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Home My WebLink AboutSHX2012-00006 SEP2012-00013 - SHX Permit / Conditions - 3/22/2012 MASON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT Planning Division 104 P O Box 279, Shelton, WA 98584 (360)427-9670 MITIGATED DETERMINATION OF NONSIGNIFICANCE (WAC 197-11-350) SEP2012-00013 Description of Proposal: SHX SUBMITTED FOR 2 PILING REPLACEMENT PROJECTS ON LAKE CUSHMAN COMMUNITY DOCKS 1) 160 N POTLATCH DR, HOODSPORT -- Replace wood pilings with four 8" galvanized steel pilings. 2) off of N LAKE CUSHMAN RD, HOODSPORT -- Replace wood pilings with six 8" galvanized steel pilings. Proponent: WATERSMITH CONSTRUCTION INC Site Address (If Assigned): Directions to Site: 1). US HIGHWAY 101 NORTH, L ON LAKE CUSHMAN RD, L ON MT TEBO WY, L ON POTLATCH DR TO SITE ADDRESS ON THE RIGHT SIDE (LOCATION OF COMMUNITY DOCK) 2) Parcel Number: 423075000062 z `00 C'e Legal Description: LAKE CUSHMAN #2 TR 62 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 Rebecca Hersha at ext. 287 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 4/5/2012. Appeal oft is determination must be filed within a 14-day period following this final deter ination date, per Mason County Code Chapter 15.11 Appeals. ��- 0)42 Aufhorized Local Government Official Date SEP2012-00013 Page 1 of 2 aE strc, J STATE OF WASt INGTON DEPARTMENT O ECOLOGY PO Box 47775 •Olympia, Washington 98504-7775 •(360)407-6300 711 for Washington Relay Service •Persons with i speech disability can call 877-833-6341 April 5, 2012 Ms.Rebecca Hersha Your address Mason County v ;; is in the Department of Community Development ".r Skokct is ® Planning Division oseaiii S PO Box 279 ' ; watershed Shelton, WA 98584 Dear Ms. Hersha: Thank you for the opportunity to comment on the mitigated determination of nonsignificance for the Lake Cushman Dock Piling Replacement projec (SEP2012-00013) located at 160 North Potlatch Drive in Hoodsport as proposed by Brad Siith, Watersmith Construction Inc. The Department of Ecology(Ecology)reviewed the env ronmental checklist and has the following comment(s): WASTE 2 RESOURCES: Mike Drumright 60) 407-6397 Property owners, developers,and contractors an encouraged to recycle all possible leftover construction, demolition, and land clearing(CD )materials and reduce waste generated. Recycling construction debris is often less expei tsive than landfill disposal. Please visit Ecology's 1 800 Recycle Hotline database at: h :H1800rec cle.wa. ov or call the 1-800-RECYCLE hotline to find facilities that t iat will accept your CDL materials for reuse or recycling. The applicant proposes to remove a structure(s) at may contain treated wood. Please refer to Ecology's publication "Focus on Treated Wood Exclusion," available at: hn://www.ecy.wa.govL/pubs/0304038.pdf, fors iggested best management practices and disposal requirements for treated wood. For additional information or clarification,please contact Dee Williams with Ecology's Hazardou Waste and Toxics Reduction program,at (360)407-6348. SEPA REVIEWER: Sonia Mendoza WATER QUALITY CONTACT: Stephanie Jackson (360)407-6294 Erosion control measures must be in place prior to any clearing, grading, or construction. These control measures must be effective to pre vent soil from being carried into surface water by stormwater runoff. Sand, silt, clay par icles, and soil will damage aquatic habitat and are considered pollutants when discharged I D waters of the state. Any discharge of sediment-laden runoff or othe pollutants to waters of the state is in violation of Chapter 90.48, Water Pollution Cor trol, and WAC 173-201A, Water Quality MASON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT Planning Division P O Box 279, Shelton, WA 98584 olos (360)427-9670 MITIGATED DETERMINATION OF NONSIGNIFICANCE (WAC 197-11-350) SEP2012-00013 CONDITIONS OF THIS DETERMINATION 1) Sediment Any discharge of sediment-laden runoff or other pollutants to waters of the state is in violation of Chapter 90.48, Water Pollution Control, and WAC 173-201A, Water Quality Standards for Surface Waters of the State of Washington, and is subject to enforcement action. X Construction During construction, all releases of oils, hydra lic fluids, fuels, other petroleum products, paints, solvents, and other deleterious materi Is must be contained and removed in a manner that will prevent their discharge to waters and soils of the state. The cleanup of spills should take precedence over all other work on the site. X Debris Proper disposal of construction debris must be on land in such a manner that debris cannot enter Mason Lake or cause water quality degradation of state waters. X SEP2012-00013 Page 2 of 2 SEPA CHECKLIST $385 - Single Family (Mason County Permit Center Use) $630 - Non-Sing)e Family 0 to 9.99 Acres SEP - $755 -10 to 20 Acres $945 -Over 20 Acres Date Rcvd: 7 ' $2,525 + 70/hr-EIS (DS)� �.�.� TICr� PN: L-_ � (��' co 60A) Purpose of Checklist: . The State Environmental Policy Act(SEPA), chapter 43.21 C RCW, requires all governmental agencies to consider the environmental impacts of a proposal before making decisions. An environmental impact statement (EIS) must be prepared for all proposals with probable significant adverse impacts on the quality of the environment. The purpose of this checklist is to provide information to help you and the agency identify impacts from your proposal (and to reduce or avoid impacts from the proposal)and to help the agency decidEl whether an EIS is required. Instructions for Applicants: Governmental agencies use this checklist to determine whether the environmental impacts of your proposal are significant, requiring preparation of an EIS. Answer the questions briefly, with the most precise information known, or give the best description you can. You must answer each question accurately and carefully, to the best of your knowledge. In most cases, you should be able to answer the questions from your own observations or project plans without the need to hire experts. If you really do not know the answer, or if a question does not apply to your proposal, write "do not know" or "does not apply". Complete answers to the questions now may avoid unnecessary delays later. Some questions ask about governmental regulations, such as zoning, shoreline, and landmark designations. Answer these questions if you can. If you have problems, the governmental agencies can assist you. The checklist questions apply to all parts of your proposal, even if you plan to do them over a period of time or on different parcels of land. Attach any additional information that will help describe your proposal or its environmental effects. The agency to which you submit this checklist may ask you to explain your answers or provide additional information reasonably related to determining if there may be significant adverse impact. There is a fee required, for the processing of the checklist, see above for the appropriate fee. Please make your check payable to"Mason County Treasurer". A. BACKGROUND 1. Name of proposed project: - _TCF__._ ,..._........ . / ..E... ....._._�..._....._.._....._.__...._ ........ _... 2. Name of applicant: til 4 Property owner: 3. Applicant mailing address: � �(x.-, h t,) Applicant phone numbers: L _ ` �3 4. Date checklist prepared: 5. Agency requesting checklist: ,__ .. ._ ._. _ ,_..._......._to. '�_..-!... _.............. Mason County SEPA Checklist 1 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. /1 8. List any environmental information you know about that has been prepared, or will be prepared, directly related to this proposal. J A-c l'- r'l 9. Do you know whether applications are pending for governor ntal 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.) 12. What is the location of the proposal? Give sufficient inform tion for a person to understand the precise location of your proposed project including a street address, if any, anV section,township, and range, if known. If a proposal would occur over a range of area, provide the range or boubdaries 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. )e (G,o ,c I P 1�t c�. Q r I �-r z v w1�� Ca r cc 1 /J w. _( 7 3 cJ ge'C r cj } TG t. . L i' C `l Gt; `t_ �C1wi C'4 vt ge'c '6cvc-1 2 L) T e�� S 4: 1a ZS Ci C `1 Mason County SEPA Checklist 2 B. ENVIRONMENTAL ELEMENTS 1. EARTH: a. Ge 1neral description of the site (circle one): Flat, rolling, hilly, steep slopes, mountainous, other(explain). 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 note any prime farmland. d. Are there surface indications or history of unstable soils in the immediate vicinity? If so, describe. �� e. Describe the purpose,type, and approximate quantities of any filling or grading proposed. Indicate source of fill. r�� 3z 11 i' ) -aJ 11 L-11 ) 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: PAIL r c<..c 2. AIR: a. What types of emissions to the air would result from t co proposal(i.e. dust, automobile, odors, industrial wood smoke) during construction and when the project is pleted? If any, generally describe and give approxima a quantities, if known. i v y (� t j b. Are there any off-site sources of emissions or odor that may affect your proposal? If so, generally describe. I'd Mason County SEPA Checklist 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 flows into. 2) Wll the project require any work over, in, or adjacent to (within 200 feet)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. Indicate the source of fill material. 4) Will the proposal require surface water withdrawals or diversions? Give general description, purpose, and approximate quantities if known. /L!o 5) Does the proposal lie within a 100-year floodplain? If so, note location on the site plan. } 5_ 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. 00 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. "j o Mason County SEPA Checklist 4 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 t system(s) are expected to serve. A10 Ft e 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? A-I 0 ti e- 2) Could waste materials enter ground or surface waters: If so, generally describe. 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 grass pasture crop or grain wet soil plants: cattail, buttercup, bullrush, skunk cabbage, other water plants: water lily, eelgrass, milfoil, other other types of vegetation b. What kind and amount of vegetation will be removed or altered? Mason County SEPA Checklist 5 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: /AllJ".1 C. 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: 0awk, heron, oeag-iesongbirds other ..--.............._............... ...........___ Mammals: deer bear, elk, eaver� other Fish: bass, sa�rn�o trout herring, shellfish, other 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. �C 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. /-/L q b. Would your project affect the potential use of solar energy by adjacent properties: If so, generally describe. /J v 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: l C�r� 0 it ��f fi � � Mason County SEPA Checklist 6 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. A /'T 2) Proposed measures to reduce or control environmental health hazards, if any: b. Noise. 1) What types of noise exist in the area that may affect your project(for example: traffic, equipment, operation, ot`her)? .e c r� `i V ''�`cI? �L-L 2) What types and 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 hour's noise would come from the site. C�~i�c . �a r C c C c �' a � a) rtf c' 3) Proposed measures to reduce or control noise impacts, if any: n / 8. LAND AND SHORELINE USE: a. What is the current use of the site and adjacent properties? t—(, C :e__r'Al '01 b. Has the site been used for agriculture? If so, describe. c. Describe any structures on the site. d. Will any structures be demolished? If so,what? 1 Mason County SEPA Checklist 7 e. What is the current zoning classification of the site? f. What is the current comprehensive plan designation of the site? u T'G� g. If applicable,what is the current Shoreline Master Program designation of the site? S ��' e h. Has any part of the site been classified as an"environmentally sensitive" area? If so, specify. k1c. i. Approximately how many people would reside or work in the completed project? J ' j. Approximately how many people would the completed project displace? k. Proposed measures to avoid or reduce displacement impacts, if any: I. Proposed measures to ensure the proposal is compatible with existing and projected land uses and plans: 9. HOUSING: a. Approximately how many units would be provided, if any? Indicate whether high, middle, or low-income housing. 0 b. Approximately how many units, if any,would be eliminated? Indicate whether high, middle, or low-income housing. �1 c. Proposed measures to reduce or control housing impacts, if any: A,01- 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? _ j c. Proposed measures to reduce or control aesthetic impacts, if any: Mason County SEPA Checklist 8 11. LIGHT AND GLARE a. What type of light or glare will the proposal produce? Whet time of day would it mainly occur? N Gr ay L 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 A r0" C d. Proposed measures to reduce or control light and glare impacts, if any: 4// 12. RECREATION: a. What esignated and informal recreational opportunitie are in the immediate vicinity? b. Would the proposed project displace any existing recreational uses? If so, describe. /`L1 U c. Proposed measures to reduce or control impacts on recreation, including recreation opportunities to be provided by the project or applicant, if any: t)f A 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. !U C) 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: Mason County SEPA Checklist 9 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. ;,L 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. 'AJ 0 c. How many parking spaces would the completed project have? How many would the project eliminate? 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). 10 c e. Will the project use(or occur in the vicinity of)water, rail, or air transportation? If so, generally describe. // G f. How many vehicular trips per day would be generated 4y the completed project? If known, indicate when peak volumes would occur. g. Proposed measures to reduce or control transportation impacts, if any: N/ 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: AJ o b. Proposed measures to reduce or control direct impacts on public services, if any: /V/4 16. UTILITIES: a. Circle utilities currently available at the site: electricity, natural gas, water, refuse service, telephone, sanitary sewer, septic system, other: A) .1 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 that might be needed. /,j, The above answers are true and complete the be t of, y knowledge. I understand that the lead agency is relying on them to ma e i s decision. Applicant Signature: Date: Mason County SEPA Checklist \10 ESA LISTED SALMONIDS CHECKLIST This worksheet was designed to help project proponents, and government agencies, identify when a project needs further analysis regarding adverse effects or purposes,d`ESA Listed Species Act) s defined as fishd salmonids. species are l listed salmon, as trout and chars, e.g. bull trout. endangered,threatened or being considered for listing. roject If ESA listed species are present or ever and you present need ton the comply withhed where your the ESA. The questions in bath sasectionuwPl help has the potential for affecting them, y 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 your project will be located? YES L NO Please describe. L 01 a,-,I r / 2. Has there ever been an ESA listed salmonid stock present iri 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. PROJECT SPECIFICES: The question's in thisr'ction are specific 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 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_JK- 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)? Mason County SEPA Checklist 11 could FISH MIGRATION: The following questions will in watee dtermine if this ows can this projec fish t goat on interfere with migration of adult and juvenile fish. Both increases and 1. Does the project require the withdrawal of: a. Surface water? YES_ NO y` Amount Name of surface water body b. Groundwater? 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_ N If yes, will this be an infiltration pond or a surface givedischarge name of the wat municipal storm water system or a surface water body? If to a surface watd y, please YES_ NO— 4. Will this project require the building of new roads? YES_ NO and may impact fish habitat. Increased road mileage may affect the timing of water reaching a stream Y 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 by filling or other partial blockage of flows? YES_ NO I If yes, how will the loss of flood storage be mitigated by your project? WATER QUALITY: The following questions will help deter ine if this project could adversely impact water quality. Such impacts can cause problems for listed species. Water quality can be made worse by runoff from impervious surfaces, altering water temperature, discharging contaminants, etc. quality, in any of the streams,within this watershed? 1. Do you know of any problems with water YES_ NO -� If yes, describe. Mason County SEPA Checklist 12 2. Will your project either reduce or increase shade along or over a waterbody? YES,_ NO-2 If yes, describe. ing of structures such as docks or floats often results in a change in Removal of shading vegetation or the build shade. 3. Will the project increase nutrient loading or have the poie�tlfi es,to 'descnbe.nutrient loading or contaminants (fertilizers, other waste discharges,or runoff)to the waterbody. y YES _ NO 4. Will turbidity be increased because of construction 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 vegetation management, clearing of parking lots? YES— NO_X1 If yes, please describe. 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 removal 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? t J I rl YES — NO_ if yes,what types of plants will you use? The above answers d co plete to t be of my knowledge. I understand that the lead agency is relying on them to make its de io Date: Applicant Signature: Mason County SEPA Checklist 13 IMASON COUNTY SON.srATFo, DEPARTMENT OF COMMUNITY DEVELOPMENT �P M c Planning Division o s o �= P O Box 279, Shelton,WA 98584 ,'- o T (360)427-9670 7 NY Y �J �0 1864 Exemption from Shoreline Management Act Substantial Development Permit Requirement Case No.: SHX2012-00006 The Proposal By: WATERSMITH CONSTRUCTION INC 5018 LAMBSKIN ST SW TUMWATER,WA 98512 To undertake the following development: SHX SUBMITTED FOR 2 PILING REPLACEMENT PROJECTS ON LAKE CUSHMAN COMMUNITY DOCKS C ODSPORT -- Replace wood pilings with `{galvanizedvani ed stee 2) off of N LAKE CUSHMAN RD, HOOD pilings. 1) 160 N POTLATCH DR, HO SPORT -- Replace wood pilings with galvanized pilings. Within LAKE CUSHMAN 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 B-normal maintenance Please contact Rebecca Hersha at ext 287 if you have,any questions. Issued: 3/22/2012 Authorized Local Government Official Expires: 3/22/2014 cc: APPLICANT WDFW USACOE WDOE TRIBAL COUNCIL ,. -- i ----------- ----------- t AGENCY USE ONLY t 2 0 1 0 M ' a,U,Po Date received: t _ £ US Army corps , of Engineers• t ' WASHINGTON STATE $eattle District Agency reference#:cam r ' Joint Aquatic Resources Permit T %Parcel#(s): (Y-WLP Application (JARPA) Form q .1510 t' USE BLACK OR BLUE INK TO ENTER ANSWERS IN WHITE SPACES BELOW. , to -fi C ! , t ' _ _ - --' Part 1—Project Identification 2 1. Project Name (A name for your project that you create. Examples:Smith's Dock or Seabrook Lane Development) hel � ' � Ci,cN rkG-T � �r.Ce-►^i e-L Part 2—Applicant The person or organization responsible for the project. hel 2a. Name (Last,First,Middle)and Organization(if applicable) y 2b. Mailing Address (Street or PO Box) 2c. City, State, Zip 2e. Phone(2) 2f Fax 2 E-mail . 2d. Phone(1) G' & (Y c.J R •-f rlln, r Part 3—Authorized Agent or Contact Person authorized to represent the applicant about the project. (Note: Authorized agent(s) must sign 11 b. of this application.) [helpl 3a. Name (Last, First, Middle) and Organization (if applicable) I I A 3b. Mailing Address (Street or PO Box) Additional forms may be required for the following permits: • If your project may qualify for Department of the Army authorization through a Regional General Permit(RGP),contact the U.S.Army Corps of Engineers for application information(206)764-3495. . If your project might affect species listed under the Endangered Species Act,you will need to fill out a Specific Project Information Form(SPI or prepare a Biological Evaluation. Forms can be found at http:r'/www.nws.usace.arrny.mil/Publickienuirvlenu.cfm?sitename=REG&pagename=mainpage_ESA . If you are applying for an Aquatic Resources Use Authorization you will need to fill out and submit an Application for Authorization to Use State- Owned Aquatic Lands form to DNR,which can be found at http://www.dncwa.goviPubiicationsiagr_use_auth_app.doc . Not all cities and counties accept the JARPA for their local Shoreline permits.If you think you will need a Shoreline permit,contact the appropriate City or county government to make sure they will accept the JARPA. 2To access an online JARPA form with[help]screens,go to http:t/www.epermitting.wa.gov/site!alias_resourcecenter!jarpa_iarpa_foi-m!9984/iarpa_form.aspx. For other help,contact the Governor's Office of Regulatory Assistance at 1-8004917-0043 or help@ora.wa.gov. Page 1 of 13 JARPA 2010 v1 3/30/2010 3C. City, State, Zip T �•q � 3 E-mailF �-/ 3d. Phone(1) 3e. Phone(2) 3f. Fax (36"Il c/ cl ( Q ) `fez -Gcu ;��. Part 4—Property Owner(s) Contact information for people or organizations owning the property(ies)where the project will occur. hei ❑ Same as applicant. (Skip to Part 5.) ❑ Repair or maintenance activities on existing rights-of-way or easements. (Skip to Part 5.) ❑There are multiple property owners. Complete the section below and fill out DARPA Attachment A for each additional property owner. 4a. Name (Last,First,Middle)and Organization (if applicable) i ' f t ti C `I C Cc h �i Cie SVl �`'Gas -� 41b. Mailing Address (street or Po JBo-x) 4C. City, State, Zip _ 4d. Phone(1) e. Phone(2) 4f. Fax 4 E-mail ,,=) (��' ) ( { 3 (mac ) - r r �, cc . Part 5-Project Location(s) Identifying information about the property or properties where the project will occur. hei ❑There are multiple project locations (e.g., linear projects). Complete the section below and use DARPA Attachment B for each additional project location. r5a:. Indicate the type of ownership of the property. (Check all that apply.) heiState Owned Aquatic Land (if yes or maybe,contact the Departmentof Natural Resources(DNR)at(360)902-1100) Federal F4 Other publicly owned (state,county,city,special districts like schools, ports,etc.) ❑ Tribal ❑ Private 5b. Street Add Cannot be a PO Box.If there is no address,provide other location information in 5p.) hei ' 1 f 5C. City, State, Zip(If the project is not in a city or town,provide the name of the nearest city or town.) hel 5d. County hel Page 2 of 13 JARPA 2010 v1 3/30/2010 5e. Provide the section, township, and range for the project location. hel '/4 Section Section Township t Range f. Providthe latitude and longitude of the project location. hei • Example:47.03922 N lat./-122.89142 W long.(NAD 83) -56 go 5g. List the tax parcel number(s)for the project location. he! • The local county assessor's office can provide this irAormation. Cb h. Contact information for all adjoining property owners. (if you need more space,use JARPA Attachment C.) hel Tax Parcel# (if known) Name Mailing Addressn/A 1 A 0- irn4 5L List all wetlands on or adjacent to the project location. Ltjem 5j. List all waterbodies (other than wetlands) on or adjacent to the project location. Ite1 Z,AKz--, l �a max/ 5k. Is any part of the project area within a 100-year flood plain? hel ❑Yes ❑ No ❑ Don't know 51. Briefly describe the vegetation and habitat conditions on the property. LLem C C, i re Page 3 of 13 DARPA 2010 v1 3/30/2010 5m. Describ�how�theproperty �curre�ntlysed. r ei 5n. Describe how the adjacent properties are currently used. hel i 5o. Describe the structures (above and below ground) on the property, including their purpose(s). [nel LA- 5 Provide driving directions from the closest highway to the project location, and attach a mmap•� t_ x Cu��hYtCc, L. LQ GAL. (?, 2-11 0 LLJO, &)�)h - L- Page 4 of 13 DARPA 2010 v1 3/30/2010 Part 6—Project Description 6a. Summarize the overall project. You can provide more det;0 ini6d. [!!--IA U� � S f C L b r- 1r?� � C � o, y Fr`k�'CJ�j� M rep L,X ._ilk 6b. Indicate the project category. (Check all that apply) Lhei Transportation Recreational ❑ Commercial ❑ Residential ❑ Institutional ❑ ❑ Maintenance ❑ Environmental Enhancement 6c. Indicate the major elements of your project. (Check all that apply) [help] ❑ Road ❑ Aquaculture ❑ Culvert ❑ Float Scientific ❑ Bank Stabilization ❑ Dam/Weir ❑ Geotechnical Survey Scientific Device ❑ Boat House ❑ Dike/Levee/Jetty ❑ Land Clearing ❑ Stairs ❑ Boat Launch ❑ Ditch ❑ Marina/ Moorage ❑ Stormwater facility ❑ Boat Lift ❑ Dock/ Pier ❑ Mining ❑ Swimming Pool ❑ Dredging ❑ Outfall Structure ❑ Bridge ❑ Utility Line ❑ Bulkhead ❑ Fence Piling ❑ Ferry Terminal ❑ Retaining Wall ❑ Buoy (upland) ❑ Channel Modification ❑ Fishway ❑ Other: 6d. Describe how you plan to construct each project element checked in 6c. Include specific construction methods and equipment to be used. LtLed Identify where each element will occur in relation to the nearest waterbody. Indicate which activities are within the 100-year flood plain. ,;� C-" k t4 6e. What are the start and end dates for project construction? (month/year) "el PA Attachment D to list the start and end dates of each phase or If the project will be constructed in phases or stages,use JAR stage. Start date: c3 f End date: cZ ❑ See JARPA Attachment D Page 5of13 JARPA 2010 v1 3/30/2010 6f. Describe the purpose of the project and why you want or need to perform it. hei 6g. Fair market value of the project, including materials, labor, machine rentals, etc. hel 6h. Will any portion of the project receive federal funding? hel • if yes,list each agency providing funds. ❑Yes YX No ❑ Don't know Part 7-Wetlands: Impacts and Mitigation ❑ Check here if there are wetlands or wetland buffers on or adjacent to the project area. (If there are none, skip to Part 8.)Lbei rDescribehowct has been designed to avoid and minimize adverse impacts to wetlands. nel G r 7b. Will the project impact wetlands? hel ❑Yes R1 No ❑ Don't know 7c. Will the project impact wetland buffers? hes ❑Yes [�'No ❑ Don't know 7d. Has a wetland delineation report been prepared? hel • if yes,submit the report,including data sheets,with the JARPA package. ❑Yes [�J No 7e. Have the wetlands been rated using the Western Washington or Eastern Washington Wetland Rating System? hel • if yes,submit the wetland rating forms and figures with the JARPA package. ❑Yes o ❑ Don't know Page 6 of 13 JARPA 2010 v1 3/30/2010 7f. Have you prepared a mitigation plan to compensate for any adverse impacts to wetlands? net • If yes,submit the plan with the JARPA package and answer 7g. • If No,or Not applicable,explain below why a mitigation plan should not be required. ❑Yes ❑ No Not applicable 7g. Summarize what the mitigation plan is meant to accomplish, and describe how a watershed approach was used to design the plan. hel 7h. Use the table below to list the type and rating of each wetland impacted; the extent and duration of the impact; and the type and amount of mitigation proposed. Or if you are submitting a mitigation plan with a similar table, you can state (below)where we can find this information in the plan. hel Activity(fill, Wetland Wetland impact Duration Proposed Wetland Name' type and area(sq. of impact3 mitigation mitigation area drain, excavate, type (sq.ft. or flood, etc.) rating ft. or yp category2 Acres) acres) project documents,such If no official name for the wetland exists,create a unique name(such as"Wetland 1"). The name should be consistent with other as a wetland delineation report. 2 Ecology wetland category based on current Western Washington or Eastern Washington Wetland Rating System.Provide the wetland rating forms with the JARPA package. 'Indicate the days,months or years the wetland will be measurably impacted by the activity.Enter"permanent'if applicable. 4 Creation(C),Re-establishment/Rehabilitation(R),Enhancement(E),Preservation(P),Mitigation Bank/In-lieu fee(B) Page number(s)for similar information in the mitigation plan, if available: 7i. For all filling activities identified in 7h., describe the source and nature of the fill material, the amount in cubic ards that will be used, and how and where it will be placed into the wetland. hel kl/A- Page7of13 JARPA 2010 v1 3/30/2010 7'J. For all excavating activities identified in 7h., describe the excavation method, type and amount of material in cubic yards you will remove, and where the material will be disposed. hel Part 8—Waterbodies (other than wetlands): Impacts and Mitigation In Part 8, "waterbodies" refers to non-wetland waterbodies. (See Part 7 for information related to wetlands.) hel Check here if there are waterbodies on or adjacent to the project area. (If there are none, skip to Part 9.) 8a. Describe how the project is designed to avoid and minimize adverse impacts to the aquatic environment. hel ❑ Not applicable Cl & 8b. Will your project impact a waterbody or the area around a waterbody? hel Ef Yes Ea No 8c. Have you prepared a mitigation plan to compensate for the project's adverse impacts to non-wetland waterbodies? het • If yes,submit the plan with the JARPA package and answ• er 8 . If No,or Not applicable,explain below why a mitigation plan should not be required. ❑Yes Q No q Not applicable Page 8 of 13 JARPA 2010 v1 3/30/2010 nused marize what the mitigation plan is meant to accomplish. Describe how a watershed approach was to design the plan. ou already completed 7g.,you do not need to restate your answer here. hel All 8e. Summarize impact(s) to each waterbody in the table below. hel Activity (clear, Waterbody impact 2 Duration Amount of material Area (sq.ft. or dredge, fill, pile name' location of impact3 to be placed in inear ft.) of removed from r Iwaterbody drive, etc.) waterbod directly affected The name nt cum nts If no offiial name for the a ecwhether the impact willodCcurpn fs,create a unique name or adjacent t to he waterbody.(such adjacen prov de the dist ncel between the be mpact and etheowa eerbody and ed. ZIndc indicate whether the impact will occur within the 100-year flood plain. 3lndicate the da s,months or ears the waterbod will be measurabl impacted b the work. Enter" ermanent"if a licable. and nature of the fill material, amount (in cubic yards) 8f. For all activities identified in 8e., describe the source you will use, and how and where it will be placed into the waterbody. [held >V- �l 4 8g. For all excavating or dredging activities identified in 8e., describe the method for excavating or dredging, type and amount of material you will remove, and where the material will be disposed. help Al Page 9 of 13 JARPA 2010 v1 3/30/2010 Part 9—Additional Information Any additional information you can provide helps the reviewer(s) understand your project. Complete as much of this section as you can. it is ok if you cannot answer a question. 9a. If you have already worked with any government agencies on this project, list them below. nel Phone Most Recent Agency Name Contact Name Date of Contact 1�x46 Fes ; . f 9b. Are any of the wetlands or waterbodies identified in Part 7 or Part 8 on the Washington Department of Ecology's 303(d) List? het • If yes, list the parameter(s)below. • if you don't know,use Washington Department of Ecology's Wate Quality Assessment tools at: http//www ecY wa goviprograms/wq/303d/, ❑Yes No 9c. What U.S. Geological Survey Hydrological Unit Code (HUC) is the project in? hel • Go to http://cfpub.epa.gov/surViocate/index-cfm to help identify the HUC. J _�_) 10 1 9d. What Water Resource Inventory Area Number(WRIA ) is the project in? hel • Gotohttp://www-ecy-wa.gov/services/gis/maps/wria/wda-htmto rind the WRIA#. 9e. Will the in-water construction work comply with the State of Washington water quality standards for turbidity? hel • Go to http/fwww ecY wa aov/programs/wg/swgs/cdteria_html for the standards. ❑Yes ❑ No 0 Not applicable F If the project is within the jurisdiction of the Shoreline Management Act, what is the local shoreline environment designation? nel • If you don't know,contact the local planning department. • For more information,go to:http:i/www.ecy.wa.gov/programs,sea/sma!la s rules/173-26/211 desi nations.html. 4{' L{. F9g. What al M Urban ❑ Natural ❑Aquatic '��o�iservancy ❑ Other s the Washington Department of Natural Resources Water Type? nel http/tvrww.dnr.wa ov/Bu sine ssPermits(Topics/ForestPracticesAppIications/Pageslfp watertYping.aspx for the Forest Practices Water Typing System. ( Shoreline ❑ Fish ❑ Non-Fish Perennial ❑ Non-Fish Seasonal Page 10 of 13 JARPA 2010 v1 3/30/2010 9h. Will this project be designed to meet the Washington Department of Ecology's most current stormwater manual? hel • If no, provide the name of the manual your project is designed to meet. ❑Yes ❑ No /u Name of manual: 9i. If you know what the property was used for in the past, describe below. hel �CC i-eA, '/ Jill 9j. Has a cultural resource (archaeological) survey been performed on the project area? nel If yes,attach it to your JARPA package. ❑Yes No 9k. Name each species listed under the federal Endangered Species Act that occurs in the vicinity of the project area or might be affected by the proposed work. lam] 91. Name each species or habitat on the Washington Department I of Fish and Wildlife's Priority Habitats and o Species List that might be affected by the proposed Page 11 of 13 JARPA 2010 v1 3/30/2010 Part 10—SEPA Compliance and Permits Use the resources and checklist below to identify the permits you are applying for. Online Project Questionnaire at http://apps ecv wa goy,/opas/. Governor's Office of Regulatory Assistance at(800) 917-0043 or helpCcDora.wa.gov. For a list of agency addresses to send your application, click on the"where to send your completed JARPA" at http://www.epermitting.wa.gov. 10a. Compliance with the State Environmental Policy Act(SEPA). Check all that apply.) hel For more information about SEPA,go to www ecV wa gov!prograrns/sea/sepale-review.html. A copy of the SEPA determination or letter of exemption is included with this application. ❑ A SEPA determination is pending with (lead agency). The expected decision date is ❑ I am applying for a Fish Habitat Enhancement Exemption. (check the box below in lob.) hel ❑ This project is exempt(choose type of exemption below). ❑ Categorical Exemption. Under what section of the SEPA administrative code (WAC) is it exempt? ❑ Other: ❑ SEPA is pre-empted by federal law. 10b. Indicate the permits you are applying for. (check all that apply.) Lhel LOCAL GOVERNMENT Local Government Shoreline permits: ❑ Substantial Development ❑ Con d" 'oval Use Variance Type (explain): 12 XShoreline Exemption Y ---' ' Other city/county permits: ❑ Floodplain Development Permit ❑ Critical Areas Ordinance STATE GOVERNMENT Wa=Hydraulic ment of Fish and Wildlife: ❑ Approval (HPA) ❑ Fish Habitat Enhancement Exemption Washington Department of Ecology: ❑ Section 401 Water Quality Certification Washington Department of Natural Resources: ❑ Aquatic Resources Use Authorization FEDERAL GOVERNMENT United States Department of the Army permits (U.S.Army Corps of Engineers): ❑ Section 404 (discharges into waters of the U.S.) ❑ Section 10 work in navigable waters) United States Coast Guard permits: ❑ General Bridge Act Permit ❑ Private Aids to Navigation (for non-bridge projects) Page 12 of 13 JARPA 2010 v1 3130/2010 I Part I I—Authorizing Signatures Signatures are required before submitting the JARPA package. The JARPA package includes the JARPA form, project plans, photos, etc. nel 11 a. Applicant Signature (required) hel I certifythat to the best of my knowledge and belief, the information provided in this application is true, complete, and accurate. I also certify that I have the authority to carry out the proposed activities, and I agree to start work only after I have received all necessary permits. I hereby authorize the agent named in Part 3 of this application to act on my behalf in matters related to this application. (initial) By initialing here, I state that I have the authority to grant access t the grope Y. I also give my consent to the permitting agencies entering the property where the project is loc ed to insp ct the project site or any work related to the project. Applic na ur Applicant Printed Name 11 b. Authorized Agent Signature i,el I certify that to the best of my knowledge and belief, the information provide s,application is true, complete, and accurate. I also certify that I have the authority to carry out the proposed activities and I agree to start work only after all necessary permits have been issued. Date Authorized Agent Printed Name Authorized Agent Signature 11 c. Property Owner Signature (if not applicant). hel Not required if project is on existing rights-of-way or easements. I consent to the permitting agencies entering the property where the project is located to inspect the project site or any work. These inspections shall occur at reasonable times and, if practical,with prior notice to the landowner. Property Owner Printed Name Property Owner Signature Date on of ny department or ency of the United tates ngly al U.S., once provides that: by any Whoever, ny manner within scheme,or device a material(fact or makes any false,fictitious,or fraudulent statementslorr falsifies,conceals,m covers up by any same to representations or makes or uses any more thanwriting or document not more thanknowing5 years or bothn any false,fictitious, or fraudulent statementor entry,shall be fined not me than$10 if you require this document in another format,contact The Governor's People with a speech disabo yffice of ail Regulatory 833Assistance(ORA). People with hearing loss can call 711 for Washington Relay Service. ORA publication number: ENV-019-09 Page 13 of 13 DARPA 2010 v1 3/30/2010 PILE WSTALLATIO REPORT DATE: wa PROJECT NAME: Lake Cushman DIVISION 2 PROJECT ADDRESS: PILE_ 2,000 Drop hammer PILE SIZE AND MATERIAL: 8 in.Sch.40 galvanized steel Depth of Hammer Depth of Hammer Pile no. penetration Hammer fall blows per Pile no. penetration Hammer fall blows per foot (feet) height(feet) foot {feet} 1 � height c," L� (0 5 Chi V'` Final pen. g t~inal pen. Pro"1.Super Approved: �Q. 4 rAa to the West's Best Contractors Preferred Supplier s ems„ LYNNWOOD PHONE (4 EEATTLE PHONE (2o6)622-7880 ' $ELLEVUE PHONE ( 25)865-6622 BREMERTON PHC �7�-gi677 OLYMPtA PHONE TACOMA PHONE (263) ERNDALE PHONE AUBURN PHONE (263)864-3922, Gf' � t� _ s t = _ t r fy THE COMPLETE CONSTRUCTION&INDUSTRIAL RENTAL SERVICE i o 1/4-inch t ick n n }u �A-boltgdWitth'h-inch carriage and machine bolts,nuts and washers o Pad-eye hinges fabricated from'/2-inch thick steel,with 3/,-inch stainless steel pins Foam-filled polyethylene floatation tubs,bolted directly to the stringers utilizing hot-dipped galvanized 3/8-inch lags al stringers using composite decking fastened to g galvanized screws with matching color heads stringers and decking using stainless steel screws Black rubber perimeter bumper strip attached to 8-inch galvanized steel cleats, as needed Our specific proposals follow. Division 1 Dock Replace the six(6)existing wood piling with 8-inch, Schedule 40 galvanized steel pipe piling, including new galvanized steel pile hoops with UJUVIW rollers . The existing piling would be pulled,if possible, or cut off at ground level,and set aside on the shore. The steel piling would be driven with either a vibratory hammer utilizing a land-based crane, or a drop hammer from a floating barge. The cost of mobilization of pile driving equipment is incorporated in this price,assuming this pile driving work would be performed at the same time as the Division 2 pile driving. Our price for this Scope of Work is$15,500. ` Division 2 Dock 1. Replace the four(4}existing w od piling with 8-Minch, Schedule 40 galvanized steel pipe piling, ers . The existing piling would including new galvanized steppile hoops with UPNff roll pulled,if possible,or cut off t ground level, and set aside on the shore. The steel piling wouull d be driven with either a vibrato hummer utilizing a.land-based crane,or a drop hammer from a floating barge. The cost of mobilization of the piffle driving equipment is incorporated in this price, assuming this pile driving work would be performed at the same time as the Division 1 pile driving. Our price for this Scope of Work is$11,000. and install three(3) 8-ft x 20-ft floating d k sections, as described above. Existing floats Build_ g =- • would be re3nvv�d_by others. Our price for this Scope of Work is $16,000., .--' ft aluminum ra p per Mantle s design, including 3. Provide and install new may. W grooved rollers and guide fiberglass grating decking fastened w -stainles s ps'U1 IIV1 brackets with ram tracks,mid-height safety rail on both yids dot-dippeg�lYanized shore p connection shackles and h• ransition plate,bolted to 4x8 pier pile-timber(supplied and installed on theiefiy others),and lower 4-ft wide aluminum transition plate -skid are sprayed""su ace and U14MW drag edge. Existing wood ramp would be removed by others. price for this Scope of Work is$5,900. r .0 • 1� T I a �Y ' 11 � � f • � j II 3� • Y x t I Vl 10 ^{y�j ihV V Y y t , e9rn�, D > Go Z 0'0 0� u' �o2: ®-® rn 1 ©� ...y m a a a pz CD z PyON_STA MASON COUNTY C DEPARTMENT OF COMMUNITY DEVELOPMENT o A o � Planning Division Y o N z P O Box 279, Shelton, WA 98584 T 7 N y Y (360)427-9670 OJ �O 1864 Exemption from Shoreline Management Act Case No.: SHX2012-00006 Substantial Development Permit Requirement The Proposal By: WATERSMITH CONSTRUCTION INC 5018 LAMBSKIN ST SW TUMWATER, WA 98512 To undertake the following development: SHX SUBMITTED FOR 2 PILING REPLACEMENT PROJECTS ON LAKE CUSHMAN COMMUNITY DOCKS 1) 160 N POTLATCH DR, HOODSPORT -- Replace wood pilings with `{galvanized steel pilings. 2) off of N LAKE CUSHMAN RD, HOODSPORT -- Replace wood pilings with6 galvanized steel pilings. (9 Within LAKE CUSHMAN 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 B-normal maintenance Please contact Rebecca Hersha at ext 287 if you have any questions. r Issued: 3/22/2012 Expires: 3/22/2014 Authorized Local Government Official cc: APPLICANT WDFW USACOE WDOE TRIBAL COUNCIL ------------------------------------, ' AGENCY USE ONLY ' t ' t � sate 2 0 1 0 M Date received: US Army Corps WAS H I N GTO N STATE of Engineers• t Saattle District i Agency reference#:�} 1 r Joint Aquatic Resources Permit Application (JARPA) Form' T xParcel#(s): CP t t USE BLACK OR BLUE INK TO ENTER ANSWERS IN WHITE SPACES BELOW. ' CoJ�/� t t Part 1—Project Identification � � �� 1. Project Name (A name for your project that you create. Examples:Smith's Dock or Seabrook Lane Development) [hela12 IneiceQ_N 4y DbC k- Part 2—Applicant The person or organization responsible for the project. [teipj 2a.. Name (Last, First,Middle)and organization(if applicable) 21b. Mailing Address (Street or PO Box) 2c. City, State, Zip z___._— 2d.. Phone(1) 2e. Phone(2) 2f. Fax 2g. E-mail (3&0 )4!f e-vZv-z (J-6 i ) 1)t !({ ez ( .T6,V ) i Z -Or F(I 6 c^, cy w c�r�'�`r'r J�►, Part 3—Authorized Agent or Contact Person authorized to represent the applicant about the project. (Note: Authorized agent(s) must sign 11 b. of this application.) [heipl 3a. Name (Last, First, Middle) and Organization (if applicable) .4c, 3b. Mailing Address (Street or PO Box) 2! Additional forms may be required for the following permits: • If your project may qualify for Department of the Army authorization through a Regional General Permit(RGP),contact the U.S.Army Corps of Engineers for application information(206)764-3495. • If your project might affect species listed under the Endangered Species Act,you will need to fill out a Specific Project Information Form(SPIF)or prepare a Biological Evaluation. Forms can be found at http://www.nws.usace.army.mil/PublicMenu/Menu.cfm?sitename=RE G&pagename=mainpage_ESA • If you are applying for an Aquatic Resources Use Authorization you will need to fill out and submit an Application for Authorization to Use State- Owned Aquatic Lands form to DNR,which can be found at http://www.dnr.wa.gov/Publications/agr_use_auth_app.doc • Not all cities and counties accept the JARPA for their local Shoreline permits.If you think you will need a Shoreline permit,contact the appropriate city or county government to make sure they will accept the JARPA. ZTo access an online JARPA form with[help]screens,go to http://www.epemnitting.wa.gov/site/alias__resourcecenterrjjarpa-jarpa_form/9984fjjarpa_form.aspx. For other help,contact the Governor's Office of Regulatory Assistance at 1-800-917-0043 or help@ora.wa.gov. JARPA 2010 v1 3/30/2010 Page 1 of 13 3c. City, State, Zip 3d. Phone(1) 3e. Phone(2) 3f. Fax 3 . E-mail G,-� )4tC'-Z6E J (a-i ('300 `Oc' .c ci Part 4-Property Owner(s) Contact information for people or organizations owning the property(ies) where the project will occur. hel ❑ Same as applicant. (Skip to Part 5.) ❑ Repair or maintenance activities on existing rights-of-way or easements. (Skip to Part 5.) ❑ There are multiple property owners. Complete the section below and fill out JARPA Attachment A for each additional property owner. 4a. Name (Last, First,Middle)and Organization (if applicable) Ii-2 6,4 ('-'Ch, /'10-( ,a `I C Co . 4b. Mailing Address (street or PO Box) 7:�j--& AJ6-7 ft 14t�c ' s� cr 4c. City, State, Zip s A -) � 4d. Phone m 4e. Phone(2) 4f. Fax 4 . E-mail Part 5-Project Location(s) Identifying information about the property or properties where the project will occur. [help] ❑ There are multiple project locations (e.g., linear projects). Complete the section below and use JARPA Attachment B for each additional project location. 5a. Indicate the type of ownership of the property. (Check all that apply.) (n 1pj ❑ State Owned Aquatic Land (If yes or maybe,contact the Department of Natural Resources(DNR)at(360)902-1100) ❑ Federal EA Other publicly owned (state,county,city,special districts like schools, ports,etc.) ❑ Tribal ❑ Private 5b. Street Add (Cannot be a PO Box.If there is no address,provide other location information in 5p.) el O� '12 s 5c. City, State, Zip(if the project is not in a city or town,provide the name of the nearest city or town.) Plelp 5d. County h[ 'U �O'S-ocl JARPA 2010 v1 3/30/2010 Page 2 of 13 5e. Provide the section, township, and range for the project location. [L-_-1.] '/4 Section Section Township Range f. Provide the latitude and longitude of the project location. C • Example:47.03922 N lat./-122.89142 W long. (NAD 83) ,�5 � 5g. List the tax parcel number(s)for the project location. [help] • The local county assessor's office can provide this i ormation. l e' 04 h. Contact information for all adjoining property owners. (if you need more space,use DARPA Attachment C.) el Name Mailing Address Tax Parcel #(if known) h/A GIlL OUJ rt,zd . b G c� AWvDd GIB. 5i. List all wetlands on or adjacent to the project location. h[ eU 4 /- 5j. List all waterbodies (other than wetlands) on or adjacent to the project location. hel K& A-0.1 5k. Is any part of the project area within a 100-year flood plain? hel ❑ Yes ❑ No ❑ Don't know 51. Briefly describe the vegetation and habitat conditions on the property. hel 1.A-�--- C c 4J Fe — w o CleIe I-ex'4 v,, 09,n !300.c LJ OCCC.-r JARPA 2010 v1 3/30/2010 Page 3 of 13 5m. Describe how the property is currently used. hey L r 5n. Describe how the adjacent properties are currently used. ,Li cec-T-d-q L / Fc,,/ A' t-x � '-� 5o. Describe the structures (above and below ground) on the property, including their purpose(s). [�-gip 5 . Provide driving directions from the closest highway to the project location, and attach a map. LqW Yl U , L- Q n "0, L vri. T" 'T�-e�ao I'lJ6 0- -O't'L nn U1 q2_11 n L&ke, &)Sh M6.,,rL i2d-) 4wd -bfpe+ L' t4-ve- aL6 h V&A_: � �.-t6 S t - --U JARPA 2010 v1 3/30/2010 Page 4 of 13 Part 6—Project Description 6a. Summarize the overall project. You can provide more detail inr6d. fligipj C cc t rZ C." x CO) Y9 ` f g %1 6b. Indicate the project category. (Check all that apply) h( eI ] ❑ Commercial ❑ Residential ❑ Institutional ❑ Transportation Recreational ❑ Maintenance ❑ Environmental Enhancement 6c. Indicate the major elements of your project. (Check all that apply) [help] ❑ Aquaculture ❑ Culvert ❑ Float ❑ Road ❑ Bank Stabilization ❑ Dam /Weir ❑ Geotechnical Survey ❑ Scientific ❑ Boat House ❑ Dike/Levee/Jetty ❑ Land Clearing Measurement Device ❑ Boat Launch ❑ Ditch ❑ Marina / Moorage ❑ Stairs ❑ Boat Lift ❑ Dock/ Pier ❑ Mining ❑ Stormwater facility ❑ Bridge ❑ Dredging ❑ Outfall Structure ❑ Swimming Pool ❑ Bulkhead ❑ Fence Piling ❑ Utility Line ❑ Buoy ❑ Ferry Terminal ❑ Retaining Wall ❑ Channel Modification ❑ Fishway (upland) ❑ Other: 6d. Describe how you plan to construct each project element checked in 6c. Include specific construction methods and equipment to be used. [,Pa • Identify where each element will occur in relation to the nearest waterbody. • Indicate which activities are within the 100-year flood plain. /eU-1 'J4 r to— 04or V, rr", , Lxfw 1&t (0 6,q C W- rci Q'J 6e. What are the start and end dates for project construction? (month/year) h[ elp] • If the project will be constructed in phases or stages, use JARPA Attachment t3 to list the start and end dates of each phase or stage. Start date: End date: P4c 1 - Z cl l'L ❑ See JARPA Attachment D JARPA 2010 v1 3/30/2010 / Page 5 of 13 6f. Describe the purpose of the project and why you want or need to perform it. h[ eAi i 7�sr 5 t y7 cx r-e p It , LIJ o--r- L I-v'• t C w rV -A ( Feel r��r C,c t G f�{e Cf d 4 C-e �- lace Lot e --L4 6g. Fair market value of the project, including materials, labor, machine rentals, etc. [helal �l, 'lam:° 16, 6h. Will any portion of the project receive federal funding? • If yes, list each agency providing funds. ❑Yes 'No ❑ Don't know Part 7-Wetlands: Impacts and Mitigation ❑ Check here if there are wetlands or wetland buffers on or adjacent to the project area. (If there are none, skip to Part 8.) 7a. Describe how the project has been designed to avoid and minimize adverse impacts to wetlands. hel Not applicable 71b. Will the project impact wetlands? [helpi ❑ Yes [A No ❑ Don't know 7c. Will the project impact wetland buffers? hel ❑ Yes [,�g No ❑ Don't know 7d. Has a wetland delineation report been prepared? h[ ep] • If yes,submit the report,including data sheets,with the JARPA package. ❑ Yes [�3 No 7e. Have the wetlands been rated using the Western Washington or Eastern Washington Wetland Rating System? hel • If yes,submit the wetland rating forms and figures with the JARPA package. ❑ Yes E"�No ❑ Don't know JARPA 2010 v1 3/30/2010 Page 6 of 13 7f. Have you prepared a mitigation plan to compensate for any adverse impacts to wetlands? • If yes,submit the plan with the JARPA package and answer 7g. • If No,or Not applicable,explain below why a mitigation plan should not be required. ❑ Yes ❑ No Not applicable 7g. Summarize what the mitigation plan is meant to accomplish, and describe how a watershed approach was used to design the plan. k14 7h. Use the table below to list the type and rating of each wetland impacted; the extent and duration of the impact; and the type and amount of mitigation proposed. Or if you are submitting a mitigation plan with a similar table, you can state (below) where we can find this information in the plan. [elpl Activity (fill, Wetland Wetland Impact Duration Proposed Wetland drain, excavate, Name' type and area (sq. of impact3 mitigation mitigation area flood, etc.) rating ft. or type (sq. ft. or category2 Acres) acres) If no official name for the wetland exists,create a unique name(such as"Wetland 1"). The name should be consistent with other project documents,such as a wetland delineation report. 2 Ecology wetland category based on current Western Washington or Eastern Washington Wetland Rating System.Provide the wetland rating forms with the JARPA package. 3Indicate the days,months or years the wetland will be measurably impacted by the activity.Enter"permanent"if applicable. 4Creation(C),Re-establishment/Rehabilitation(R),Enhancement(E),Preservation(P),Mitigation Bank/In-lieu fee(B) Page number(s) for similar information in the mitigation plan, if available: 7i. For all filling activities identified in 7h., describe the source and nature of the fill material, the amount in cubic yards that will be used, and how and where it will be placed into the wet and. [i e A". A. JARPA 2010 v1 3/30/2010 Page 7 of 13 7j. For all excavating activities identified in 7h., describe the excavation method, type and amount of material in cubic yards you will remove, and where the material will be disposed. h�elnl I x�V)I-. Part 8—Waterbodies (other than wetlands): Impacts and Mitigation In Part 8, "waterbodies" refers to non-wetland waterbodies. (See Part 7 for information related to wetlands.) h[ elw ❑Check here if there are waterbodies on or adjacent to the project area. (If there are none, skip to Part 9.) 8a. Describe how the project is designed to avoid and minimize adverse impacts to the aquatic environment. ❑ Not applicable cJ—G� 8b. Will your project impact a waterbody or the area around a waterbody? El Yes 91 No 8c. Have you prepared a mitigation plan to compensate for the project's adverse impacts to non-wetland waterbodies? ItLeN • If yes,submit the plan with the JARPA package and answer 8d. • If No,or Not applicable,explain below why a mitigation plan should not be required. ❑ Yes ❑ No q Not applicable JARPA 2010 v1 3/30/2010 Page 8 of 13 8d. Summarize what the mitigation plan is meant to accomplish. Describe how a watershed approach was used to design the plan. • If you already completed 7g.,you do not need to restate your answer here. h i_:-] N�/I 8e. Summarize impact(s) to each waterbody in the table below. hel Activity (clear, Waterbody Impact Duration Amount of material Area (sq. ft. or dredge, fill, pile name' location of impact3 to be placed in or linear ft.) of drive, etc.) removed from waterbody waterbody directly affected If no official name for the waterbody exists,create a unique name(such as"Stream 1")The name should be consistent with other documents provided. 2Indicate whether the impact will occur in or adjacent to the waterbody. If adjacent,provide the distance between the impact and the waterbody and indicate whether the impact will occur within the 100-year flood plain. 3Indicate the days,months or years the waterbody will be measurably impacted by the work. Enter"permanent"if applicable. 8f. For all activities identified in 8e., describe the source and nature of the fill material, amount (in cubic yards) you will use, and how and where it will be placed into the waterbody. help) t14 8g. For all excavating or dredging activities identified in 8e., describe the method for excavating or dredging, type and amount of material you will remove, and where the material will be disposed. JARPA 2010 v1 3/30/2010 Page 9 of 13 Part 9—Additional Information Any additional information you can provide helps the reviewer(s) understand your project. Complete as much of this section as you can. It is ok if you cannot answer a question. 9a. If you have already worked with any government agencies on this project, list them below. hel Agency Name Contact Name Phone Most Recent Date of Contact A)A 'I A 4A ( ) ( ) 9b. Are any of the wetlands or waterbodies identified in Part 7 or Part 8 on the Washington Department of Ecology's 303(d) List? hel • If yes,list the parameter(s)below. • If you don't know,use Washington Department of Ecology's Water Quality Assessment tools at: v/Programs/wa/303d/. ❑ Yes No 9c. What U.S. Geological Survey Hydrological Unit Code (HUC) is the project in? [titi j] • Go to http://cft)ub.epa.gov/surf/locaterindex.cfm to help identify the HUC. '�_) )z> ) 9d. What Water Resource Inventory Area Number(WRIA#) is the project in? [i,e!p] • Go to http://www.ecy.wa.gov/services/gis/maps/wria/wria.htm to find the WRIA#. 0 P-1 * 1 (/,a 9e. Will the in-water construction work comply with the State of Washington water quality standards for turbidity? h( eM • Go to http://www.ecy.wa.gov/programs/wg/swgs/criteria.htmi for the standards. ❑ Yes ❑ No [9 Not applicable 9f. If the project is within the jurisdiction of the Shoreline Management Act, what is the local shoreline environment designation? MM • If you don't know,contact the local planning department. • For more information,go to:http://www.ecy.wa.gov/programs/sea/smtta/laws ruies/173-26/211 designations.htmi. Rural Urb'ari ❑ Natural ❑Aquatic 6o4servancy ❑ Other 9g. What is the Washington Department of Natural Resources Water Type? LtLeM • Go to http://www.dnr.wa.gov/BusinessPermitsfTopics/ForestPracticesApplications/Pages/fl) watertyging.aspx for the Forest Practices Water Typing System. LP M' Shoreline ❑ Fish ❑ Non-Fish Perennial ❑ Non-Fish Seasonal JARPA 2010 v1 3/30/2010 Page 10 of 13 9h. Will this project be designed to meet the Washington Department of Ecology's most current stormwater manual? Gn,_gj • If no, provide the name of the manual your project is designed to meet. ❑ Yes ❑ No /f Name of manual: 9i. If you know what the property was used for in the past, describe below. [r f t] 14 C r-eA J 1-1 9j. Has a cultural resource (archaeological) survey been performed on the project area? u �J] • If yes,attach it to your JARPA package. ❑ Yes No 9k. Name each species listed under the federal Endangered Species Act that occurs in the vicinity of the project area or might be affected by the proposed work. [t1eip] 91. Name each species or habitat on the Washington Department of Fish and Wildlife's Priority Habitats and Species List that might be affected by the proposed work. bglo JARPA 2010 v1 3/30/2010 Page 11 of 13 Part 10—SEPA Compliance and Permits Use the resources and checklist below to identify the permits you are applying for. • Online Project Questionnaire at http://apps.ecy.wa.gov/opas/. • Governor's Office of Regulatory Assistance at (800) 917-0043 or help a�ora.wa.gov. • For a list of agency addresses to send your application, click on the "where to send your completed DARPA" at http://www.epermitting.wa.gov. 10a. Compliance with the State Environmental Policy Act (SEPA). (check all that apply.) hem • For more information about SEPA,go to www.ecy.wa.gov/programs/sea/sepa/e-review.htmi. A copy of the SEPA determination or letter of exemption is included with this application. ❑ A SEPA determination is pending with ___------ (lead agency). The expected decision date is ❑ I am applying for a Fish Habitat Enhancement Exemption. (Check the box below in 10b.) ❑ This project is exempt (choose type of exemption below). ❑ Categorical Exemption. Under what section of the SEPA administrative code (WAC) is it exempt? ❑ Other: ❑ SEPA is pre-empted by federal law. 10b. Indicate the permits you are applying for. (Check all that apply.) [:�ejp LOCAL GOVERNMENT Local Government Shoreline permits: ❑ Substantial Development ❑ Condimtional Use ❑ Variance Shoreline Exemption Type (explain): , 1 !d�r. _r Y t�'�'L;t Other city/county permits: ❑ Floodplain Development Permit ❑ Critical Areas Ordinance STATE GOVERNMENT Washington Department of Fish and Wildlife: ❑ Hydraulic Project Approval (HPA) ❑ Fish Habitat Enhancement Exemption Washington Department of Ecology: ❑ Section 401 Water Quality Certification Washington Department of Natural Resources: ❑ Aquatic Resources Use Authorization FEDERAL GOVERNMENT United States Department of the Army permits (U.S. Army Corps of Engineers): ❑ Section 404 (discharges into waters of the U.S.) ❑ Section 10 (work in navigable waters) United States Coast Guard permits: ❑ General Bridge Act Permit ❑ Private Aids to Navigation (for non-bridge projects) JARPA 2010 v1 3/30/2010 Page 12 of 13 Part 11—Authorizing Signatures Signatures are required before submitting the JARPA package. The JARPA package includes the JARPA form, project plans, photos, etc. n( ei 11a. Applicant Signature (required) [-��pl I certify that to the best of my knowledge and belief, the information provided in this application is true, complete, and accurate. I also certify that I have the authority to carry out the proposed activities, and I agree to start work only after I have received all necessary permits. I hereby authorize the agent named in Part 3 of this application to act on my behalf in matters related to this application. ______ (initial) By initialing here, I state that I have the authority to grant access t the prope y. I also give my consent to the permitting agencies entering the property where the project is loc ed to insp ct the project site or any work related to the project. ________ — Applicant Printed Name Appli na ure Date 11 b. Authorized Agent Signature h[ pid certify that to the best of my knowledge and belief, the information provide application is true, complete, and accurate. I also certify that I have the authority to carry out the proposed activities and I agree to start work only after all necessary permits have been issued. --------------- --------------- -- ------------------------------- ------------------- Authorized Agent Printed Name Authorized Agent Signature Date 11 c. Property Owner Signature (if not applicant). Not required if project is on existing rights-of-way or easements. I consent to the permitting agencies entering the property where the project is located to inspect the project site or any work. These inspections shall occur at reasonable times and, if practical, with prior notice to the landowner. ------------ — -- -- -------------- ------------ Property Owner Printed Name Property Owner Signature Date 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. If you require this document in another format, contact The Governor's Office of Regulatory Assistance(ORA). People with hearing loss can call 711 for Washington Relay Service. People with a speech disability can call(877)833-6341. ORA publication number: ENV-019-09 JARPA 2010 v1 3/30/2010 Page 13 of 13 MASON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT Planning Division P O Box 279, Shelton, WA 98584 otoM (360)427-9670 MITIGATED DETERMINATION OF NONSIGNIFICANCE (WAC 197-11-350) SEP2012-00013 Description of Proposal: SHX SUBMITTED FOR 2 PILING REPLACEMENT PROJECTS ON LAKE CUSHMAN COMMUNITY DOCKS 1) 160 N POTLATCH DR, HOODSPORT -- Replace wood pilings with four 8" galvanized steel pilings. 2) off of N LAKE CUSHMAN RD, HOODSPORT -- Replace wood pilings with six 8" galvanized steel pilings. Proponent: WATERSMITH CONSTRUCTION INC � �boo s� � Site Address (If Assigned): R4iIIA51t40,41- Directions to Site: 1). US HIGHWAY 101 NORTH, L ON LAKE CUSHMAN RD, L ON MT TEBO WY, L ON POTLATCH DR TO SITE ADDRESS ON THE RIGHT SIDE (LOCATION OF COMMUNITY DOCK) 2) Parcel Number: 423075000062 2 q:)O Xl C e Legal Description: LAKE CUSHMAN #2 TR 62 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 Rebecca Hersha at ext. 287 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 4/5/2012. Appeal of this determination must be filed within a 14-day period following this final dete,rnination date, per Mason County Code Chapter 15.11 Appeals. Authorized Local Government Official Date SEP2012-00013 Page 1 of 2 x ��{Y aEE4 T`O STATE OF WASHINGTON DEPARTMENT OF ECOLOGY PO Box 47775 •Olympia. Washington 98504-7775 •(360)407-6300 711 for Washington Relay Service •Persons with a speech disability can call 877-833-6341 April 5, 2012 Ms. Rebecca Hersha Your address Mason County Is in the Department of Community Development S ;E"-. Planning Division _ , ,, PO Box 279 ' _: watershed Shelton, WA 98584 ' Dear Ms. Hersha: Thank you for the opportunity to comment on the mitigated determination of nonsignificance for the Lake Cushman Dock Piling Replacement project(SEP2012-00013) located at 160 North Potlatch Drive in Hoodsport as proposed by Brad Smith, Watersmith Construction Inc. The Department of Ecology(Ecology)reviewed the environmental checklist and has the following comment(s): WASTE 2 RESOURCES: Mike Drumright(360) 407-6397 Property owners, developers, and contractors are encouraged to recycle all possible leftover construction, demolition, and land clearing(CDL)materials and reduce waste generated. Recycling construction debris is often less expensive than landfill disposal. Please visit Ecology's 1 800 Recycle Hotline database at: http://1800recycle.wa.gov or call the 1-800-RECYCLE hotline to find facilities that that will accept your CDL materials for reuse or recycling. The applicant proposes to remove a structure(s)that may contain treated wood. Please refer to Ecology's publication "Focus on Treated Wood Exclusion," available at: hLtp://www.ecy.wa.gov/pubs/0304038.pdf, for suggested best management practices and disposal requirements for treated wood. For additional information or clarification,please contact Dee Williams with Ecology's Hazardous Waste and Toxics Reduction program, at (360)407-6348. SEPA REVIEWER: Sonia Mendoza WATER QUALITY CONTACT: Stephanie Jackson (360) 407-6294 Erosion control measures must be in place prior to any clearing, grading, or construction. These control measures must be effective to prevent soil from being carried into surface water by stormwater runoff. Sand, silt, clay particles, and soil will damage aquatic habitat and are considered pollutants when discharged to waters of the state. Any discharge of sediment-laden runoff or other pollutants to waters of the state is in violation of Chapter 90.48, Water Pollution Control, and WAC 173-201A, Water Quality MASON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT Planning Division P O Box 279, Shelton, WA 98584 olos (360)427-9670 MITIGATED DETERMINATION OF NONSIGNIFICANCE (WAC 197-11-350) SEP2012-00013 CONDITIONS OF THIS DETERMINATION 1) Sediment Any discharge of sediment-laden runoff or other pollutants to waters of the state is in violation of Chapter 90.48, Water Pollution Control, and WAC 173-201A, Water Quality Standards for Surface Waters of the State of Washington, and is subject to enforcement action. X Construction During construction, all releases of oils, hydraulic fluids, fuels, other petroleum products, paints, solvents, and other deleterious materials must be contained and removed in a manner that will prevent their discharge to waters and soils of the state. The cleanup of spills should take precedence over all other work on the site. X Debris Proper disposal of construction debris must be on land in such a manner that debris cannot enter Mason Lake or cause water quality degradation of state waters. X SEP2012-00013 Page 2 of 2 SEPA CHECKLIST $385 - Single Family (Mason County Permit Center Use) $630 - Non-Singl e Family 0 to 9.99 Acres y _ SEP $755 -10 to 20 Acres $945 - Over 20 Acres Date Rcvd: Z.- 1-1 2- $2,525 + 70/hr- EIS (DS)� ) �� `� p �� ce.C�hrvt�..,e�. 3�9.��M �o�xx7 Purpose of Checklist: The State Environmental Policy Act(SEPA), chapter 43.21 C RCW, requires all governmental agencies to consider the environmental impacts of a proposal before making decisions. An environmental impact statement (EIS) must be prepared for all proposals with probable significant adverse impacts on the quality of the environment. The purpose of this checklist is to provide information to help you and the agency identify impacts from your proposal (and to reduce or avoid impacts from the proposal)and to help the agency decide whether an EIS is required. Instructions for Applicants: Governmental agencies use this checklist to determine whether the environmental impacts of your proposal are significant, requiring preparation of an EIS. Answer the questions briefly, with the most precise information known, or give the best description you can. You must answer each question accurately and carefully, to the best of your knowledge. In most cases, you should be able to answer the questions from your own observations or project plans without the need to hire experts. If you really do not know the answer, or if a question does not apply to your proposal, write "do not know" or "does not apply". Complete answers to the questions now may avoid unnecessary delays later. Some questions ask about governmental regulations, such as zoning, shoreline, and landmark designations. Answer these questions if you can. If you have problems, the governmental agencies can assist you. The checklist questions apply to all parts of your proposal, even if you plan to do them over a period of time or on different parcels of land. Attach any additional information that will help describe your proposal or its environmental effects. The agency to which you submit this checklist may ask you to explain your answers or provide additional information reasonably related to determining if there may be significant adverse impact. There is a fee required, for the processing of the checklist, see above for the appropriate fee. Please make your check payable to"Mason County Treasurer". A. BACKGROUND 1. Name of proposed project: /-\.M' c..........._.CI �..C. R 1. ................_ t.0 '............ t.._G .._W..6............... ��t"z`' C 2. Name of applicant: iQq �-Ct- Property owner: G ci e N K c K c e �� G .. ... c� 3. Applicant mailing address: U/ (Zimf �� , w �} f Applicant phone numbers: - 41 2 - oZO L ' S&,) - cf yt l zo 4. Date checklist prepared: 5. Agency requesting checklist: _.... ..Cf...Is...G-A..............._ `_` ... ......_................_............ .... Mason County SEPA Checklist 1 7 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. 8. List any environmental information you know about that has been prepared, or will be prepared, directly related to this proposal. J A.,e P/1 &J�o at, e A 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. ✓C/c 1-0.List any government approvals o ermits 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.) pwS41 k9ovj � �� ► �� GY t-e ��4�e y� vC� yi �cc� Seel (�� 1 ►�� 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. '-T-Zwv S"o-V-S r . F6-a el s r o r o A- ;9a r ccA J v. 4 13 0 � - V- &OV k L Toc-14 . 0 'L3 . ram 64 4T9 'H' g1gI -J/Z30 fy, flz ► r DiuoSi�� Pa:1L �- i1.1, Lake �ua �► c.,, �A. �o�tCt /��v: gzvo• , ,Sc�c:-�cc�r� Zc7 ! Tor..a k i 4• � Z3 � c Ct�-i s� AJ g Mason County SEPA Checklist 2 o Z13 Z © O B. ENVIRONMENTAL ELEMENTS 1. EARTH: a. General description of the site (circle one): Flat, rolling, hilly, steep slopes, mountainous, other(explain). 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 note any prime farmland. d. Are there surface indications or history of unstable soils in the immediate vicinity? If so, describe. ILIc- e. Describe the purpose, type, and approximate quantities of any filling or grading proposed. Indicate source of fill. ® 4 C L tJrt c•c c f. Could erosion occuras a result of clearing, construction, or use? If so, generally describe. NO ( `-t g. About what percent of the site will be covered with impervious surfaces after project constructions (for example, asphalt or buildings)? r 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. ` f 4101 i U e b�"r S�/4t f 0 , U `�.. L�"t � �"t (Z�fs '/I s..c.� ' �I C�CC` f►"C-�S b. Are there any off-site sources of emissions or odor that may affect your proposal? If so, generally describe. Mason County SEPA Checklist 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 flows into. FALL � -"C"-1 9 L o LO-- c L' 0 4"- - 2) Will the project require any work over, in, or adjacent to(within 200 feet)the described waters? If yes, please describe and attach available plans. Qc, weer )S L^-d� P:ese—k 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. 4) Will the proposal require surface water withdrawals or diversions? Give general description, purpose, and approximate quantities if known. /J�L- 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. j 'l.,t 0 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. Mason County SEPA Checklist 4 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? /Lletie- 2) Could waste materials enter ground or surface waters: If so, generally describe. d. Proposed measures to reduce or control surface, ground, and runoff water impacts, if any: A 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 grass pasture crop or grain wet soil plants: cattail, buttercup, bullrush, skunk cabbage, other water plants: water lily, eelgrass, milfoil, other other types of vegetation b. What kind and amount of vegetation will be removed or altered? Ail) Mason County SEPA Checklist 5 c. List threatened or endangered species known to be on or near the site. A L14 d. Proposed landscaping, use of native plants, or other measures to preserve or enhance vegetation on the site, if any: ,4.1,)n 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: awk heron, eagle songbirds other_ ............ <..._.._�. Mammals: deer bear,- elk eave other Fish: bass, salmo-A, trout herring, shellfish, other 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. /,li- 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. doK -f b. Would your project affect the potential use of solar energy by adjacent properties: If so, generally describe. JU 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 SEPA Checklist 6 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. N/'T 2) Proposed measures to reduce or control environmental health hazards, if any: b. Noise. 1) What types of noise exist in the area that may affect your project(for example: traffic, equipment, operation, other)? rtc MC 1 _ 2) What types and 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 hour's noise would come from the site. r-G.r.c �� ( c L� �: per C tpl �v 3) Proposed measures to reduce or control noise impacts, if any: YA 8. LAND AND SHORELINE USE: a. What is the current use of the site and adjacent properties? b. Has the site been used for agriculture? If so, describe. 0, 0 c. Describe any structures on the site. d. Will any structures be demolished? If so,what? Mason County SEPA Checklist 7 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. i. Approximately how many people would reside or work in the completed project? �� eL j. Approximately how many people would the completed project displace? �"+0 k. Proposed measures to avoid or reduce displacement impacts, if any: 4�4- I. Proposed measures to ensure the proposal is compatible with existing and projected land uses and plans: 9. HOUSING: a. Approximately how many units would be provided, if any? Indicate whether high, middle, or low-income housing. b. Approximately how many units, if any, would be eliminated? Indicate whether high, middle, or low-income housing. 61, 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? V Cc(-,dC � C b. What views in the immediate vicinity would be altered or obstructed? c. Proposed measures to reduce or control aesthetic impacts, if any: J /U 0 Mason County SEPA Checklist 8 11. LIGHT AND GLARE a. What type of light or glare will the proposal produce? What time of day would it mainly occur? AJ 4 `7 b. Could light or glare from the finished'prroject be a safety hazard or interfere with views? f�t f c. What existing off-site sources of light or glare may affect your proposal: /L/0 1 d. Proposed measures to reduce or control light and glare impacts, if any: 12. RECREATION: a. What esignated and informal recreational opportunities are in the immediate vicinity? yp b. Would the proposed project displace any existing recreational uses? If so, describe. M 0 c. Proposed measures to reduce or control impacts on recreation, including recreation opportunities to be provided by the project or applicant, if any: IJJA 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. X-s 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: CIA' Mason County SEPA Checklist 9 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. lam' «,` S; � 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. i, c. How many parking spaces would the completed project have? How many would the project eliminate? '/'/1 e- 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). e. Will the project use(or occur in the vicinity of)water, rail, or air transportation? If so, generally describe. ,AJV f. How many vehicular trips per day would be generated by the completed project? If known, indicate when peak volumes would occur. / '.L c_ g. Proposed measures to reduce or control 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: AJ u b. Proposed measures to reduce or control direct impacts on public services, if any: 16. UTILITIES: a. Circle utilities currently available at the site: electricity, natural gas, water, refuse service, telephone, sanitary sewer, septic system, other: /1-10 t-f— 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 that might be needed. The above answers are true and complete the be t of y knowledge. I understand that the.lead agency is relying on them to ma e i s decision. -`� Applicant Signature: �- Date: Z �— Mason County SEPA Checklist �10 ESA LISTED SALMONIDS CHECKLIST 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 your project will be located? YES NO Please describe. ccA/- 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. PROJECT SPECIFICES: The questions in this section are specific to the project and vicinity. 1. Name of watershed: _S`, 2. Name of nearest waterbody: /'t/ie. 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)? Mason County SEPA Checklist 11 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 waterbody, please give the name of the waterbody. YES_ NO_ 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 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 by filling or other partial blockage of flows? YES_ NO I If yes, how will the loss of flood storage be mitigated by your project? 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 quality can be made worse by runoff from impervious surfaces, altering water temperature, discharging contaminants, etc. 1. Do you know of any problems with water quality, in any of the streams, within this watershed? YES_ NO -J� If yes, describe. Mason County SEPA Checklist 12 2. Will your project either reduce or increase shade along or over a waterbody? YES_ NO If yes, describe. Removal of shading vegetation or the building of structures such as docks or floats often results 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? If yes, describe. YES _ NO 4. Will turbidity be increased because of construction of the project or during operation of the project? YES NO X 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 vegetation management, clearing of parking lots? YES_ NO k If yes, please describe. 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 removal 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? The above answ d co plete to th be of my knowledge. I understand that the lead agency is relying on them to make7its,.de ' io Applicant Signature: Date: Mason County SEPA Checklist 13