r- 5,F) �AwiTtomf�i_Drank-S
PREPARATION OF DRAWINGS: SEE SAMPLE DRAWINGS AND GUIDANCE FOR COMPLETING THE DRAWINGS. ONE SET OFORIGINAL OR GOOD QUAL17YREPRODUCIBLE DRAWINGS
MUS7BEATTACHED. 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 8-1,12 X',1 IAICH SHEETS. LARGER DRAWINGS MAY BE R��QUIRED BY O T•HER AGENC/cc.
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 uq�7c InIFL i!�NC�D
THE DESIGN.
�'(��i�d t`i t,�h•i f i 1��� t��-� �`t�•�-�,w`r"!�..�' l�kC i2 r»e.�-s�I 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 C AND
AQUATIC UFE. IDENTIFY WHICH GUIDANCE DOCUMENTS YOU HAVE USED. ATTACH A SEPARATE SHEET IF ADDTIONAL SPACE IS NEEDED.�e e -tJ j Jo`_
LA Ice.L 'TO t3� �� o2�t�1 A L 7,1 AjJY aF —j 4 C tf}kt�C=, t �+ l lSr 5 t?F VV �-
tS WA ce-
Ejc' DY". J�M p/+CJ—S To iSt-t F- Adkt=ti dL LIFE- t t.'dt.LL. BE 101 tit M A-L , C�?R i ir�C,- WILL
t�b�A C� ��t► b t,aC, I LC Lvt LL- 3F _
jDV\,V+e rg tA/ {i k} i} F"r'�S-i 114 C,- PILE. bP-W r� U� f r�i C;- A'Y-L PP H-Ai vtvt-:� �C j-1 1 G tit�
DLAr'idaC; rjU-WA- W&F le V�,d�1 ~•✓� 5;" �LfStt�i% 'air T� f.lo —w, -77tE FLcA:T
bi�5i Crr,j CONI P L I C 5 W ITO Wbf'L l C-Ri t`E-YZI A F--pQ IAA--;Ej?- 62AAA L)r y`,
t,J�LL. 3� t��2�v�r�r-t�r�i L F'►�aC/� thIr Y 2p �' i - Wc)pe,5 'b PIT.-S AtZE._ AC-2-4
W I L-L iv\-czq ofZ7 �-: CCI 9-b
E{ C Si�r`t� � "�7�-�� tt fl` (jt {jVte'�delt '� -s•i j �b��tf t7 C iG s GGdlilPalAx�)
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? C-TIES ONO (SEE USEFUL DEFINITIONS AND INSTRUCTIONS)
8,WILL THE PROJECT BE CONSTRUCT cD IN STAGES}? (y r r� ` -�- / f n YES F+•190
PROPOSED STARTING DATE: A5 JL''}(..?1Y � PEk0, Vlt i-5 Ax?C 1,55--4�'-b �ii J-- �'_ '�F t._fS f.1-� G"Yl•#✓a�'!r�-410N4
ESTIMATED DURA's ION OF ACTIVITY: r, <" E c'
9.CHECK IF ANY TEMPORARY OR PERMANENT STRUCTURES WILL Bi_PLACED:
6 T nRWARD OF THE ORDINARY HIGH WATER MARK OR LINE FOR FRESH OR TIDAL WAITERS,AND/OR
[;J�iTERWARD OF MEAN HIGHER HIGH WATER,LINE IN TIDAL WATERS
10.WF,1 FILL MATERIAL(ROCK,FILL,BULKHEAD,OR OTHER MA.T ERIA-)BE PLACED: (4 o
El WATERWARD OF THE ORDINARY HIGH WATER MARK OR LINE FOR FRESH WATERS? IF YES,VOLUME(CUBIC YARDS) !AREA NACRES)
G WATERWARD OF THE MEAN Hi G H E R HIGH WATER FOR-T:CAL WF.TERS? IF YES,VOLUME(CUBIC YARDS) AREA (ACREc)I
TARP? RP[rl c= 7/n, (nntari fh Riat?,n;ZA acn notnn mires, rPe m-t 4ccic am inr ATPC ;-�rcinn F 1id(i_7( nr R(1 )lQ 1','_ �)L
Wl'.�MATEr'Z'RL B=?LACED Itv'W=i Lkh::S? a YES 2'(O
IF YES:
�1
P,. IMPACi=D AREA IN ACRES:
i
B. HAS A DELINEATION BEEN COMPLETED? IF YES,PLEASE SUBMIT W7H APPLICATION. ❑YES G NO
C. HAS AWET'-.Ate REPJi:T 3cEN?R=PARED7 fF YcS,PLEASE SU3Mi-WIT A?PLICATiOtc ❑YES ^NO
i
D. 7YPE AND COMPOSITION OF FILL MPSERIAL E.G.,SAND,ETC
E. MATERIAL SOURCE:
F. LIST ALL SOIL SERIES OF SOIL)LOCATED AT THE PRCE CT SITE,L INDICATE IF THEY ARE CN THE COUNTY'S L IST OF HYDRIC SOILS SOILS INFORt'1F:TION CAN SE DETAINED
FROM THE NATURAL RESOURCES CONSERVATION SEFZVICE(NRCS):
G. WILL PROPOSED ACTIVITY CAUSE FLOODING OP DRAINING OF WETLANDS? ❑YES ❑NO
IF YES,IMPACTED AREA IS_ACRES OFDRAINED WETLANDS.
NOTE: If your project will impact greater than'A 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 ceaifa:ation wilf be required from Ecokgy in addfion to an approved mitigation plan r yourproject imoacts v edands that are: a)greater than 3. acre in size,or
b)tidal v tiands or v etiands adjacent to tidal water. Piease submit the DARPA fomn and mitigation plan to Ecology for an indfvidua/401 cerlifrcation i;a)orb)applies.
12. STORMWATER COMPLIANCE FOR NATIONWIDE PERMITS ONLY: jv /A,
THIS PROJECT IS(OR WILL BE)DESIGNED TO MEET ECOLOGY'S MOST CURRENT STORMWATER MANUAL,OR AN ECOLOGYAPPROVED LOCAL STORMWATER MANUAL 0 YES ❑NO
IF YES-WHICH MANUAL MIL.YOUR PROJECT BE DESIGNED TO MEET
If NO-FOR CLEAN WATER ACT SECTION 401 AND 404 PERMITS ONLY-PLEASE SUBMITTO ECOLOGY FOR APPROVAL, ALONG W(T.H THIS DARPA APPLICATION,DOCUMENTATION THAT
DEMONSTRATES THE STORMiNATER RUNOFF FROM YOUR PROJECT OR ACTIVITY WILL COMPLY WITH THE WATER QUALITY STANDARDS,WAC 1?3.201(A)
13,WILL EXCAVATION OR'DREDGING BE REQUIRED IN WATER OR WETLANDS? El YES ff<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:
14.HAS THE STATE ENVIRON ENTAL PO ICY ACT(SEPA)BEEN COMPLETED? El YES QTO
SEPA LEAD AGENCY: /Z 5Z)N .ice SEPA DECISION: DNS,MONS,EIS,ADOPTION,EXEMPTION DECISION DATE(END OF OOMMENT PERIOD):
SUBMIT A COPY OF YOUR SEPA DECISION LETTER TO WDFW AS REQUIRED FOR A COMPLETE APPLICATION
15.LIST OTHER APPLI CATIONS,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 STORMWATEF
TYPE OF APPROVAL ISSUING AGENCY IDENTIFICATION DATE OF APPLICATION DATE APPROVED COMPLETEC
5` NO.
-&A,kLpI ACx
A vv b C-
us
C A Lb f iq k t t5�1
16_HAS ANY AGENCY D IFD APPROVAL FOR THE ACTIVITY YOU'RE APPLYING FOR OR FOP,ANY ACTIVITY DIRECTLY RELATED TO THE ACTIVITY DESCRIBED
HEREIN?DYES NO IF YES,EXPLAIN:
1
T:•RF.'� 'R,7;CPA A T.'l�taro
SECTION B-Use for Shoreline and Corps of Engineers permits on]y-
17a. TOTAL COST OF PROJECT. THIS MEANS THE FAIR MARKET VALUE OF THE PROJEC ,!NCI_jD:NG M-;TERi.�S.r A BOR,MCHINE:EiNTALS.ETC- �,Z l�
1?b f=P.oRCSECT OR ANY?OR Oh OF A�R Jt T? IV S FUNDING FROM A. .� A�AGENCY.T4-[:;-AGENCY IS RESP^',,SiB_E FDR ESA.CONSUL T rTION. PiEASE INDICATE t=v0;,t
WILL RECEIVE FEDERAL FUNDS AND WHET FEDERAi G N !S FR VI:D,NG -CSE F JNDS. SEE INSTRUCTIONS FOR INFORMATION ON ESA"
s
-EDERAL=JND'NIG a YES 1V., IF YiES t-EASE-IS. ,HE _DERAL AGENCY
8.LOCAL GOVERNMENT WITH JURISDICTION: p q t
I15.FOR CORPS,COAST GUARD,AND DNR PERMITS,PROVIDE NAMES,:0.13D?ESSES,AND TELEPHONE NJMSERS OF ADJOINING PROPEF,'Y aAINERS._ESSE=S.ETC._.
1 PLEASE NOTE: SHOr2E!.fNE MANAGEMENT COMPLJANCEMAvREQUIREAD-BIDONAL,NO-'Cc—CONSULT YCJRLOCAL GOVEPNIM=.Ni.
NAME ADDRESS � P I
1 '.HONE NUMBER
[,lk l7o NA i tE i fc5 �o-fr-itii ife d,tr� _ 6VI'4i
MZSEPH 'C 96-t2rM-C-A GAkA.iDDO 3/JL•Y1 5vV /-,7-/ : SF
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 TiHE 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 WH[CH
HIS APPLICATION IS MA➢E,THE RIGHT TO ENTER THE ABOVE-DESCRIBED LOCATION TO INSPECT THE PROPOSED,IN-PROGRESS OR COMPLETED WORK, I
AGREE TO START WORKONLY AFTER ALL NECESSARY PERMITS HAVE BEEN RECEIVED,
SIGNATURE OF APPLICANT ID
ATE
SIGNATURE OF AUTHORIZED AGENT ATE
//��
Gsoct !U Cry
I HEREBY DESIGNATE A ill V L Fi_rldA td LIMA /NF 5, tW_ 'eyS r A<JS E-SStjg j'l\j/..3� DATE
tIGNATURE
ACT AS MY AGENT IN MATTERS RELATED TO THIS APPLICATION FOR PERMIT(S). 1 UNDERSTAND THAt IF A FEDERAL PERMIT IS ISSUED,
UST SIGN THE PE N T.
OF APPLICA _ ➢ATEGNA E OF LANDOWN R(EX PT PUBLIC ENTITY LANDOWNERS,E.G.DNR)
IS APPLICATION MUST BE SIGNED B TH APPUCANT 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 tick,scheme,or device a
material factor 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.
Ct�MPLETED BY LOCAL OFFICIAL
A i�tature of the ex�sfmg shorelrrte :(Descni e type ofshorellne such as manne stream lake lagoon marsh bog swat p flood
plain ;floodway delta;type.of.beach;'.such as:accreflon erosion high bank,iowbank ortllke material such as sand gravel mud clay;
rock.nprap •and extent and type of l ufkheading mf any)
B in`.the event that any of ttze proposed buildings tar structures W l:.6e kceed a height of thirty five feet above the ay.erage'grade
I vet dlcate.the ap?jro Imat Iccati:on of and number of residential unita ewstrng;and potential >that wEl[have an obstructed weir
C If the application involves a conditional-use or vanance,set forth inn full`.that portion of the master program which provides that
the proposed use may tine a condrtloai use,;or, m the:caseof a var.'iance,from which the vanance;:is.being sougit
These Agencies are Equal Opportunity and Affirmative Action employers.
For special accommodation needs,please contact the appropriate agency in the instructions-
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