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HomeMy WebLinkAboutWAI2024-00028 - WAI Health Waiver - 4/5/2024 MASON COUNTY COMMUNITY SERVICES Building,Planning Emlronmental Health,Community Health 415 N 61h Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 4- Better (360)2754467 ext 400 tir Elms: (360)482-5269 ext 400 FAX (360)427-7787 Application for WVveel al Amount Paid: JJ Receipt Number.ZO?'�r�( Instructions � fjaa� 1. Complete Parts 1 and 2. No determination can be made until these parts are fully completed. 2. Fees maybe billed for waivers and appeals, based on the Environmental Health Fee Schedule. 3. Submit completed application with attachments to Mason County Public Health for review. PART 1. ApplicanVParcel Identification Name of Applicant AMANDA BUMGARNER Telephone Mailing Address of Applicant 301 W FREDSON ROAD City SHELTON State WA Zip 98584 12-digit Tax Parcel No. 3 1 9 0_7 --- 1 2 _-_0 0 0 9 0 Site Address 303 W FREDSON RD, Subdivision Name and Lol PART 2: Nature of Waiver/Appeal ❑ CDnIraC[Of Certification Requirements ❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists) ❑ Separation ❑ Food Sanitation Requirements ❑ Building Permit Review Policies ❑ Group B Water System Regulations V Location,WAG 246-272A-0210 ❑ Water Adequacy Requirements ❑ Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines ❑ Mason County Onsite Standards ❑ Departmental Determinations ❑ Other Description of Waiver/Appeal(include justification,additional material may be attached.): CLASS A WAIVER:TRANSPORT LINE CROSSING OF DRAINAGEISTREAM. MEETS CLASS A MITIGATION REQUIREMENTS OUTLINED. SEE STATE FORM g SEPTIC DESIGN SITE PLAN FOR COMPLETE WAIVER MITIGATION DETAILS. THIS IS A REPAIR OF A FAILING OSS Applicant Signature: Q*01` 9 a tl �Date: f1�s� 7 tf 1:\EH Forms\Waiver-Appeal Mason County Local Revised 1/202017 Page 1 of2 PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver(if applicable) ❑Appeal YWaiver ❑ None required lass A ❑ Class B ❑ Class C 2. Identification of Specific Code/Standard/Determination (include date of determination or latest Code/ Standard revision) 1^l��i. / _2-7-�DZt Q 3. Nature of Appeal: V V W D 5 4w-y- � I�[r�Spv4 k �2 W t 1r1 &A✓r,s_ww31 CQ-Otsari .[ r C 4. Hearing Official: ❑ Board of Health ❑ Health Officer ❑ Pollution Control hearing Board ❑ Public Health Director ❑ Certified Contractor Review Board Environmental Health Manager 6. Mitigating Factors: a o VV ne r 6. 1 have received this waiver/appeal request. It is complete and mitigation required by the state and local policy has beensubmitted. Staff Signature: 1'�-f 7`"� � qW Date: PART 4: Determination of the Hearing Official The hearing official has determined that approval of this request will not adversely affect public health and is hereby granted.This decision is based on the following findings and conditions: ❑ The hearing official has determined that approval of this request could potentially adversely effect public health and is hereby denied. This decision is based on the following findings and conditions: Hearing Official Signature: tE7 /�, Date: T L 1 1:\EH Ponns\Waiver-Appeal Mason County Local Revised 1/2=017 Page 2 of 2 Granting Waivers from State On-Site Sewage System Regulations Chapter 246-272A WAC Effective Date: July I,2007 Revised April 2017 On-Site Sewage Systems (Chapter 246-272A WAC) Re uest for Waiver from State Regulations Section I. (completed byapplican9 Name: () AMANDA BUMGARNER LocalHcalm 0 inst ant/District (z) (see instrueNons) Add. 301 W FREDSON RD .. ....... . ........... . .......- ........ . .-- ........ --.... .....--- SHELTON, WA 98584 Telephone: ( ) ,. ....................._..._.........................................--. ._._ ._.... .. .......__..- _ . ......- —. ......... _ .._—................... Signal Property identification: Of319 7-1 -00090, 303 W FREDSON RD Section IL (completed by applicant) WAC Number: (4) WAC Requirement: (5) Waiver Sought: (6) 246-272A 0210 PRESSURE SEPTIC LINE SEPTIC LINE CROSSING OF_,_. Subsection: TA 11 BLE IV. .......10'+ FROM 9IJRFA E'W.47ER ...._SURFACE WAT15 Justification(mitigarion measures to be provided): (7) TRANSPORT LINE WILL BE ENCASED IN SCH.40 STEEL, BURIED 3FT .................................................... ....1.. I...... ...... .. DEEP BELOW BOTTOM OF DRAINAGE&WAN 10 DEG.PERPENDICULAR TO DRAINAGE LINE WILL BE PRESSSURE .._......... ..........._.. ............... ......... ........ .. .......... ..... TESTED FOR LEAKS AT TIME OF INSTALLATION. J#JARPA REQ.PER COUNTY. MEETS CLASS A REQS. Section lII. (completed by health officer) Review Criteria: (8) Mitigation Measures fin addition to those proposed): p)( .. ..._....... ...... ......... . .._........__--..... Comments/Conditions: (10) Type of Waiver: (11) jo9 Cla%A [ 1 Class B [ ]Class C—Request DOH review before granting? Yes— No Neighbor Notification: (12) Required? Yes_ No_ lfneeded,are agreements,easements, etc.properlyfiled? Yes _ No Section IV. 'Co by health officer) This Request For Waiver From State Regulations has been revievred according to the provisions of Chapter 246-272A WAC On-Site Sewage Systems. The review criteria applied,and the mitigation measures proposed and/or required,have been evaluated for their ability to provide public health protection at least equal to that provided by this rapter WAC. [ ) Denied K Approved/Granted—Su 'ecl to all riments,conditions and requirements n d in Se ions II and III. Local Health Officer (13) Date: � 12 Z'V DOH 337-021 Page 26 of 32 FREDSON ROAD I / II I AT"TEXISTING SHARED III, ` DRIVEWAY I I II ill APPROXIMATE EXISTING WELL I III II, I t" w r EXISTING WELL I j, ' Ate' , APPROXIMATE r CROSS STREAM AT CULVERT, SEE EXISTING WELL I � / JI BELOW WAIVER REQUIREMENTS. DRY WEATHER CONDITIONS R \ I MAY BE EQUIRED FOR I \�\ R700, �f ROPER INSTALLATION / SEASONAL DRAINAGE I / I \ ------ II I I DRAINAGE CROSSING REDS II II INSTALL 1. DOUBLE SLEEVE TRANSPORT LINE IN SCH. TRANS PORT 40 STEEL WITHIN IOFTON EA5IDEOF I LINE WITHIN CROSSING. INSTALL 5KID5. 2.BURY TRANSPORT LINE 3FT BELOW I I PROPERTY BOTTOM OF STREAM. 7s I f BOUNDARIES 3.INSTALL TRANSPORT LINE WITHIN 1O I Q_ I PERPENDICULAR DIRECTION TO STREAM. 4.PERFORM PRESSURE LEAK TEST PER STATE MITIGATION REQ'S. / I I r / PROPOSED 2 BEDROOM ` DRAINFIELD AN CHARASBUILT/INSTALL SIF OFFINSTALLATION FEE WILL BE CHARGED AT TIME OF INSTALLATION LU5TOMM:AMANDA 6UMGNlN rFCT uoi.P 4 Trsr uo�s s. PIONEER DIGGNG, NC 366`,I' 3F ILL PARCEL#:31907-02-0W90 lG+IILI, 3W 11LL SEPTIC DESIGNS ADDRESS, 303WFRFDSONRD ItJJr1@sG Iia�rs�w 3083 E MASON BENSON KD. CRAPEVIEW WA9a546 DESIGNER: ROBFRT R PAYSSE .: :.:o.NP�ES ONLY o m OFACE-360426I803 FAX 36042]2353 SHEET: SIZE PLAN SCALE P=100' °"�Po Il........ oesio.0 ..ssw.s a�asa �.ws P05�ERV E SHEL ON 21U MARK E REEDTWAV UNIT MAIN ,HELTON, WA 98584-9998 04/10/2024 18001275-8777 -----------------------, 02:50 PM Product _____ ___________.- 0tr Unit Price -----_.._ Price Flrst-Class ---'--- --- Postal Service Large Envelope --1 $1.87 OlymPla, WA 98501 m CERTIFIEDWeight: 0 lb 2.50 oz e Estimated Delivery Date Fri r` • my certified4B Ma? 024 vmol ar Tracking B: $4.40 CeNfl¢tlM ir¢` 1 4.4 ' 0388 Total 9589 0710 5270 1430 9879 37 7' 91m 6mwae ees kne¢keor,wor[o ¢� P4 $6.27 r� ❑Pemrn ge[tld fndewpyl 6 T't - - _______________ ❑mow.tl�[mo,sb�..m: s voam.n ----- Total: "- 0¢�6.=es.�Ae[s[�¢..[s. s in On t` ❑n[msm[aoae.aw,ee a �'�"¢ _________ $6.27 �ao Personal/Bus ----------"-'- Oaaws¢�[rvetlm¢emoowp,s qU Ltleok ---- ao.eso 51.87 ______ ,tea s epalagaeno w¢6 04/18($OY4 Text your tracking number. to 28777 (2USPS) to get the latest status. Stm card Message and Data rates may dppiy. Y, may a)so P s¢.,rr �. visit Www.usps.cm USPS Tracking m ..a.--.)�. d.�.._...___,_...___._.__. 1-8,00-222-1811. or call lM� g' CM?"Sre7e;7JPiA'..........._............_......._.._._........_._..__.._...... Preview T rour Nail Track ages Sign LIP for FREEhttps://Informeddelivery.usps.can All sales flnal on stamps and postage. Th Refurl for guaranteed services only. Thank You for your business. Tell us about vow experience. a•°scan thisscodeoWith yourimobile device. { or Ball 1-800-410-7420. UFN: 547742-0388 Recelpt. 6: 840-59800265-2-6907370-2 Clerk: 04 --------------------------- AG@1CY U3EONLY WASHINGTON STATE Datereceived: Joint Aquatic Resources Permit Application (JARPA) Formf'2 1 Agency reference#: USE BLACK OR BLUE INK TO ENTER ANSWERS W THE WHIM SPACE e BELOW. Tax Parent R(s): ---------------- �Oulr2d -F(� L.1DFr.1 ��lav� � I�ssov>1C'�c��W,wagov Part 1—Project Identification o yl 1-1 1zZ1Z iiq 1. Project Name(A name for your project that you create. Examples: Smim'E Door or Seabrook Lane Development) Lh&M BUMGARNER SEPTIC REPAIR Part 2—Applicant The person and/or organization responsible for the project. [2g1 2a. Name(Last, Final,Middle) AMANDA BUMGARNER 2b.Organization(if applicable) NA 2c. Mailing Address (Street or PO Box) 301 W FREDSON ROAD 2d. City, State, Zip SHELTON, WA 98584 2e. Phone(1) 2f. Phone(2) 2g. Fax 2h. E-mail 425-Z41-0386 'Additional forms may be required for the follrnNng permits: • I(your project may qualify for De .,brat of the Army authodamlon through a Regional General Permit(RGP),corfaq the O.S.Army Carps o/ Engineers for application information(203)701-3495. • Not all olees and Counties accept the JARPA for their local Shoreline permits.If you need a Shoreline permit,contact the appropriate city or county government to make sure they accept the JARPA. aTo access an online JARPA form with[help)screens,go to h1tp:1f~NBcerm'tti W8C0 /sI al' S rcacenl ( roa ' rO fn /g R For other help,Contact the Governor's @Fca far Regulatory Innovation and Assistance at(e00)917-0043 or helpaoria.Wa Oov. ORIAwvia•rl ommas Page 1 of 14 Part 3—Authorized Agent or Contact Person authorized to represent the applicant about the project. (Note: Authorized agent(s) must sign 11b of this application) h( W 3a. Name(Lest,First,Middle) ROBERT PAYSSE 3b. Organization (If applicable) PIONEER DIGGING INC. 3c. Mailing Address (Street or PO Box) 3083 E MASON BENSON ROAD 3d. City, State, Zip GRAPEVIEW WA 98546 3e. Phone(t) 3f. Phone(z) 31:1. Fax 3h. E-mail 360-416-1803 Part 4—Property Owner(s) Contact information for people or organizations owning the property(ies)where the project will occur. Consider both upland and aquatic ownership because the upland owners may not own the adjacent aquatic land. hLeM O 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 upland property owners. Complete the section below and fill out JARPA Attachment A for each additional property owner. ❑ Your project is on Department of Natural Resources (DNR)-managed aquatic lands. If you don't know, contact the DNR at(360) 902-1100 to determine aquatic land ownership. If yes, complete JARPA Attachment E to apply for the Aquatic Use Authorization. 4a. Name(Lest, Fin( Middle) 4b. Organization inapplicable) 4c. Mailing Address(Street or PO Box) 4d. City, State, Zip 4e. Phone(t) 41F. Phone(z) 4g. Fax 4h. E-mail ORIXIIIII OM20 Page 2 of 14 Part 5—Project Location(s) Identifying information about the property or properties where the project will occur. Ilisipl ❑ 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.) ihelol © Private ❑ Federal ❑ Publicly owned (state,county,city,special districts like schools, ports,etc.) ❑ Tribal ❑ Department of Natural Resources(DNR)—managed aquatic lands (Complete JARPA Attachment El 5b. Street Address(Cannot be a PO Box. If there is no address,provide other location information in 5p.) [ttlpj 303 W FREDSON ROAD 5C. City, State, Zip(If the project is not in a city or town,provide the name of the nearest city or town.) bial ] SHELTON, WA 98584 5d. County g1l MASON COUNTY Se. Provide the section, township, and range for the project location. hh( M 1/4 Section Section Township flange 07 19 03 5f. Provide the latitude and longitude of the project location. Ih W Example:47.03922 N let/-122.89142 W long.(Use decimal degrees-NAD 83) 5g. List the tax parcel number(s)for the project location. IbliM Tho local county assessoea amce can provlde this infomlatlon. 31907-12-00090 5h. Contact information for all adjoining property owners. (if you need more space,Ise JARPA Attachment C.) fthSP] Name Mailing Address Tax Parcel#(it known) CHARTER TRUSTEE,SAMUEL 260 WEST 100 SOUTH 319071200100 RESIDENmAL REAL PROP TR CIUM OF SANDRA MITCHELL IVINS, UT84738 LOWE, BRADFORD R 305 W FREDSON RD 319071200080 SHELTON, WA 98584 RICE, RONALD W& 291 FREDSON RD 319071200070 JACQUELINE S SHELTON, WA 98584 ORIAr and 0212020 Page 3 of 14 51. List all wetlands on or adjacent to the project location. mW NONE KNOWN 5j. List all waterbodies (other than wetlands)on or adjacent to the project location.mail SEASONAL UNMAPPED DRAINAGE/STREAM 5k. Is any part of the project area within a 100-year floodplain7 ftlo ❑ Yes O No 17 Don't know 51. Briefly describe the vegetation and habitat conditions on the property. ffi&j FORESTED PROPERTY W/ SOME CLEARING ON THE NORTHERN END FOR EXISTING RESIDENTIAL DEVELOPMENT. PROPERTY HAS SOME SLOPE TOWARDS THE SOUTH END WHERE SAID SEASONAL DRAINAGE/STREAM IS LOCATED. 5m. Describe how the property is currently used. Ma RESIDENTIAL USE 5n. Describe how the adjacent properties are currently used. ftm RESIDENTIAL USE 5o. Describe the structures (above and below ground) on the property, including their purpose(s) and current condition. IIIei TWO RESIDENCES AND A GARAGE. 5p. Provide driving directions from the closest highway to the project location, and attach a map. [held HWY 101 TURN WEST ON FREDSON ROAD. DRIVE TO SITE ADDRESS AND TURN LEFT INTO SHARED DRIVEWAY. STAY RIGHT AND CONTINUE TO APPLICANT PROPERTY/HOME. ORIA- .d OW2020 Page 4Of 14 Part 6—Project Description Ba. Bde6y summarize the overall project. You can provide more detail In 6b. I[tElm INSTALL 2"SCH.40 TRANSPORT LINE FOR SEPTIC PURPOSES ACROSS A SEASONAL UNMAPPED STREAM. CROSSING WILL BE MADE AT EXISTING CULVERT LOCATION. AT CROSSING LINE WILL BE SLEEVED IN STEEL PIPING LOFT IN EA. DIRECTION AND SKIDS INSTALLED PER STATE HEALTH REQUIREMENTS. LINE WILL BE CURIED 3FT BELOW BOTTOM OF STREAM AND INSTALLED IN DRY WEATHER CONDITIONS AT PERPINDICULAR ANGLE TO STREAM. LINE WILL ALSO BE LEAK TESTED PER STATE HEALTH REQUIREMENTS. 6b. Describe the purpose of the project and why you want or need to perform it. li??tjW ONE OF THE EXISTING SEPTIC SYSTEMS HAS FAILED. DUE TO EXISTING DEVELOPMENT AND SETBACK REQUIREMENTS A REPAIR AREA HAS BEEN LOCATED SOUTH FURTHER UP HILL. THIS PROPOSED AREA REQUIRES THE SEPTIC TRANSPORT LINE TO CROSS A SEASONAL UNMAPPED STREAM. So. Indicate the project category. (Check all that apply) n[ ems] ❑ Commercial 0 Residential ❑ Institutional ❑ Transportation ❑ Recreational ❑ Maintenance ❑ Environmental Enhancement 6d. Indicate the major elements of your project. (Check all that apply) [help) ❑ Aquaculture ❑ Culvert ❑ Float ❑ Retaining Wall ❑ Bank Stabilization ❑ Dam/Weir ❑ Floating Home (upland) ❑ Boat House O Dike/Levee/Jetty ❑ Geotechnical Survey Road ❑ Boat Launch ❑ Ditch ❑ Land Clearing Scientific Measurement Device ❑ Boat Lift ❑ Dock/ Pier ❑ Marina/Moorage ❑ Stairs ❑ Bridge ❑ Dredging ❑ Mining ❑ Stormwater facility ❑ Bulkhead ❑ Fence ❑ Outfall Structure ❑ Swimming Pool ❑ Buoy ❑ Ferry Terminal ❑ Piling/Dolphin ❑ Utility Line ❑ Channel Modification ❑ Fishway ❑ Raft 0 Other:SEASONAL UNMAPPED STREAM, SEPTIC TRANSPORT LINE, EXISTING CULVERT. 0111 "O== Pape6d14 F escribe how you plan to construct each project element checked in 6d. Include speck construction ethods and equipment to be used. [bQ] Identify where each element will occur in relation to the nearest wmerbody. Indicate which activities are within the 100-year floodplain. ALL 2" SCH. 40 TRANSPORT LINE FOR SEPTIC PURPOSES ACROSS A SEASONAL APPED DRAINAGE/STREAM. CROSSING WILL BE MADE AT EXISTING CULVERT TION. AT CROSSING LINE WILL BE SLEEVED IN STEEL PIPING 10FT IN EA. DIRECTION AND SKIDS INSTALLED PER STATE HEALTH REQUIREMENTS. LINE WILL BE BURIED 3FT BELOW BOTTOM OF STREAM AND INSTALLED IN DRY WEATHER CONDITIONS AT PERPINDICULAR ANGLE TO STREAM. LINE WILL ALSO BE LEAK TESTED PER STATE HEALTH REQUIREMENTS. 6f.What are the anticipated start and end dates for project construction?(Month/Year) [ ply • If the project will be constructed in phases or stages,use JARPA Attachment D to list the start and and dates of aeon phase or stage. Start Date: ASAP,'1YEAR End Date: &7 DAYS FOLLOWING ❑ See JARPA Attachment D 6g. Fair market value of the project, including materials, labor, machine rentals, etc. fta $20,000 Sh.Will any portion of the project receive federal funding? LnePl • If yes,list each agency providing funds. El 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.) het ] 7a. Describe how the project has been designed to avoid and minimize adverse impacts to wetlands. hl eM O Not applicable 71b.Will the project impact wetlands? h(_M ❑ Yes 0 No ❑ Don't know 7c.Will the project impact wetland bluffers? IltkiW ❑ Yes O No ❑ Don't know ORIA- "own2a Page 6 of 14 7d. Has a wetland delineation report been prepared? fhhstg] • If Yes,submit the report,including data sheets,with the JARPA package. ❑ Yes 71 No 7e. Have the Wetlands been rated using the Western Washington or Eastern Washington Wetland Rating System? MWI It Yes,submit the wetland rating forms and figures with the JARPA package. ❑ Yes 0 No ❑ Don't know 7f. Have you prepared a mitigation plan to compensate for any adverse impacts to wetlands? tkm • N 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 El No ❑ Don't know 7g. Summarize what the mitigation plan is meant to accomplish, and describe how a watershed approach was used to design the plan. h(_elgj 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. theM Activity(fill, Wetland Wetland Impact Duration Proposed Wetland drain, excavate, Name' type and area (sq. of impact' mitigation mitigation area flood, etc.) rating ft. or type4 (sq.fL or category2 Acres) acres If no official name for the wetland exists,create a unique name(such as^Wetland 1). The name should tb consistent with other project domm als, such as a wetland delineation report. 'Ecology w ama category based on current Westem Washington or Eastern Washington Wetland Rating System.Provide the wetland Mang tome Wth the JARPA package. sindicate the days,months or years the wetland will be measurably Impacted by the activity.Enter'permenenr If applicable. `Oreallon C,Rc estebgshmenilRehabllaatlon R,Enhanrsmera Preservation MI anon Bank/ln-leu fee B Page number(s)for similar information in the mitigation plan, if available: ORIA-nMa•e Oeaeae Page 7 of 14 71. 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 wetland. (� NA 4 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. Ih€PI NA 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.) Lftsi l ❑ Check here If there are waterbodies on or adjacent to the project area. (If there are none, skip to Part 9.) ffSKIDS e how the project is designed to avoid and minimize adverse impacts to the aquatic environment. applicable SCH. 40 TRANSPORT LINE FOR SEPTIC PURPOSES ACROSS A SEASONAL D DRAINAGE/STREAM. CROSSING WILL BE MADE AT EXISTING CULVERT . AT CROSSING LINE WILL BE SLEEVED IN STEEL PIPING 10FT IN EA. DIRECTION S INSTALLED PER STATE HEALTH REQUIREMENTS. LINE WILL BE BURIED 3FT TTOM OF STREAM AND INSTALLED IN DRY WEATHER CONDITIONS AT PERPINDICULAR ANGLE TO STREAM. LINE WILL ALSO BE LEAK TESTED PER STATE HEALTH REQUIREMENTS. 81b.Will your project impact a waterbody or the area around a waterbody7 @slv] ❑ Yes O No ORIA-i W ON2020 Page 8 of 14 8c. Have you prepared a mitigation plan to compensate for the project's adverse impacts to non-wetland waterbodies7 h(_elpj • If Yes,submit the plan with the JARPA package and answer ad. • If No,or Not applicable,explain below why a mitigation plan should not be required. ❑ Yes O No ❑ Don't know 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 70 you do not need to restate your answer here. hl ell ] Be. Summarize impact(s)to each waterbody in the table below. EW Activity(clear, Waterbody Impact Duration Amount of material Area (sq.ft. or dredge, fill, pile name' location' of Impacts (cubic yards)to be linear ft.)of drive, etc.) placed in or removed waterbody from waterbody directly affected 'If no ofcial name for the waterbody exists,create a unique name(such as'Sbeam 11 The name should be consistent wlih aher documents provided. s Indicate whether the impact will occur Ina adjacent to the waterbody. If adjacent,provide the distance between the Impact and the waterbody and Indimta whether the impadwill occur within the 100-year flood plain. -Indicate the days.months or years the watertoody will be measurably impacted by the work. Enter'Permenenrifelpiplicable. 8f. For all activities identified in Be, 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. ihal0l ORIA--1-d aw2020 Pegs 9 of 14 fPFERPINDICULAR ll excavating or dredging activities identified in 8e, describe the method for excavating or dredging, and amount of material you will remove, and where the material Will be disposed. Lllely 2" SCH. 40 TRANSPORT LINE FOR SEPTIC PURPOSES ACROSS'A SEASONAL ED DRAINAGE/STREAM. CROSSING WILL BE MADE AT EXISTING CULVERT N. AT CROSSING LINE WILL BE SLEEVED IN STEEL PIPING 1OFT IN EA. DIRECTION DS INSTALLED PER STATE HEALTH REQUIREMENTS. LINE WILL BE BURIED 3FT OTTOM OF STREAM AND INSTALLED IN DRY WEATHER CONDITIONS AT ANGLE TO STREAM. LINE WILL ALSO BE LEAK TESTED PER STATE HEALTH REQUIREMENTS. TRENCHING WILL LIKELY BE COMPLETED W1 AN EXCAVATOR AND BACKFILLED W/ORIGINAL NATIVE MATERIAL. 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. fh�el Agency Name Contact Name Phone Most Recent Date of Contact MASON CO HEALTH RHONDA THOMPSON 36-427-9670 4/18/24 91b.Are any of the wetlands or waterbodies identified in Part 7 or Part 8 of this JARPA on the Washington Department of Ecology's 9 P ology's 303(d) List? nLelp� • If Yes,list the parameter(s)below. • If you don't know, use Washington Depertmant of Ecology's Weter quality Assessment tools at:htloadlecolo a ANat - Shorelinss/Water-oual'N/W Ser imoroyementlA met ( t t 1 303d. ❑ Yes El No 9c.What U.S. Geological Survey Hydrological Unit Code(HUC) is the project in? MW Go to=1/Noub eoa /_u do ternd cfrn to help identify the HUC. 9d.What Water Resource Inventory Area Number(WRIA#) is the project in? eI DI Go to hgpay/ecoloav we yAN ter-sh mlin ANate to find the WRIA#. WRIA 14 ORIA�0=020 Pape 10 of 14 9e.Will the in-water construction work comply with the State of Washington water quality standards for turbidity? Mes • Go to htWs:Neceloavwaoo Mater-Shores' NVaWe liWFr hwaWo rfa y-standams/Criteda for the standards. ❑ Yes ❑ No ❑+ Not applicable Of. If the project is within the jurisdiction of the Shoreline Management Act, what is the local shoreline environment designation? [o • If you don't know,contact the local planning department. • For more Information,go to:baps,//ecoloov wa oovANater-Shorelines/Shoreline mastal manaaemenH horeline ast I planning/Shoreline-la s-mies-snd-rasa•. [] Urban ❑ Natural ❑ Aquatic ❑ Conservancy O Other: SEASONAL UNMAPPED 9g.What Is the Washington Department of Natural Resources Water Type? [hgy • Go to hdo�/AvAm dnr wa aovftmat-0 a ices- t No' a for the Forest Practices Water Typing System. ❑ Shoreline ❑ Fish ❑ Non-Fish Perennial ❑ Non-Fish Seasonal 9h.WIII this project be designed to meet the Washington Department of Ecology's most current stormwater manual? Ihpjw If No,provide the name of the manual your project Is designed to meet. 0 Yes ❑ No Name of manual: 91. Does the project site have known contaminated sediment? Lhif-10 • If Yes,please dewdbe below. ❑ Yes O No 9j. If you know what the property was used for In the past, describe below. net 9k. Has a cultural resource(archaeological)survey been performed on the project area? [ham] • N Yes,ouch it to your JARPA package. ❑ Yes O No ORIA-r•tl••d 0=00 Page 11 of 14 91. Name each species listed under the federal Endangered Species AM that occurs in the vicinity of the project area or might be affected by the proposetl work. el NA 9m. 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, rhelvl NA Part 10—SEPA Compliance and Permits Use the resources and checklist below to identify the permits you are applying for. • Online Project questionnaire at httm//aoos oria wa oov/ooaa, • Governor's Office for Regulatory Innovation and Assistance at(800) 917-0043 or help®oria wa goy. • For a list of addresses to send your JARPA to, click on agency addresses for completed DARPA. Ramapplying with tRHabitat ironmental Policy Act(SEPA). (check all that apply.) het formatiogo to httOs// Igor wa g &_ slab ilgS PA n en�l re ew. he SEtion or letter of exemption is included with this application. termining with (lead agency). The expected decision date ng for t Enhancement Exemption. (Check the box below in lob.)gam( ❑ This project is exempt(choose type of exemption below). ❑ Categorical Exemption. Under what section of the SEPA administrative code(WAC) is a exempt? ❑ Other: ❑ SEPA is pre-empted by federal law. ORIAraww Ozm20 Page 12 Of 14 10b. Indicate the permits you are applying for. (check all that apply.) rhalgl LOCAL GOVERNMENT Local Government Shoreline permits: ❑ Substantial Development ❑ Conditional Use ❑ Variance ❑ Shoreline Exemption Type(explain): 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—Attach Exemption Form Washington Department of Natural Resources: ❑ Aquatic Use Authorization Complete DARPA Attachment E and submit a check for$2s payable to the Washington Department of Natural Resources. Do not send cash Washington Department of Ecology: ❑ Section 401 Water Quality Certification ❑ Non-Federally Regulated Waters FEDERAL AND TRIBAL GOVERNMENT United States Department of the Army(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: For projects or bridges over waters of the United States,contact the U.S.Coast Guard at:113-of-dl3bridgestD sca mil ❑ Bridge Permit ❑ Private Aids to Navigation or other non- 9 ( bdtlge permits) United States Environmental Protection Agency: ❑ Section 401 Water Quality Certification (discharges into waters of the U.S.) on tribal lands where tribes do not have treatment as a state(TAS) Tribal Permits: (Check with the Vibe to see if there are other tribal permits,e.g.,Tribal Environmental Protection Act, Shoreline PGrnits,Hydraulic Project Permits,or other in addition to CWA Section 401 WOC) ❑ Section 401 Water Quality Certification (discharges.into waters of the U.S.) where the tribe has treatment as a state (TAS). CRIA-,nuked OL2020 Papa 13 of 14 Part 11—Authorizing Signatures Signatures are required before submitting the JARPA package. The JARPA package includes the JARPA form, project plans, photos, etc. Leii 11a.Applicant Signature(required) fineigli 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 allthori a 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 to the property. I also give my consent to the permitting agencies enter g the property where the project is located to inspect the project site or any work related to the project. I (initial) YYYlu 6- Appkcent Printed Name pplrcaM Signature Date 11 b.Authorized Agent Signature her 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 all necessary permits have been issued. 6�o�rri— k} 2N ASP � ffil' e t Authorized Agent Pdnte3d�l em Authon'zed agent Si atu� Date 11 C. Property Owner Signature (if not applicant) fhelol Not required if project is on existing rights-of-way or easements(provide copy of easement with JARPA). 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. e}eyOwW er Parinted WQ("n n OeSa r a� f/9-2 f w . Data 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 was 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 tam, if you require this document in another format,contact the Governor's Office for :11 i Innovation and Assistance(OR IA)at(800) 917-0043. People with hearing loss can call 711 for Washington Relay service. People with a speech disability can call 1877)833- 6341. ORIA publication number. ORIA-16.011 rev.092018 ORL"veee exrsam Page 14 of 14