HomeMy WebLinkAboutSHX2009-00045 Replace Bulkhead - SHX Permit / Conditions - 10/14/2009 MASON COUNTY
DEPARTMENT OF COMMUNITY DEVELOPMENT
Courthouse Annex
P.O.Box 279,Shelton,WA 98584
(360)427-9670
SHORELINE PERMIT APPLICATION
PERMIT NO. �7IfXZoL i"�� �� SHORELINE SUBSTANTIAL DEVELOPMENT
SHORELINE VARIANCE
DATE RECEIVED SHORELINE CONDITIONAL USE
x SHORELINE EXEMPTION h
The Washington State Shoreline Management Act (RCW 90.58) requires that substantial developments within
designated shorelines of the state comply with its administrative procedures(WAC 173-14)and the provisions of the
Mason County Shoreline Management Master Program.The purpose of this Act and local program is to protect the
state's shoreline resources. The program requires that substantial development(any development of which the total
cost or fair market value exceeds $5,000.00 or materially interferes with the normal public use of the water or
shorelines of the State be reviewed with the goals, polices, and performance standards established in the Master
Program.
Answer all questions completely. Attach any additional information that my further describe the proposed
development. Incomplete applications will be returned.
APPLICANT: &141 PL11,4"
ADDRESS: ,
(city) (state) O (zip)
TELEPHONE: �� 5 -lo 34
(home) (business)
AUTHORIZED REPRESENTATIVE:
ADDRESS: �� a
(City) /� p� (state) (zip)
TELEPHONE: A �(L_ (D(D" L Q
PROPERTY DESCRIPTION:
General location(include property address,water body and associated wetlands—identify the name of e
shoreline):
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Legal description (include section, township, and range to the nearest quarter, quarter section or latitude and
longitude to the nearest minute. Projects located in open water areas away from land shall provide a longitude
location)-include all parcel numbers:
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DEVELOPMENT DESCRIPTON
Development(identify and describe the proposed project,including the type of materials to be used,construction
me ods,principle dimensions,and other pertinent information):
A A I A I -kM &M a 0-,U,&j JA rm Ahu 1i LAW JS dldk�
Use(identify current use of property with exist improvements:
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Reason for requesting development:
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ACKOWLEDGEMENT
I here,§declare,to the best of my knowledge and belief,the forgoing information and all attached information is
true W co
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(applicant or authorized representative) (date)
...............................................................................
TO BE COMPLETED BY LOCAL OFFICIAL
Identify and describe existing features of the site and surrounding area:
If proposed structures will exceed a height of 35 feet above the existing grade level,indicate the location of any
residential units that will have an obstructive view:
PCOOr1-STgT�O MASON COUNTY
c 4-1 DEPARTMENT OF COMMUNITY DEVELOPMENT
o n o N Planning Division
r o N z P O Box 279, Shelton, WA 98584
N Y O ti (360)427-9670
OJ �
1864
Exemption from Shoreline Management Act
Case No.: SHX2009-00045 Substantial Development Permit Requirement
The Proposal By: ALLAN ROSS
15605 163RD AVE ME
WOODINVILLE,WA 98072
To undertake the following development:
Remove existing failing creosote timber bulkhead and replace with new various size granite rock
bulkhead 70 feet long by 6' high.
Within CASE INLET 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 Grace Miller at ext 360 if you have any questions.
Issued: 10/14/2009
Expires: 10/14/2011 Authorized Local Government Official
cc: APPLICANT WDFW USACOE WDOE TRIBAL COUNCIL Gym b`
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MASON CO. ENVIROMENTAL CHECKLIST
A. BACKGROUND
1. Name of proposed project, if applicable: REPLACEMENT : Bulkhead
2. Name of applicant:
3. Address and phone number of applicant and contact person:
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4. Date checklist repared:
5. Agency requesting c ecklist: _
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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.
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.
I /.,
10. List any government approvals or permits t 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.) , , �J 9 �° I I 1 �c►��e�, f'e�Z
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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. V(--� 54
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B. ENVIRONMENTAL ELEMENTS:
1. EARTH:
a. General description of the site (circle one)-.Flat, rolling, hilly, steep slopes, mountainous, other
b. What is the steepest slope on the site (approximate percent slope)?
c. What general types of soils are found on the site (for example, 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,
.ter-j�'�' -u-/�a-�.-�1 ,��° �✓�u..�,�' �.�� ,�.,�:,�.�G-x..
e. Describe the purpose, type, and approximate quantities of any filling or grading propose
Indicate source of fill. ,f�,w��t 7U Pori- � �
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f. Could erosion occur as a result of clearing, construction, or use: If so, generally describe.
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g. About what percent of the site will be covered with impervious surfaces after project
constructions (for example, asphalt or buildings)?
h. Proposed measures to reduce or control erosion, or other impacts to the earth, if any:
2. AIR:
a. What types of emissions to the air would result from the proposal (i.e. dust, automobile, odors,
industrial wood smoke) during construction and when the project is completed? If any,
generally describe and give approximate quantities, if known.
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) 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., cv�J
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.
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4) Will the proposal require surface water withdrawals or diversions? Give general
description, purpose, and approximate quantities if known.
5) Does the proposal lie within a 100-year floodplain? If so, note location on the site plan.
6) Does the proposal involve any discharges of waste materials to surface waters? If so,
describe the type of waste and anticipated volume of discharge.
b. Ground:
1) Will ground water be withdrawn, or will water be discharged to ground water? Give
general description, purpose, and approximate quantities, if known.
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? If so, describe.
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: jr,
cedar, other
shrubs ,
v 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?
C. List threatened or endangered species known to be on or near the site.
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d. Proposed landscaping, use of native plants, or other measures to preserve or enhance
vegetation on the site, if any: Cl-Cf ��
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: _h��eck, hewn, eagle, so�ds, other
Mammals: deer, bear, elk, beaver, other
Fish: bass, salmon, trout, herring, shellfish, other
b. List any threatened or endangered species known to be on or near the site.
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C. Is the site part of a migration route? If so, explain.
d. Proposed measures to preserve or enhance wildlife, if any:
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6. ENERGY AND NATURAL RESOURCES:
a. What kinds of energy (electric, natural gas, oil, wood stove, solar) will be used to meet the
completed project's energy needs? Describe whether it will be used for heating,
manufacturing, etc.
b. Would your project affect the potential use of solar energy by adjacent properties: If so,
generally describe.
C. What kinds of energy conservation features are included in the plans of this proposal? List
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7. ENVIRONMENTAL HEALTH:
a. Are there any environmental health hazards, including exposure to toxic chemicals, risk of fire
and explosion, spill, or hazardous waste, that could occur as a_result of this proposal? If so,
describe.
1) Describe special emergency services that might be required.
2) Proposed measures to reduce or control environmental health hazards, if any:
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b. Noise.
1) What types of noise exist in the area which may affect your project (for example: traffic,
equipment, operation, other)?
2) What types and levels of noise would be created by or associated with the project on a
short-term or a long-term basis (for example: traffic, construction, operation, other)?
Indicate what hour's noise would come from wthite,
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3) Proposed measures to reduce or control noise impacts, if any:
8. LAND AND SHORELINE USE:
a. What is the current use of the site and adjacent properties?
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b. Has the site been used for agriculture? If so, describe.
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C. Describe any structures on the site.
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d. Will any structures be demolished? If so, what?
e. What is the current oning Yassific tion of the ite?
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f. What is the current comprehens' a 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.
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i. Approximately how many people would reside or work in the completed project?
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j. Approximately how many people would the completed project displace?
k. Proposed measures to avoid or reduce displacement impacts, if any:
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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?
e. What is the current oning assific tion of the ite?
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f. What is the current comprehensive plan designation of the site?
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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.
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i. Approximately how many people would reside or work in the completed project?
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j. Approximately how many people would the M �com�pleted project displace?
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k. Proposed measures to avoid or reduce displacement impacts, if any:
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11. LIGHT AND GLARE
a. What type of light or glare will the proposal produce? What time of day would it mainly occur?
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b. Could light or glare from the finished project be a safety hazard or interfere with views?
C. What existing off-site sources of light or glare may affect your proposal:
d. Proposed measures to reduce or control light and glare impacts, if any:
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:
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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.
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b. Generally describe any landmarks or evidence of historic, archaeological, scientific, or cultural
importance known to be on or next to the site.
C. Proposed measures to reduce or control impacts, if any:
14. TRANSPORTATION:
a. Identify public streets and highways serving the site and describe proposed access to the
existing street system. Show on site plans, if any. n- `�}
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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.
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).
e. Will the project use (or occur in the immediate vicinity of) water, rail, or air transportation? If
so, generally describe.
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f. How many vehicular trips per day would be generated by the completed project: If known,
indicate when peak volumes would occur.
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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: "
b. Proposed measures to reduce or control direct impacts on public services, if any:
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I. Proposed measures to ensure the proposal is compatible with existing and projected land uses
and plans, if any:
9. HOUSING: 4JW)
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.
dazo
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?
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b. What views in the immediate vicinity would be altered or obstructed?
C. Proposed measures to reduce or control aesthetic impacts, if any:
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I. Proposed measures to ensure the proposal is compatible with existing and projected land uses
and plans, if any:
9. HOUSING. �)�A�)
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.
C. Proposed measures to reduce or control housing impacts, if any:
10. AESTHETICS:
a. What is the tallest height of any proposed structure(s), not including antennas; what is the
principal exterior building material(s) proposed?
b. What views in the immediate vicinity would be altered or obstructed?
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C. Proposed measures to reduce or control aesthetic impacts, if any:
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16. ' UTILITIES:
a. Cir ities currently available he sit elect_rici , natural gas, �refu�ses
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elepho , sanitary sewer, ptic s , other:
b. Describe the utilities that are proposed for the project, the utility providing the service, and the
general construction activities on the site or in the immediate vicinity which might be needed.
Signature:
The above answers are true and complete to the best of my knowledge. I understand that the
lead agency is relying on them to make its decision.
I'M` b# oil �
Signature: lilt
Date submitted: 44
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EXISTING CONCRETE
li BULKHEAD
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2009 i AGENCY USE ONLY
US Army Corps , Date received:
,
WASHINGTON STATE of t.d
Joint Aquatic Resources Permit
Application (DARPA) Form [-�:,)
Agency reference#:
USE BLACK OR BLUE INK TO ENTER ANSWERS IN WHITE SPACES BELOW. Tax Parcel#(s):
;
Part 1—Project Identification
Unique project information that makes it easy to identify. hei , --------------------------------------;
1a. Unique Project Identifier Number (UPI #) LLLeM
• Don't have one yet?Get one at http://www.epermifting.wa.gov or call the Washington Governor's Office of Regulatory Assistance
at(800)917-0043.
1 b. Project Name (Examples: Smith's Dock or Seabrook Lane Development) Lhel
Part 2—Applicant
The person or organization responsible for the project. hel
2a. Name (Last, First, Middle)and Organization (if applicable)
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2b. Mailing Address (Street or PO Box)
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2c. City, State, Zip
2d. Phone(1) 2e. Phone(2) 2f. Fax 2 . E-mail
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.) hel
3a. a (Last, First, Middle) and Organiz on (if applicable)
3 Mailing Address ( reet or PO Box)
3c. City, State, Zip
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3d. Pho a(1) 3e. Phone(2) 3f. Fax 3 . E-mail
fyao ( ) (tea 6�i'GvtWLi G�
Part 4—Property Owner(s) heI
Contact information for people or organizations owning the property(ies) where the project will occur. Lijei
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 use JARPA Attachment A for each
additional property owner.
4a. ame (Last, First, Middle)and Organization (if applicable)
-12 ea
4 . IV14iiling Address (Street or PO Box)
6,�tz / /�
4C. ity, State, Zip
�2t40111A
4d. Phone( ) 4e. Phone(2) 0. Fax 4 . E-mail
(3bo 444-1 ogl 34ftll lute
Part 5—Project Location(s)
Identifying information about the property or properties where the project will occur. hel
❑ There are multiple properties or project locations (e.g., linear projects). Complete the section below and use
JARPA Attachment B for each additional property.
5a. Street Address (Cannot be a PO Box. If there is no address, provide other location information in 5n.)
5b. City, State, Zip(If the project is not in a city or town, provide the name of the nearest city or town.) [helpl
5c. County 11fhelpl
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5d. Provide the section, township, and range for the project location. fhelpl
1/4 Section Section Township Range
5e. Provide the latitude and longitude of the project location. nel
• Example: 47.03922 N lat. /-122.89142 W long
4,7. /- / 2- Z 4001y
5f. List the tax parcel number(s) for the project location. rheigi
• The local county assessor's office can provide this information.
5g. Indicate the type of ownership of the property. (Check all that apply.) hC e
❑ State Owned Aquatic Land ❑ Tribal ® Private
❑ Other publicly owned (federal, state, county, city, special districts like schools, ports, etc.)
5h. Contact information for all adjoining property owners, lessees, etc. (If you need more space, use DARPA
Attachment 0 hel
Name Mailing Address Tax Parcel # (if known)
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5C Is any part of the project area within a 100-year flood plain? el
❑ Yes No ❑ Don't know
5j. Briefly describe the vegetation and habitat conditions on the property. Ihelpl
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5k. Describe how the property is currently used. hel
51. Describe how the adjacent properties are currently used. hel
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5m. Describe the structures (above and below ground) on the property, including their purpose(s). [LeM
44 aNU.c-(•�'l ) �'�r�.'uu,:•v
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5n. Provide driving directions from the closest highway to the project location, and attach a map. hel
Part 6—Project Description
6a. Summarize the overall project. You can provide more detail in 6d. hey
,�i-m.o-ue, .�Qau:��5 �i;v�c:�t.cn,�P�e,o.d,�c.) -�c.�Ue� • .tout � .Ui�Fue ,�
6b. Indicate the project category. (Check all that apply.) hel
❑ Commercial Residential ❑ Institutional ❑ Transportation ❑ Recreational
❑ Maintenance Environmental Enhancement
6c. Indicate the major elements of your project. (Check all that apply.) hel ]
❑ Aquaculture ❑ Culvert ❑ Float ❑ Road
j Bank Stabilization ❑ Dam /Weir ❑ Geotechnical Survey ❑ Scientific Measurement
❑ Boat House ❑ Dike/ Levee / Jetty ❑ Land Clearing 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 (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. hei
• Identify where each element will occur in relation to the nearest waterbody.
• Indicate which activities are within the 100-year flood plain.
6e. What are the start and end dates for project construction? (month/year) hel
• If the project will be constructed in phases or stages, use JARPA Attachment D to list the start and end dates of each phase or
stage.
Start date: E at ❑ See JARPA Attachment D
6f. Describe the purpose of the work and why you want or need to perform it. hei
6g. Fair market value of the project, including materials, labor, machine rentals, etc. Lhetp]
6h. Will any portion of the project receive federal funding? Lam]
• If yes, list each agency providing funds.
❑ Yes EJ 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. [helpi
❑ Not applicable
cts-.ems A A-t
7b. Will the project impact wetlands? heI
❑ Yes No ❑ Don't know
7c. Will the project impact wetland buffers? [helpi
❑ 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 a 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
7f. Have you prepared a mitigation plan to compensate for any adverse impacts to wetlands? L7]
• If yes, submit the plan with the JARPA package.
❑ Yes ❑i 'No ❑ Not applicable
7g. Use the table below to list the type and rating of each wetland that will be impacted; the extent and duration
of the impact; and the type and amount of compensatory mitigation proposed. If you are submitting a
compensatory mitigation plan with a similar table, you may simply state (below) where we can find this
information in the mitigation plan. hel
Activity causing Wetland type Impact area Duration Proposed Wetland
impact (fill, and rating (sq. ft. or acres) of impact2 mitigation mitigation area
drain, excavate, category' type' (sq. ft. or acres)
flood, etc.
Ecology wetland category based on current Western Washington or Eastern Washington Wetland Rating System. Provide the wetland
rating forms with the JARPA package.
2 Indicate the time(in months or years, as appropriate)the wetland will be measurably impacted by the activity. Enter"permanent" if
applicable.
3 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:
7h. For all filling activities identified in 7g., 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. el
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7i. For all excavating activities identified in 7g., describe the excavation method, type and amount of material in
cubic yards
you will remove, and where the material will be disposed.
r /� w
7j. Summarize what the compensatory mitigation plan is meant to accomplish, and describe how a watershed
approach was used to design the plan. I,eI ]
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.) [qejPJ
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
au
� a a �
8b. Will your project impact a waterbody or the area around a waterbody? hei
❑ Yes LJA
No
8c. Summarize impact(s) to each waterbody in the table below. Lhel
Activity causing Waterbody Impact Duration Amount of material Area (sq. ft. or
impact(clear, name location' of impact2 to be placed in or linear ft.) of
dredge, fill, pile removed from waterbody
drive, etc.) waterbody directly affected
Indicate 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-
2 Indicate the time (in months or years, as appropriate)the waterbody will be measurably impacted by the work. Enter"permanent" if
applicable.
8d. Have you prepared a mitigation plan to compensate for the project's adverse impacts to non-wetland
waterbodies? heI
• If yes. submit the plan with the JARPA package.
❑ Yes o ❑ Not applicable
8e. Summari e what the compensatory mitigation plan is meant to accomplish. Describe how a watershed
approach was used to design the plan.
0 If you already completed 7j., you do not need to restate your answer here. LgSIJ
8f. For all activities identified in 8c., 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. h(_elp]
8g. For all excavating or dredging activities identified in 8c., describe the method for excavating or dredging,
type and amount of material you will remove, and where the material will be disposed. rteip]
Cam`
Part 9—Additional Information
Any additional information you can provide helps the reviewer(s) understand your project.
9a. If you have already worked with any government agencies on this project, list them below. hei
Agency Name Contact Name Phone Most Recent
Date of Contact
►1lw�rr P"� ( ).elm2 IF4 70
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:
hdp://www.ecy.wa.gov/programs/wg/303d/-
El Yes No
9c. What U.S. Geological Survey Hydrological Unit Code (HUC) is the project in? heip]
• Go to hftp://cfpub.epa.gov/surf/locate/index.cfm to help identify the HUC.
-7/l6
9d. What Water Resource Inventory Area Number (WRIA#) is the project in?
• Go to hftp://www.ecy.wa.gov/services/gis/maps/wria/wria.htm to find the WRIA#.
16
9e. Will the in-water construction work comply with the State of Washington water quality standards for
turbidity? hf eld
• Go to http://www.ecy.wa.gov/programs/wq/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? k
• If you don't know. contact the local planning department.
• For more information, go to: http://www.ecy.wa.gov/programs/sea/sma/laws rules/173-26/211 designations.htmm.
TRural ❑ Urban ❑ Natural ❑ Aquatic ❑ Conservancy ❑ Other
9g. What is the Washington Department of Natural Resources Water Type? hem
• Go to http://www.dnr.wa.gov/BusinessPermits/Topics/ForestPracticesApplications/Pages/fp watertypinq.aspx for the Forest
Practices Water Typing System.
9S ❑ F ❑ Np ❑ Ns
9h. Will this project be designed to meet the Washington Department of Ecology's most current stormwater
manual? hem
• Y no, provide the name of the manual your project is designed to meet.
Yes ❑ No
Name of manual:
9i. If you know what the property was used for in the past, describe below. [help]
9j. Has a cultural resource (archaeological) survey been performed on the project area? hel
• 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. hem
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. hei ]
Part 10—Identify the Permits You Are Applying For
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(o)-ora.wa.gov.
10a. Compliance with the State Environmental Policy Act (SEPA). (Check all that apply.) hf gm
• For more information about SEPA, go towww.ecy.wa.gov/programs/sea/sepa/e-review.html.
A copy of the SEPA determination or letter of exemption is included with this application.
❑ A SEPA determination is pending with d' (lead agency). The expected decision date is
❑ I am applying for a Fish Habitat Enhancement Exemption. (Check the box below in 10b.)
• Submit the Fish Habitat Enhancement Project form with this application. The form can be found at
http://www.epermitting.wa.gov/Portals/ JarpaResourceCenter/images/default/fishenhancement.doc
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. Llielpi
10b. Indicate the permits you are applying for. (Check all that apply.) Lhei
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
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)
SECTION B - Use for Shoreline and Corps of Engineers permits only:
CM 17a. Total cost of project.,This means the fair market value of the project, including materials, labor, machine rentals, etc.
143,o o o
CM 17b. If a project or any portion of a project receives funding from a federal agency,that agency is responsible for ESA consultation.
Please indicate if you will receive federal funds and what federal agency is providing those funds.
FEDERAL FUNDING ❑ YES ❑ NO If YES, please list the federal agency.
18. Local government with jurisdiction:
CM 19. Provide names,addresses and telephone numbers of adjoining property owners, lessees, etc. Please rwte: Shoreline
Management Compliance may require additional notice—consult your local government.
NAME ADDRESS PHONE NUMBER
SECTION C- This section MUST be completed for any permit covered by this application
m 20. Application is hereby made for a permit or permits to authorize the activities described herein. I certify that I am familiar with the
information contained in this application,and that to the best of my knowledge and belief,such information is true,complete,
and accurate. I further certify that I possess the authority to undertake the proposed activities. I hereby grant to the agencies to
which this application is made,the right to enter the above-described location to inspect the proposed, in-progress or completed
work. I agree start work ONLY after all necessary permits have been received.
� DATE/
SIG T'IJRE F APPLICANT
t DATE
SIGNATURE OF AUTHORIZED AGENT
I HEREBY DESIGNAT TO ACT AS MY AGENT IN MATTERS RELATED TO THIS APPLICATION FOR
PERMIT(S). I UNDERS N THAT
EDERAL PERMIT IS ISSUED, I MUST SIGN THE PERMIT.
SIGNATURE OF APPLICANT DATE
7
XSIGNATURE dr LANDOWNER(EXCEPT PUBLIC ENTITY LANDOWNERS, E.G. DNR)
THIS APPLICATION MUST BE SIGNED BY THE APPLICANT AND THE AGENT, IF AN AUTHORIZED AGENT IS DESIGNATED.
18 U.S.0§1001 provides that: Whoever, in any manner within the jurisdiction of any department or agency of the United States knowingly
falsifies,conceals,or covers up by any 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.
COMPLETED BY LOCAL OFFICIAL
A. Nature of the existing shoreline. (Describe type of shoreline,such as marine,stream, lake, lagoon, marsh, bog, swamp,flood
plain,floodway, delta;type of beach, such as accretion,erosion, high bank, low bank,or dike; material such as sand, gravel, mud,clay,
rock, riprap; and extent and type of bulkheading,if any)
B. In the event that any of the proposed buildings or structures will exceed a height of thirty-five feet above the average grade level,
indicate the approximate location of and number of residential units,existing and potential,that will have an obstructed view:
C. If the application involves a conditional use or variance,set forth in full that portion of the master program which provides that the
proposed use may be a conditional use, or,in the case of a variance,from which the variance is being sought:
These Agencies are Equal Opportunity and Affirmative Action employers.
For special accommodation needs,please contact the appropriate agency in the instructions