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HomeMy WebLinkAboutSEP99-0016 JARPA SPI99-0006 - SEP Determinations - 2/11/1999 Permit No. MASON COUNTY TWO BUILDING PERMIT APPLICATION 426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628 (Calling From: Seattle 464-6968, Belfair 275-4467, Elma 482-5269) PLEASE PRINT � pti/T/t1C #1 Owner v1A7- - �cE ,v Phone# 3G Z7s—909 i� Site Address po'l Fire District# City P0Cr3saor_-r *,Ww 9851E St Zip Directions to Job Site — C� I-ra //NveOSOD2T l�b o A1t< l;, '/ AfV„� �D ?D MCS% AC IA?LOPE7AtQ/V 7- _roleA..( t.L 4-7 TO LG K E CcJ 5 f-Ff(*#4� 41 Owner Mailing Address - City .. St Zip L ien0tle Holder Address City St ZI #2 Contractor Name ko(=-W1L Cowa s-r �Mc. Contractor Reg# ogq�z Address p.o. aF,`1 - tR FLFPIQ Expiration Date (�' / 1� /. 9<� City 2 St V( Zi Phone#_ i,o--Z7 s -9d9 9 #3 If septic is located on project site, include records. Connect to Septic? Public Water Supply_Well Connect to Sewer System? Name of System (if residential, proof of potable water is required) '/ So #4 ` Parcel No. �t 2 . (� - Legal Description LAkc- Cush L L c (o #5 Building Square Footage: 1st FI !2 5-0 2nd FI 3rd FI Loft Basement #Bedrooms Z_ # bathrooms 0— Deck S 1 Z Other Garage_ 5Z6 Carport (Circle:Attached or Detached?) #6 Use of building ()time C& Describe work #7 Type of Job: New _Add Alt _Repair Other #8 MOBILE/MANUFACTURED HOME INFORMATION Model Year Make Model Installer Name: Length Width Serial No. Certification Number: #Bedrooms # Bathrooms Type of Heat Purchase Price$ #9 WATER ON OR WITHIN ;L001 OF THE PROPERTY [ ]SALT [ ]RIVER/CREEK [ ]POND [LAKE [ ]WET NAME OF BODY OF WATER ___ Kf_-_G.5r4mp� _Slopes�Bluffs r"> ,YES NO Plumbing Fixtures, Fig Mechanical Fixtures No. 2 Toilets 2 CIRCLE FUEL TYPE: Gas, Electric, B 11 8 Heatpump, Other_ ?P_0PA'-x—_ O Bath Tubs No Unk Fees Showers Furn BTU Hot Water Htr _ Heatpumps Laundry Washer _ Vent Systems Sinks _ Spot Vent Fans Floor Drains No. Boilers/Compressors _Laundry Basins _ HP Dishwasher No. Air Handling Units _Disposal _ cfm# _Urinals No. Fire Protection Systems _Other _ Auto. Fire Alarm Sys fixed Fire Supp. Sys Permit Basic Fee _ Auto Fire Sprink Sys TOTAL PLUMBING $ No. Other Z Gas Outlets `7 t� _ Wood, Gas, Pellet Stove Propane Tank q , J NOTICE: THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COM- MENCED WITHIN 180 DAYS OR IF CONSTRUCTION OR Permit Basic Feel WORK IS SUSPENDEDOR ABANDONED FORA PERIOD TOTAL MECHANICAL $ OF 180 DAYS AT ANY TIME AFTER WORK IS COM- MENCED. PROOF OF CONTINUATION OF WORK 1S BY MEANS OF A PROGRESS INSPECTION. OWNERS AFFIDAVIT CONTRACTORS AFFIDAVIT I CERTIFY THAT I AM EXEMPT FROM THE REQUIRE- I CERTIFY THAT I AM A CURRENTLY REGISTERED MENTS OF THE CONTRACTORS REGISTRATION LAW CONTRACTOR IN THE STATE OF WASHINGTON AND I RCW 18.27, AND AM AWARE OF THE MASON COUNTY AM AWARE OFTHE ORDINANCE REQUIREMENTS REGU- ORDINANCE REQUIREMENTS FOR WHICH THIS PER- LATING THE WORK FOR WHICH THE PERMIT IS ISSUED MIT IS ISSUED AND THAT ALL WORK DONE WILL BE IN AND ALL WORK DONE WILL BE IN CONFORMANCE CONFORMANCE THEREWITH.NO CHANGES SHALL BE THEREWITH. NO CHANGES SHALL BE MADE WITHOUT MADE WITHOUT FIRST OBTAINING APPROVAL FROM FIRST OBTAINING APPROVAL FROM THE BUILDING, THE BUILDING DEPARTMENT. DEPARTMENT. X OWNER X BY i DATE DATE 9 > � 31 11�" ou �` '6I i Plumbing Fixtures , d Fgg Mechanical Fixtures No. 2 Toilets Z CIRCLE FUEL TYPE: Gas, Electric, Heatpump, Other �/L�PA-mac T Bath Tubs No. Unk Fees _Showers Furn BTU / Hot Water Htr _ Heatpumps I Laundry Washer _ Vent Systems Sinks _ Spot Vent Fans _Floor Drains No. Boilers/Compressors _Laundry Basins _ HP Dishwasher No. Air Handling Units _Disposal cfm# _Urinals No. Fire Protection Systems Other �_� _ Auto. Fire Alarm Sys Fixed Fire Supp. Sys Permit Basic Fee �0 _ Auto Fire Sprink Sys TOTAL PLUMBING $ _ No. Other Z Gas Outlets �,-7 = t� Wood, Gas, Pellet Stove Propane Tank NOTICE: THIS PERMIT BECOMES NULL AND VOID IF k WORK OR CONSTRUCTION AUTHORIZED IS NOT COM- MENCED WITHIN 180 DAYS OR IF CONSTRUCTION OR Permit Basic Feed WORKIS SUSPENDEDOR ABANDONED FORA PERIOD OF 180 DAYS AT ANY TIME AFTER WORK IS COM- TOTAL MECHANICAL $ � MENCED. PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. OWNERS AFFIDAVIT CONTRACTORS AFFIDAVIT I CERTIFY THAT I AM EXEMPT FROM THE REQUIRE- I CERTIFY THAT I AM A CURRENTLY REGISTERED MENTS OF THE CONTRACTORS REGISTRATION LAW CONTRACTOR IN THE STATE OF WASHINGTON AND I RCW 18.27, AND AM AWARE OF THE MASON COUNTY AM AWARE OFTHE ORDINANCE REQUIREMENTS REGU- ORDINANCE REQUIREMENTS FOR WHICH THIS PER- LATING THE WORK FOR WHICH THE PERMIT IS ISSUED MIT IS ISSUED AND THAT ALL WORK DONE WILL BE IN AND ALL WORK DONE WILL BE IN CONFORMANCE CONFORMANCE THEREWITH.NO CHANGES SHALL BE THEREWITH. NO CHANGES SHALL BE MADE WITHOUT MADE WITHOUT FIRST OBTAINING APPROVAL FROM FIRST OBTAINING APPROVAL FROM THE BUILDING. THE BUILDING DEPARTMENT. DEPARTMENT. X OWNER X BY i ,-- --' DATE DATE 9 R IL1S� 001Y/fx�;�a�wj, y re/ "+5 y o, Accebtad:bv: x ,,,, - ...., x, 4�. iII . ,f'a,., 0 aO D O Z ;:Lr v � ( Dn � co � cCX)i, � _ c � D O Z rn IN20' -2o rn_ � �E A2� Z rn CoN[Q�s`t j atM*� 0 rn F--xN,-rIA4 5F(>VC fu4 L �tTt bPOSEA Z _ ac l p 1 I Roo0Stt� tii 1Tl C� u C4- f , a� a) ° = �' o � � c=n' k t x W cr i -4 0000 T -- cn m d p Oca O _. � . CCD � as Cfl O _� LAKE CO O co Cn N 00 n Receipt No. Amount Paid ✓ • 5 DEPARTMENTAL REVIEW Cash neckck FOR OFFICE USE ONLY Check ,� Approved Cond. Hold Approval Planning: Environmental Health: Building Plan Review G'0--, -,. Occupancy Group:- Type of Const: Fire Marshal: Other: Fee Calculations: FEES Building Permit �® Plan Check u d S 7 72 . S Plumbing Fee Mechanical Fee zz Wood/Gas/Pellet Stove Violation Fee Site Inspection Building State Fee UFC Plan Review Other Other Building Valuation: TOTAL FEE Receipt No. Amount Paid 5 DEPARTMENTAL REVIEW Cash — Check ✓ FOR OFFICE USE ONLY Check # Approved Cond. Hold Approval i Planning: Environmental Health: Building Plan Review Occupancy Group: Type of Const: Fire Marshal: Other: Fee Calculations: FEES Building Permit Plan Check Plumbing Fee Mechanical Fee Wood/Gas/Pellet Stove Violation Fee Site Inspection Building State Fee UFC Plan Review Other Other Building Valuation: TOTAL FEE Show following on the site plan Lot Dimensions Fends Existing Structures Driveways Structure Setbacks Shorelines Water Lines Topography Drainage Plan Wells Septic Systems Easements Proposed Improvements Name of Side Street Indicate Directional by (N, S, E, W) Name of Fronting Street in relation to plot plan APPLICANT TO DRAW SITE PLAN BELOW 4�L APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW � F � Vl _� _(_ LAB SEP99-0016 MASON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT Planning-Landfill-Utilities MITIGATED DETERMINATION OF NONSIGNIFICANCE (WAC 197-11-350) Description of Proposal : CONSTRUCT 1.5 FT HIGH BY 110 FOOT LONG ROCK BULKHEAD FOR BANK PROTECTION ACROSS TWO LOTS WITH UPLAND RESIDENCES. REPAIR/REPLACE EXISTING DOCK ON LOT 8, CONSTRUCT DOCK ON LOT 65. DOCKS 'IARE 30 FEET LONG, 6 FEET WIDE, WITH 10 FOOT BY 6 FOOT FLOAT AT RIGHT ANGLE AT END. Proponent: JAMES JENSON Location of Proposal : 200 N POTLATCH DR HOODSPORT PARCEL#:423185000008 LAKE CUSHMAN #3 TR 8 LAKE CUSH RD TO DIV 2,3,4, DOWN HILL ELFT AT BOTTOM ON POTLATH DR JUST PAST BOAT RAMP ON RIGHT. 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 .21C. 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. MITIGATION MEASURES ARE ATTACHED. _ Please contact Pa'�w at ext. o�q with any questions . This DNS is issued under 197-11-350 (2) , the Lead Agency will not act on this proposal for 14 days from the date below. Comments must be submitted by 02/25/99 . DATE• 2/11/99 Signa r of responsible official Date Responsible Official : Gary Yando — b (5, Director of Community Development �.iJ 426 W. Cedar, un PO BOX 578 �:�-C►v 07� � - Shelton, WA 98584 Jam : (360) 427-9670 I 16�t �.tt{31S Bo*EbE.< 01 Q9 4 MIT-DNS, rev: 08/23/96 ��il ,',AD� 02-09-1999 13:24 8775952 LAKE CUSHMAN REALTY P.02 Is P RECEIVED P,f(�-� `� F E B 0 91999 CO.MAOM MR. ( 1 � 1 / c--}+ (�s to foe ha�5� i ryS Zti 90 QQCP- �fl4 ko Aine 02-09-1999 13:24 8775952 LAKE CUSHMAN REALTY P.03 R CE1 ED FEB 0 9 1999 WE ON co.PLAM DO. fA C f � f �► p cn 41 � 1 r I -t cl 0 r , � i X y J I 02-09-1999 13:25 8775952 L KE CUSHMAN REALTY P.06 IP FF8 d 9 t4g9 co, i i ' � N � 'K r 1 � � I I 02-09-1999 13:24 8775952 LAKE CU3HMAN REALTY P.05 RECEIVED FEB 0 9 1999 mwN co.POMNG DEFT. 06 -L -�I 1 r "T 02-09-1999 13:24 8775952 LAKE CUSHMAN REALTY P.04 RECE ED FEB 0 91499 low Qa car, �y C c� C rt � r c N h • 4r F MASON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT Planning Division 411 N. Fifth, P.O. Box 578 Shelton, WA 98584 (360) 427-;670 DATE: 01/21/99 TO: 1ATTHEW KLEIN 14315 BATH RD E.HMAN ROAD PUYALLUP WA 98374 RE: RETAINING WALL Case No. : SPI99-0006 Parcel No. : 423075000065 Dear Applicant: As part of this department ' s review on your permit application, a Shoreline (SPI) site inspection was performed on your property. Below you will find comments made regarding the proposed development and it ' s critical values . In some cases, setbacks for developmen* from shorelines, steep slopes, streams, and wetlands must be included in your specific proposal; these setbacks are included as part of the comments listed below. This information is based on County and State regulations as they exist to date. These regulations may change and may affect the requirements for development of the subject property. Please contact me at (360) 427-9670 or 360) 275-4467, ext. � if you have any questions . Sincerely, Land Use Planner Department of Community Development COMMENTS: Site visits for Klein & Jenson & Letter of Incompleteness: Planning staff performed site visit and observed and photographically documented that this site does not appear to have an existing seawall as referenced in the permit applcation. Please clarify whether this is to be viewed as new construction as new construction of a bulkhead across the entire two parcels, or as installation of a small section (where?) . In G addition, the site plan references "repair dock" on Jenson site, and "new dock" on Klein site. Please submit dock plans for both docks. Once they are received, review and SEPA issuance will occur. In the meantime, no action will occur on this permit pending receipt of required materials. cc: Sund & Sons, Contractor P.O. 477 Hoodsport, WA 98548 SPI, rev. 05/16/96 C'L L-+c, Or-% c 1'A' i I i I I 1 l I i I I I �• 7 G r � (P t 1 i` �j to 14 t JARPA FORM Oki (for us*in Wasrington Sf W) t•LCASE TYPE On rnarT Mi BU1E on MAGK PC &,,od on pie pfvooding djo4ftt.1 ern sending oople>t of 9119 epplImtion 10 the 10"OV V: (Q(1BCkad that apply) Local GoverTinieht for ehoretine: l7 Substruttial D�evelolxnent []Condltiorvd Use [3 Variance ❑ExenVtkxi:or,if applicable E]Ffaodplaln Management ❑Crlticaf Arens Ordinance "KA Washington Deparbnerlt of f'isli+And WOdUfe for I WA ` Washkngton Department of Eooiogy for. L Af><Irmad b Allow Temporary Exoeedance of Water Quality Starxtards ❑401 Water Quality Certification Nationwide PemTlts [] Washington[fepartmerit of Natural Fto_sourves for:[1 Acpm0o resources Use AutfToiization Notification :[- Corps Erghwers for: ❑S©cWn 404 [1 section 10 pemttt Coast Qitard for. ❑Section 8 ELd2o Pemtit E=ONA -Us*forafl permits covwvd br this plkedom Be sure!to Rlso compfets Soctlon C(Signaftav Bloch forefl permit llclydons. ArP(1GANr".. , FlOr PliOrrE FAX# NOT agent Is acting for the opplicArrt during tile pomilt process,complete IZ AUnfMZED AGENT �. IAAII.MKt ADDRESS �. WORK P11Me Mom- rAx. nr AYMSr#f`or Ar n"m To rn(N'EtTY: 17 O TACR D rvnctQsm O LESSEE Q OMER: ate• 'l5 H"AF ADORE-M AND r+loffE NL mrn or PtiovEfTTY owuMs)•w cmiEn UM AMPUCAW.- .t w- y p y�.j C?�. Z- 17l A--TT F— (e—t ✓t^., Q IY U�(�� U p (k) f ,1 5 i LOCATION(STREET ADOPESS.P#CLtKM4G CITY,COUNTY AND ZIP COOS-WHERE PROPOSED ACTraTY EXISTS On WILL OCCUR) `j a "t'�f)C7 ���0 Lt ��� r �J � v S TRI AR OF ATEntIODY 6TC'iTOrI TOWNSfIIP n/VIGE GOVPR AFUTLOT SiIORELrNEDESIGNATION ZONING DESIGNATION Jr PARCEL No. [:t"�! I `� �"LL`., G J C., L� DNR STFiEA1A TYPE.IF Y.rJOWT1 A,Vkallon PAQf 1 of 4 • M R Of:SCf1TOE TV CT CtXVU W T USE Or n lE PfWlEnTY.AND STRUCTUTTES tO=*a oN TITE PfiOPERTY.IF ANY PORTION of THE Pf10POS6D ACTivTTY IS ALREADY AOIft" � ON nss Pf10PERTY.tNDrATX MONTH AND YFAn OF OOMPL.ETION tS n IC-Pf14PEfTTY AGTUCUI.TVRAL LAND?E]YES 4 No ARE YOU A USDA P110GRAM PARTIMAIM E3 YES O No T�. DCSCfUBE n/E PROPOSED WOfUC COMPLETE PLANS AND smanCATIONS SIKJVLO BE PROVIDED FOR ALLrviow WATEiRWAno of THE ordm ARY IHG11 WATER MARK on I • m Oc_s=3E nIE PtXV'Ose of ntE PROPOSED WORK ._.}. 7a DF-SCME TILE POTENTIAL M.11'ACTS TO CIW1ACTtRISTIC USES Of TI1E WATER BOOM, nIESE USES MAY t1"tooE FlSII AND AQUATIC LIFE•WATER OUAIM.WATER SITM'LY,RECRE.ATIM•M AE-STI IETICS. tDENTTEY PROPOSED ACTIONS TO AVOID.MIMM M AND MITIGATE IMENTAL IMPACTS.AND PROVIDE PROPER PROTECTION fMTEPARATION Of DRAWINGS: SEE APPENDIX A-SAMPLE DRAW1UGS AND CHECKLIST FOFi COMPLETING T11E DRAWINGS ONE SET Of ORIGINAL OR GOOD OUAUTT' REOROOMftl.E OM WINGS&fM BE ATTACHED. NOTE: APPLICANTS ARE ENC0VnAGED TO SUBMIT Pt10TOGRMt1S Of THE PROJECT SITE,8UT THESE DO NOT SUBSTITUTE TOR DRAWINGS. INE CORPS Of ENGINEERS AND COAST GUARD REQUIRE DRAWINGS ON 8-1/7 X 1I MYCH SHEETS. LAROER DRAWTNOS IITAY BE REQUIRED BY OTHER AQEtAVEa �."t;t.n+e PROJECT BE OONSTTIUCTED IN STAGES? ❑YES NO PROPOBEO I"ART1t10 DATE .IEI V •EI I C:, (il_II I E' F r 8775952 _ k USt�nar Rc Al T Y 1�-�9-1998 11'4.' iCCJTIUN t-U"for Nror+11n.S*d comps N por"I'ller Aev ' .a r.00rrnr r+w�oT• e.w r w.�s+sVYW T�,urna+a*..+=�sa uas>,+�uus •r#or�rNt�w+�ta►sra � A+n°eusµ �nixilOrNt�� vwrIlPtilkuMrMt+n.r...,M M IiMMI Rcm 1+tJWn t e")OH 0."0"t"m asurr be cWMAD e for"p"t --vr+d y et>3r airpgodl+r► WE TM AOTNTIrms ADd�*�tApftKIAMIN d�cAof.T►a no►a a t�tllr TM To Tv�� ro�VMWJ c APM ALL t W fern KWE� of�R oa wtrlorstm pp�. rr+tisr !O YI�/OrrT M! VQ TM a'ILMOr SOH FOR rWMV1'p4 1 IM�T T1"T W A Ilr16fTM IiRJR I IRKrMa fli►�YT. "I LJ.rar}OM'1�11 r►rrRY �.Dr/r t►l?11. �N/AI�/ll6ATKrM�Y M��1'TrM NTIAIWt Mil Tlr KlI+L�wi/t11MOrn'✓M�AI�fT M p�wrMT�. l�MtrryW%mrw.M&V M Ar66~ wwrVA"111M 1a1ofOV dowe""of M Rw* 1 w .frw = + � ~ 41 It It Theo"Ap+ncbr•f1 604W CV?OrtvvW wi d A 4-mv"A#W ORWIvr•n. 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BACKGROUND: 1. Hame of proposed project, if applicables 2. Hame of applicant: 3. Address 1 phone number of applicant & contact persons ,cd �zGy~l'� oc� S�tN < < tJ - J r-� Ss`1 `1 �CD � �' 4. Date checklist prepared: t-1—_ -7--7__ 5. Agency requesting eheeklistt 6. Proposed timing or schedule (including phasing, if applicable)s 7. Do you have any plans for future expansions or further activity related to or connected with this proposalt If yes,, explain. t� a. List any environmental information you know about that has been prepared, or will be prepared, directly related to this proposal. ' n-� C0 r 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. La. List any government spprovale or permits that will be needed for your proposal, if.knovn. 11. Give a brief, complete description of your I proposal, including the proposed uses and the size of the project and site. There are several questions later in thin 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. ) 7 J l 1 r. . To BE t onpLLTED BY APPLICANT MICTALM FOR � QxT.Y 12. What in 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 aite(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. port e.1--}'I�j B. EMROKKEHTAL ELENEHTS c 1. EARTH: a. : General-description of the site (sire Le one) : Flat, rollin hilly, steep slopes, ■ untainoun, other b. What' is the steepest slope on the site (approximate percent slope)? ;z- _ �o o. What general types of soils are found' on the site (for example, clay, sand, gravel, peat, suck)? If you know the classification of agricultural coils, apecify then and not any prime farmland. SeA,r'-A Y &-r-4L0 ��I S d. Are there surface indications or history of unstable voila in the immediate vicinity? If ao, describe. � J 2 To an Camnxm BY APPLICANT EtlALUATIox FM AGENCY USE ONLY e. Describe the purpose, type, and approximate quantities of any filling or grading proposed. Indicate source of fill. f. Could erosion occur as a result of clearing, construction, or uae? Ijf so, generally describe. XJ g. About what percent of the site will be covered with impervious surfaces after project constructions (for example, asphalt or buildings)? h. : Proposed measures to reduce or control erosion, or other impacts to the earth, if any. : 2. AIR: a. What types of emissiona 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. t . b. Are there any off-site sources of emir ions or odor that may affect your proposal? If so, generally describe. H/A C. Proposed measures to reduce or eontrollemisaions or other impacts to air, if any: /V N/A 3 t TO BE (�2iPI.ET® DT APf'i.ICAxT EVALUATICm Fm AGMICT USE o3tLy 3. MATERs a. Surfaces 1) Is there any surface water body on or in the immediate vicinity of the site (including year-round and seasonal streams, saltwater, lakes, ponds, wetlands)? If yes, describe type and provide names. If appropriate, state what stream or river it flows into. / 2) Will the project require any work over, in, or adjacent to (within 200 feet) of the described waters? If yes, please describe and attach available plans. L� 3) Estimate the amount of fill and dredge material .that would be placed in or removed from surface water or wetlands and indicate the area of the site that would be {affected. Indicated the source of fill material. 4) Will the proposal require surface water withdrawals or diversions? Give general description, purpose, and approximate quantities if known. o 5) Does the proposal lie within a 100-year•floodplain? If no, note location on the site plan. AA3 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. 4 FOR To BE COMMEM BY APPLICAXT AGENCYGENCUATIOx T USE MI.MY T b. Grounds 1) Will ground rater be withdrawn. or will rater be discharged to ground ratert Give general description, purpose, and approximate quantities, if known. lj 2) Describe waste material that will be discharged into the ground from septic tanks or other sources, if any (for example, Domestic sewages Industrial, containing the general size of the system, the number of such systems, the number of houses to be served (if applicable), or the number of animals or humane the system(s) are expected to serve. C. Water Runoff (including storm water)s 1) Describe the source of runoff (including storm water) and method of collection and disposal, if any (include quantities, if known). Where will this water flow? Will this water flow into other,-waters? If so, describe. Z 2) Could waste materials enter ground or surface raters? If so generally describe. ,f , d. Proposed measures to reduce or control surface; ground, and runoff water impacts, if anys i 4. PLAHTS: a. Check or circle types of vegetation found on the site: /deciduous trees alder, maple, aspen, other —,Z evergreen tree: fir, cedar, pine, other shrubs grass pasture crop or grain vet soil plants: cattail, buttercup, bullrush, skunk cabbage, others water plants: water lily, eelgrass, milfoil, other 5 Fm IO To BE COKPL M BY APPLICANT AGF�CY tl EVALUA USE SE UYI.YMT b. What kind and amount of vegetation will be removed or altered? I 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: �- rr�4 x► „� �\r U�,, `� 5. ANIKALSS 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: hawk, heron, eagle, songbirds, other 1�4Isc�• �� r S _._,_,�. mammals: <ff—ee-Rh bear, elk, beaver, other fish: bass, salmon, _ ou , 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. AJO d. Proposed measures to preserve or enhance wildlife, if any: 6. ENERGY AHD 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. H/A 6 EVALUATION FOR TO g8 CaffIS fiD BY APPLICANT AGENCY USE ONLY b. Mould you project affect the potential use of solar energy by adjacent properties? If so, generally describe. H/A ' 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 t H/A 7. EHVIROHKEHTAL 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. 11 describe special emergency services that might be required. /I ce-42— K/A 2) Proposed measures to reduce or control environmental health hazards, if any: b. Noise. 1) What types of noise exists in the area which may affect your project (for example: traffic, equipment operation, other)? H/A 2) What types of levels of noise o would be created by or associated with the project or a long-term basis (for examplet traffic, construction, operation, other)? Indicate what AA hours noise could come from the site. , cLv'Z-< �I tQ GG1.1✓1 P't,l 41 7 EVAI ATION FM TO BE cO2iP1.E m BT ♦PPLICW ♦GENCT USE Ony 3) Proposed measures to reduce or control noise impacts, if any: . g. LAND AHD 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. / C. Describe any structures on the site. k CY-UAS2- d. Will-any structures be demolished? If so, what? e. What is the current zoning clnassific tion of the site? Qrvi ��. i f. What is the current comprehensive plandesignation of the site? P 5 t c�lp^�✓ g. If applicable, what in the current shoreline master program designation of the site? h. Has any part of the site been classi ied as an `environmentally sensitive' area? If no, specify. i. Approximately how many people would reside or work in the completed project? H/A A J. Approximately how may people would the completed project displace? H/A 8 To BE COHPLETED 8x APM1CkKT EVALUATION FOR AGENCY USE My k. Proposed measures to avoid or reduce displacement impacts, if any: H/A 1. Proposed measures to ensure the proposal is compatible with existing and projected land uses and plans, if anyx g. HOUSING: a. Approximately how may units, if any, would be provided? Indicate whether high, middle, or low- income housing. H/A b. Approximately how many units, if any, would be eliminated? Indicate whether high, middle, or low- income housing. H/A C. Proposed measures to reduce or control housing impacts, if any s H/A 10. AESTHETICS: a. What is the tallest height of any proposed ' structure(s), not including antennas; what is the principal exterior building material(s) proposed? A/ b. What views in the immediate vicinity would be altered or obstructed? /,///q c. Proposed measures to reduce or control aesthetic impacts, if any: J 11. LIGHT AND GLARE: a. What type of light or glare will the p�oposal produce? What time of day would it mainly occur? H/A 9 FM TO HE COHPIXTED BY APPLICAYT EALUATI AGfiHCY USEE OlLyxLY b. Could light or glare from the finished 'project be a safety hazard or interfere with views? , N/A I C. What existing off-site sources of light or glare may affect your proposal: H/A d. Proposed measures to reduce or control light and glare impacts, if any: H/A 12. RECREATION: a. ' What designated and informal recreational opportunities are in the immediate vicinity?, b. Would the proposed project displace any existing recreational uses? If so, describe. C. Proposed measures to reduce or control impacts on recreation, including recreation opportunities to be provided by the project or applicant if any: 13. HISTORIC AND CULTURAL PRESERVATION: a. Are.there any places or objects listed on, or proposed for, national, state, or local preservation registers known to be on or next to the site? If no-generally describe. ILA) b. Generally describe any landmark or evidence of historic, archaeological, scientific, or cultural importance known to be on or next to the site. /1/ n---Q e. Proposed measures to reduce or control impacts, if any: �,� 10 Fm TQ BE (aHPLEM BY APPLICAKT EIIAar UM any A(ifi�CY tlSfi Qx1.Y 14. TRAHSPORTATIOHs a. Identify public streets and highways serving the site and describe proposed access to the existing street system. Show on site plans, if any. b. Is site currently served by public transit? If not, what is the approximate distnnaelto the existing street system. Show on site plans, if .any. H/A C. How many parking spaces would the completed project have? How many would the project eliminate? H/A d. Will the proposal require any new roads or streets, or improvements to existing roads or streets, not including driveways? If no, generally describe (indicate vhether -public or private). H/A e. Will the project use (or occur in the immediate vicinity of) water, rail, or air transportation? If so generally describe. H/A 1, f. How many vehicular trips per day would be generated by the completed project? If known, indicate when peak volumes would occur. H/A g. Proposed measures to reduce or control transportation impacts, if any: H/A 11 TO BE CORPLETED BY APPLICAKT EVALUATIOM FOR AGQCT USE OIELY 1g, PUBLIC SERVICES: a. Mould the project result in an increased need for public service (for example: fire protection, police protection, health care, schools, other)? If so generally describe. H/A I b. Proposed measures to reduce or control direct impacts on public services, if any: N/A l 16. UTILITIES: I a* IMIle cities currently avaleblc. 8t—the�site: ectri y. natural gas, water a service telephone, 'sanitary serer, s ptic i3 bier. b. Describe the utilities that are proposed for the project, the utility providing the service, -and the general construction activities on the site or in the immediate vicinity vhich might be needed. 17. SIGNATURE: The above ansrers are true and complete to the best of my knowledge. I understand that the lead agency is relying on them to make its decision. Signature: Date Submitted: 12