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HomeMy WebLinkAboutMEP, JARPA, Environmental Checklist - PLN General MASON CO.-EWIROMEWAL0 CHECKLIST A. BACKGROUND PARCEL NUMBER: Z 3a 9- 76- o ooCea 1. Name of proposed project, if applicable: 2. Name of applicant: 3. Address and phone number of applicant and contact person: 3 3 0.2- A//-" - IV&A/i-.*� ACL. 7i9-,i a y,*, LiI'�? 4. Date checklist prepared: 5rf�''�D�' 5. Age cy reques ng checklist: /1�1.9s��,1 C�cs ` ���-.��inr'� .�.��r.��'71���►f7� 6: Proposed timing or schedule (including phasing, if applicable): l /0 7. Do you have an plans for future expansion, or further related to or connected with this Y Y pl xp activity proposal 1f yes, explain. A/0 8. List any environmental information you know about that has been prepared; or will be prepared, directly related to this proposal. J�JrONG. 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. ,A/o 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 inl�rmation on project description.) We 4A' 4- f�s�c,,,/�' /�,�,¢,/�/��-5+�0�! 7 V hulAd., O.J �lt. A144-zli 3W.* t,e_, Ot+r OF-"409 1 Y B4O9Y , --Z:7-- 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. /vE%y r-?, $ N ,3 Af 3 hI B. ENVIRONMENTAL ELEMENTS: 1. EARTH: a. General description of the site (circle one): Flat, rolling, hilly, steep slopes, mountainous, other 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, day, sand, gravel, peat, muck)? If you,know the classification of agricultural soils, specify them and note any prime farmland. Ivh9 d. Are there surface indications or history of unstable soils in the immediate vicinity: If so, describe. -A Mason County Environmental Checklist Page 2 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: 2: AIR: a. What types of emissions to the air would result from the proposal (i.e. dust, automobile, odors, industrial woad smoke)during construction and when the project is completed? If any, generally describe and give approximate quantities, if known. 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 C. Proposed measures to reduce or control emissions or other impacts to air, if any: 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 Mows into. 47,4 2) WIWV%jel ct require any work over, in or adjacent to (within 200 feet)the described waters? If yes, please describe and attach available plans. V J1. S - 9 7—.0C''i�c44- C�O 0,&✓Lt Eii. 1/ 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. Indicate the source of fill material. nId N� 4) Will the proposal require surface water withdrawals or diversions? Give general description, purpose, and approximate quantities if known. Mason County Environmental Checklist Page 4 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) Wifl ground water be wiftrawn, or will water be discharged to ground water? Give general description, purpose, and approximate quantities, if known. w/� 2) Describe waste material that will be discharged into the ground fromrru tanks or other sources, if any (for example; domestic sewage, industrial, con the following chemicals..., agricultural, etc.). Describe the general size of the syste number of such systems, the number of houses to be served (if applicable), or mber 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 oDection and disposal, if any(include quantities, if known). Where will this water flow? Will this flow into other waters? If so, describe. /v1/4 2) Could waste materials enter ground or surface waters: If so, generally describe. Mason County Environmental Checklist Page 5 d. Proposed measures to reduce or control surface, ground, and runoff water impacts, if any: 4. PLANTS: a. Check or circle types of vegetation found on the site: deciduous tree: alder, maple, aspen, other evergreen tree: fir, cedar, pine, other shrubs grate pasture crop or grain wet soil plants: cattail, buttercup,buArush, skunk cabbage, other water plants: water lily, eelgrass, milffoil, other other types of vegetation 1\1/� 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. .Do /U/�/<xroU-0-) d. Proposed landscaping, use of native plants, or other measures to preserve or enhance vegetation on the site, if any: ^1/ig Mason County Environmental Checklist Page 6 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: onoth u o -•s Mammals: e r + er, other Fish: bas sa mor ut herrin she11 sh other b. List any threatened or endangered species known to be on or near the site. DO /C/o%'-i''C.,✓DGj/ C. Is the site part of a migration route? If so, explain. 00 J1ja`��n f b Lri� d. Proposed measures to preserve or enhance wildlife, if any: .�r'SI..A�.., T aL�- ?7i�- ���� w.mac. s`.�—'�r�.►! 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. 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: Mason County Environmental Checklist Page 7 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. 2) Proposed measures to reduce or control environmental health hazards, if any: b. Noise. 1) What types of noise exist in the area which may affect your project (for example: traffic, equipment, operation, other)? 2) What types and levels of noise would be created by or associated with the project on a short-term or a long.-temp basis(for example:,traffic, construction, operation, other)? Indicate what hour's noise would come from the site. -i A..2Z,.Ls 3) W91-j?—e�Sol:�rref;%""up-..jert3;lWri6ise impacts, if any: 8. LAND AND SHORELINE USE: a. What is the current use of the site and adjacent properties? Mason County Environmental Checklist page 8 b. Has the site been used for agriculture? If so, describe. C. Describe any structures on the site. (3:7-i Del d. Will any structures be demolished? If so,what? lap 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. L Approximately how many people would reside or work in the completed project? . /K Bn�la�fHNp� j. Approximately how many people would the completed project displace? k. Proposed measures to avoid or reduce displacement impacts, if any: Mason County Environmental Checklist Page 9 I. Proposed measures to ensure the proposal is compatible with existing and, projected land uses and plans, if any: 9. a. Approximately how many units would be provided, if any? Indicate whether high, middle, or low-in me housing. b. Approximately how many units, if any, would be eliminated? Indicate whether high, middle, or low-income housing. C. Proposed measures to reduce or control housing impacts, if any: 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? C. Pr oposed sed measures to reduce or control aesthetic is impacts, if any: Mason County Environmental Checklist Page 10 11. LIGHT AND GLARE a. What type of light or glare will the proposal produce? What time of day would it mainly occur? 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: d. Proposed measures to reduce or control light and glare impacts, if any: 4/109 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. 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 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 landmarks or evidence of historic, archaeological, scientific, or cultural importance known to be on or next to the site. C. Proposed measures to reduce or control impacts, if any: 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. IVAY 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. N/� C. How many parking spaces would the completed project have? How many would the project eliminate?. IVIA 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). Mason County Environmental Checklist Page 12 e. Will the project use (or occur in the immediate vicinity of)water, rail, or air transportation? If so, generally describe. //a f. How many vehicular trips per day would be generated by the completed project: If known, indicate when peak volumes would occur. g. Proposed measures to reduce or controt transportation impacts, if any: 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: I Mason County Environmental Checklist Page 13 16. UTILITIES: a. Circle utilities currently available at the site: electricity, natural gas, water, refuse service, telephone, sanitary sewer, septic system, other. 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 which might be needed. Signature: The above answers are true and complete to the best of my knowledge. I understand that the lead agency is relying on them to make its decision. Signature: Date submitted: Mason County Environmental Checklist Page 14 ESA Le RECE 1 Y' : HECKLIST 2,5 rf�ta_ Anficant I.aformation Proiect Information Name AIA" l�l�, .�cc Name ,a<c5.t.. Phone � ��, '3"!2—?aey4 Locationed=tW Description This workshect was designed to help project proponents, anti government agencies, identify when a project needs further analysis regarding adverse effects on ESA (Endangered Species Act) listed sauhnonids. Sslmonids are salmon,trout and chars, e.g. bull trout. For our purposes, "ESA Listed Sahmrrids" 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 Manger at the appropriate Deportment of FM and Wildlife(DM regional offte can provide information for the f "fag two gamtlona. �- 1. Are ESA listed salmonids currently present in the watershed in which your project will be located? YES NO PI describe. f57Oa ///?' eA.107 2. Has there ever been an ESA listed salmonid stock present in this watershed? YES NO Uncertain V Please describe. mow'�'"r�C,✓vy/ If you answered"yes" to either of the above questions,you should complete the remainder of this checklist. April 2003 _ i _ PROJECT SPECIFICES: The questions in this section .are speciQc to the project and vicinity. 1. Name of watershed: 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 SftM7jSn-r0&Ujj the Cfig&e of a iegfdve iupwt to fish. 4. What is the current land use between the project and the potentially affected water body (panting lots,farmland,etc.)? Ju/A 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 any resident sahnonid populations above the blockage? YES _ / NO Don't know 7. What percent of the project will be impervious surface(including pavement&roof area)? -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 fhih 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 _ks/ 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 Z Increased road mileage may affect the timing of water reaching a stream and may mVw fish habitat 5. Are culverts proposed as part of this project? YES NO 6. Will topography chang- gesvect the duration/direction of runoff flows? YES NO If yes,describe the changes. 7. Will the project involve any reduction of the floodwa r floodplaw 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- WATER QUALITY: The following questions will help determine if this project could Adversely impact water quality. Such impacts can cause problems for listed species. Water gnaft can be made worse by runoff from impervious surfaces,altering water temperature,discharging contaminants,etc. 1. Do you know of any problems witloViter quality, in any of the streams, within this watershed? YES NO ` If yes,describe. 2. Will your pyeect either reduce or increase shade along or over a waterbody? YES t/ NO Removal of shading vegetation or the building of structures such as docks or floats often results m a change in shade. 3. Will the .project increase nutrient loading or have the potential to increase nutrient loading or contammantsodtilizers, other waste-discharges, or runoff)to the waterbody? YES NO 4. Will turbidity be increased because of nstruction of the project or during operation of the project? YES NO In water or near water work will often increase turbidity. 5. Will your project require long term maintenance, i.e. bridge cleaning, highway salting, and chemical sprays for v on managealnent,clearing of parking lots? YES NO t,,00 If yes,please describe. -4- r VEGETATION: The following questions are designed to determine if the project will affect riparian vegetation,thereby,adversely impacting salmon. 1. Will the project involye the?rodQ 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? -s- PLANNI - -cr fV JOINT AQUATIC RESOURCES PERMIT APPLICATION {for use b WnW*Np1on stale) CE-4 R J PLEASE TYPE tH PRINT IN BLACK INK ❑I am 8A*ing for a Fish Heb&at Enhancement PmJect per requirements of RCW 75.20.350. You must submit a copy of this complieted JARPA appIcabo n form,and the(Fish Habitat Enhancement JARPA Adaiih on)to your local Covemment Planing Department and Washington Deparbnent of Fish&YID Area HabNat Bk*gist on the same day. NOTE: LOCAL GOVERNMENTS-You must submit any comments on time projects to WDFW within 15 woddng c Based on the Instructions provided,I am sending copies of this application to the foNca*V. (check aN HWJAPW ❑ Local coverriment for SIKWItl W D Substantial Development D Corditional use ❑Variance ^Exwnpdon ❑Revision ❑Flood)Wn Management D Critical Areas Ordnance Washington Deperb wd of Fish and WkWe for 14PA(Submit 3 copies to WDFW Region) Washington Department of Ecology for 401 Water Quality Certification Nationwide Pei.. (b Regional olka-Federal Pemrit UNt) ❑ Washinglon Department of Mural Resources for Aquatic Resources Use authorization Notification Corps of ENTgineers for: ❑3ectlon 404 ❑Section 10 penva Coast Guard for Section 9 Bridge Permit ❑ US Fish&Wildlife Service or National Marine Fisheries Service for Endangered Species Act(ESA)Consultation SECTION A-the far ak pw tfs covered by this a ppNcef m Be sere fo Also concealer Secdw C(SlyNabre abdb fbr aft!pw Nr gpplfCafl w& G - MMJW ADDRESS 3 a --6 S WORK PHONE E-MAL ADOR6S3 1HOMEPHONE FAX i Wan a99WIsRc***W"appftWdkwkW So pmuR process,conVilefe 0l AUtrNO UDAGENT M&M ADDRESS WORK PHONE E M L AbOtESS HOME PHONE FAX/ Fa ATIOmw OF APPLICANT TO PROpmy:)'bwmR D PURCNNA w O umm D om*3t NAME.ADDRESS,AND PHONE NUMBER OF PROPERTY OWNER n F O`FHM THAN MVLK',AW LOCJITION AOORES$NNL CrrY AND IF WI*M PROPO6ED AGTMIY E)OSrs ORR WNl OcM" - GMW Main WrrH AXWD CTION(CnY OR COMM SECTNON I SECTDN I TOWNSW RANGE GOVERtM BIr OT SHOF13MVENGMTM TNTINIE A LONenum o G TDNN Ax PARCEL NO STNEAM TYPE,F KNOWN 3�3.2g Wmap PROPERTY,m7m 7 E WNM ON 7FE PROPERTY.IF ANY PORTION OF THE PROPOBEDACTMFY IS ALREADY OOMPLET®ON THIS 13 7HE PROPERTY AGRICULTURM.LAND?13VM)960 ARE YOU A USDA PROGRAM PARTICPANI? O YES a DESCFMETHEPROPOMCONSTRUCTKNANDORFLL WORK FOR THEPIVMCTTHATYOUWANTTOBREDTHATNEEMAQUATICPERMITS:COMPLETERANSAND SPECIFICATIONS SHOULO M PROVIlM FOR ALL WORK WATERWARO OF THE ORDINARY HIGH W0MIR MIRK OR LINE.NCIAlFING TYPES OF EQUIPMENT TO SE USE).F APPLYING FOR A 3lbRELIE PERMIT.DESCRBE ALL WORK WRHN AND BEYOND 200 FEET OF TIE OIDNNRY HIGH WATER MIRK.ATTACH A SEPARATE WHET F ADDRIONAL SPACE B NEEDED. 7tLOGSCR THE PURPOSE OF THE PROPOSED WORK AND WHY YOU WANT OR NEED TO PERFORM IT ATTHE SITE PLEASE EVLAIN ANY SPECIFIC NEEDS TWAT WIVE BFLUENC®. THE DESIGN. c DESCRBE THE POTENTIAL IMPACTS TO CtARAC OWTIC UGGS OF THE WATER BODY.THESE USES WAY BICLIIDE FISHAND AQUATIC Lk.WATER QUALITY.WATERSUVI.Y. RECIRMTDN,SM AESTFETICB. IDENTIFY PROPOSED ACTIONS TD AVOID.WAMME.AND MRiGATE OETRIBIEMAL IPACTS,AND PROVIDE PROPER PRO TECTION OF FIS"AND AQUATIC LIFE ATTACH A SEPARATE SHEET F ADOMONAL SPACE IS NEEDEDVitATION . OFORAIN MM SEE SAIPLEORNNIiGBANDQUM1NfE FOR COM+LETING THE DRAW M GME'EfOFQIBBNNi fltelOQDfNA1{llY pDU�FDIQyR11NBI FAT7r4QN!=MUTE APPLIC M MAIWONCO T�OSUNWRI TOGRAPHSOFTMPROA CTSITE,MCNI�epoMDTSUBBTMmmrdROIMAMd m nwcom Bop LAIVOBRONN�tlIBM/tm4y4wA�IBBdAYdNNMIA*wxm OJWI BECONSTRUCTEDNSTAGES? DYES O NNO STARING DATE ESTIMATEODURATIOHOFACTMTV- S. CHECK IF ANY STRUCTURES VOL BE PLACElk )dwATERWARD OF THE ORDINARY HIGH WATER MARK OR LINE FOR FRESH OR TIDAL WATERS.ANIDIDR A7ERWARD OF LEAN HIGH WATER LIE IN TIDAL WATERS I O.WLL FILL MATERIAL VIOCK FILL.WAX NEA&OR OTHER MATERIAL)BE PLACED,. CI WATERWARD OF THE ORDINARY HIGH WATER MARK OR LINE FOR FRESH WATERS? �� F YES,VOLUME ICRBIC Y 13 WATERWARD OF THE MEAN HIGHER HIGH WATER FOR TIDAL WATERS? F YES.VOLUME l'CUW Y it WILL..L MATERIAL BE PUKED IN WETLANDS? ,r© 13 YES 11D A IMPACTED AREA IN ACRES: �( B.HAS A DELINEATION BEEN OOMPLETED?F YES,PLEASE SUBMIT WRH APPLICATION. 17 YES (mow C. HAS A WETLAND REPORT BEEN PREPARED? F YES.PLEASE SUBMIT WITH APPLICATION. YES D.TYPE AND COMPOSITION OF FILL MATERIAL(E.G..SAND.ETC.k 13 E.MATERIAL SOURCE- F. LIST ALL SOL SERIES(TYPE OF SOIL)LOCATED AT THE PROJECT SITE.&INDICATE F THEY ARE ON THE COU NTY'S LIST OF HYORIC SOLE.SOILS IFORAIATIDN CAN BE OBTAIN FROM THE NATURAL RESOURCES CONSERVATION.SERVICE PWKSB 12.WILL PROPOSED ACTIVITY CAUSE FLOODING OR DRAINING OF WETLANDS? Y63 IFYFA IMPACTED AREA K_ACRES. ,&WILL EXCAVATION OR DREDGING BE REQUIRED IN WATER OR WETLANDS? OYES F YES: )00 A VOLUME: (CUBIC YARDS)UREA (ACRES) B. COMPOSITION OF MATERIAL TO BE REMOVED: C. DISPOSAL SITE FOR EXCAVATED MATERIAL: D. METHOD OF DREDGMN& 4.HAS THE STATE ENVIRONMENTAL POLICY ACT 09W gI OOMPLETED? O NO SEPALEADAGENCY: SEPADEpfIDW Oft MDN6,BLADOPTION,EXEMPTION DECIBgNDATE(EDOFPE11pDk SUBMIrA COPY OFYOUR DECISION LErMTO•WPFWABFI DFORAOOMPLETEAPPUCATI(W 5.LIST OTHERAPPLICATIONS,APPROVALS.ORCERTIFICAMMI2111011110TIOR F111001M.40TATEORLOCONLAANCEBFORAINYOWMESK CIRMTRUCTIOKD MW43MOR THERACTNITIESDESCRBEPIITHEAPPUCATION(LE»PRELI "WPUMTAPPIIOVAL.IEALTHDWINCTAPPROVAL,BURAMOM Mr.SE9AItREWIW,FEDERAL ENERGY REGULATORY COMMISSION LIME(FERC),FOREST PRAGTICEB APPUCATIDK ETC.)ALSO INDICATE WAI MEt W RIlt NMI SEEM COMPLETED A D INDICATE ALL EXISTING WORK ON DRAWWW& TYPE OF APPROVAL ISSU14 AGENCY KN3094CATION DATE OF APPLI ATION DATE APPROVED, COMPLETED? NO. &HAS ANY AGENCY DEPPM APPROVAL FOR THE ACTMTY DESCRY HEREIN OR FOR ANY AC MM DIIREMY RgATED TO THE ACTMTY DESCREMS] HEREIN? D YES IWMIF YES,EXPLAIN: SECTm B•LANs 1brshwaffm old of 7.TOTAL COST OF PROJECT,THIS MEANS THE FAR MARKET VALUE OF THE PROJECT.NCLUDINp MKFOWtB,LAMM MACHINE OWTAL%ETC w a LOCAL GOVENMM INT' XIpODIOTION: 9.FOR 0DRM COASTGUA lIk A►D DWPISINTM PROVIDE NAME ADOBE$AND TELEPHONE ORMUZ OF AONOINB PROPEtTYOVRNEIS, ESSEW ETC. PIEASENon--&VORL4IAE"VVAB4WrCQIpLN"A41YMQtWEADDIT"M NOTICE—COAISELTYOURLOCALM Bff NAME ADDRESS PHONE NUMOt r sECMN C-Tft soft MU8Tb& Ibrawmmmill .APMMATM IS HERE8Y UiAE FORA PERMIT OR PERIARE TO AUTHORIZE TIME ACTTVTTiF8 OEB BFD H� i cw"EMr1P'nw l AM smft R WTRI7HE NFORMATION CONTAEIED MI 7m APPLICATION.AND THAT 7O THE 6EST OF MY KNOWLEDGE AND BELL.SUCH M MTIQM IB 714M OOI MMIE,AND TE I FURTHER CERTIFY THAT 1 POSSESS THE AUTHORITY TO UNDERTAKE THE PROPOSED ACTIVIT1E& 1 HW*SY OW ff TO7HE AGENCIES TO W M APPLICATION IS MADE,THE RIGHT TO ENTER THE LOCATION TO INSPECT THE PROPOSED.MbPR MMS OR COMPLETED WORK, 1 AGREE TO START WORK QW AFTER ALL NECESSARY PERMRS HAVE BEEN RECEIVED. SIGNATURE OF APPLICANT OR AUTHORQED AGENT Dr 1 DESIGNATE TO ACT AS MY AGENT M MATTERS RELATED TO TM APPLICATION FOR PERMIft I MXMTAND THAT IF A FEDE &PERMT IS 1 MUST SIGN THE PERMIT. SIGNATURE OF APPLICANT DATE SIGNMTURE OF LANDOWNER ENTITY LANDOWNERS.E.G.DNR) TIf16 Tt011 ME 8101ED MYZkMMTAM7MAGW.IF AN AU"ClI MA INT IIS UMMOATED: 19 U.&C SIWI Provides drat-Whoever in any newer malmi ihapiedo m or my-V I nMlt or.Maq,al w 0thA liIMea l a 'q fmbNNW apwwls,«ours w br arrr ble�..a�.nR«eMo.. maul tact«nlekes tales acaaorn.«iaarerdsk stalrnarrts«trproseNaisns«makes«toss any fNes wM M or doommod bwwYq crams 10 asntein any fetes Ecafous.«saedWat ahlanrrd or Oft OW be Rrred not more Ilm S•M.000 or kwisoned not more than 5yaas«bosL v + ---Qgm dyy - "-f•4 A. t li ISO #'" gum -'3 y These Apencles are Equal ppporharity and AMirrrrOn Acllon amployaa. Fbr 3P6cM a000reffMMon needs.Please confect MIe approprials agency in the instrucuorm 1 PERMIT NO.: DATE RE RECEaUAWN DE P tRTM tT OF ` DIY 25 6i1:1RE1 ORDINANCE 411 N.5TH Street/P.O.Box 279,Shepon, WA 9"" 426 W. CE...-... . .. MASON ENVIRONMENTAL PERMIT M CONDITIONAL USE❑ VARIANCE❑ The purpose of the Resm"Ordinance Is to protect Mason'County's natural resource lands and critical areas and Is under the authority of Chapters 36.32,36.70A,39.34,58.17,76.09,84.33, 84.34 and 90.58 RCW. PLEASE PRINT ' Site Address: Owner Mans Address: �t/e A City: City: ►� f �61 �?t Od S Lien/Tide Holder. r----Fire D:Da t#mc� — � Address: city: Zip: Signature: 2• Parcel Number: Legal description. Parcel Size: 3S _ 3 Directions to Site 7-Z- p v 4. State what sections require a permit: In-Holding Lands,Chapter 17.01.062 ❑ Long-Term Commercial Forest,Chapter 17.10.060 ❑ Wetlands,Chapter 17.01.070 ❑ Mineral Resourc c Lands,Chapter 17.01.066 ❑ Frequently Flooded Areas,Chapter 17.01.090 ❑ Aquifer Recharge Arens,Chapter 17.01.080 ❑ Landslide Hazard Areas,Chapter',17.01.100 ❑ Erosion Hazard Areas,Chapter 17.01.104 ❑ Seismic Hazard Areas,Chapter 17.01.102 ❑ S. Fish and Wildlife Habitat Conservation Areas,Chapter,17.01.110 ❑ current use of property with existing Improvements:r .� L�1 ��..1 .✓ 6' Identify and describe the proposed project,including the type of materials to be used,construction methods,principle dimensions and other pertinent informati (Attach additional sheets if needed): , T Any water on or adjacent to property: Saltwater Lake ❑ River ❑ Pond ❑ Wetland ❑ Other Seasonal Runoff ❑ 8. Will there be an alteration of a wetland and/or wetland vegetation area? Yes ❑, No 9. If septic is located on project site,include records. Connect to septic? -ty Sic? ❑ Public Water supply? 0'Well?TZP 10. Type of Job:• New Add ❑ Alt ❑ Repair ❑ Demolition ❑ Other Ibis Permit's granted pursuant to the Resource Ordinance(Chapter 17.01 MCC)and nothing in this applicaat from compliance with piergit shall excuse the any other federal,state,or local statutes,ordinances,or regulations'applicsble to this project,but not inconsistent with the Resource Ordinance.The permit may be rescinded pursuant to the event the permittee fails to comply with the conditions of this ordinance. MASON ENVIRONMENTAL PERMIT: $510AWS305.00(with maa m permit) MASON CONDITIONAL USE MWM PERMrr: $1,225.00 MASON RESOURCE ORDINANCE VARIANCE: SIX5,00 REVISED: 12,5-2003 HEARINGS EXAMIIVERt $330.00 kTLANNINOWAMACENVIRONMBNTAL PERMIT APPLICATION $how the foflowina on the Site plan Lot Dimensions Flood Zones Existing Structures Fences Water Lines Driveways Drainage Plans Shorelines Septic System Topography Indicate Directional SEW by(1`l, , , ,etc.) Proposed improvements Easements In relation to plot plan Name K Flanking Street APPLICANT TO DRAW SITE PLAN BELOW: "a /-lack.&0- , .t 1 f jdid,E GrGo.�l� APPLICANT TO DRAW TOPOGRAPHY BELOW: