HomeMy WebLinkAboutSEP Environmental Checklist and JARPA - SEP Application - 10/21/2002 TO. BE COMPLETED BY APPLICANT E1IALUATION FOR
' AGEKCT USE ONLY
A. BACKGROUND:
1. Name of proposed project, if applicable:
2. Name of applicant:
i.-J'AME: & MK}2T)N
�. Anoa H. P. C6+• el
3. Address L phone number of applicant L contact erson: )$77-
Vane. C. Mt�r�"i'n - ayo A/. HJock B(fa..ch I)r,, .� ►nlArti�, �A 9�555 9�65
a /�nna M• a es�'er >509 N w loo S�, Sect3lic. ►�lA 4j17 7-5�0J
Coy-ra�� ertsfl n: S>'woy► Mott- - /-"CC 1a� �N A),� r13o5
4. Date checklist prepared: -- -�-1`- (Wa :)S-V' 755V
5. Agency requesting checklist: M0,50Y1 �• �'1anYliyl�
6. Proposed timing or schedule (including phasing, if applicable) :
A S n•P -- be-+o r(f, Lei yite-r- 0'- a0 Da
7. Do you have any plans for future expansion, or further activity
related to or connected with this proposal? If yes, �xp ain.
'Z-F 1�'►C� e-C'OSi on ('.Un'�"'b n u,eS in �i to ��®ur� r�S, �nc�-Furrier �hr�a.�"en5 6u1�
8. List any environmental information you know about that has been
prepared, or will be prepared, directly related to this
proposal. �o Y1 o t !un p
9. Do you know whether applications are pending for governmental
approvals of other proposals directly affecting the propertyZrlAtJJet�
covered by your proposal? If yes, explain. NON fib , (ff��
10. List any government approvals or permits that will be needed
for your proposal, if.known.
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1a.nni na
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11. Give a brief, com Ae 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. )
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----- �. 426 W
CON
TO BE COMPLETED BY APPLICANT EVALUATION FOR
AGENCY USE ONLY
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, tovnship, and range, if knovn. If a proposal vould
occur over a range of area, provide the range or boundaries of
the site(e). 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 vith any
permit applications related to this checklist.
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B. ENVIRONMENTAL ELEMENTS:
1. EARTH:
a. General description of the site (circle one) :
Flat, rolling, hilly, steep slopes, mountainous,
er
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 knov the classification of agricultural soils,
specify them and not any prime farmland.
d. Are there surface indications or history of
unstable soils in the immediate vicinity? If so,
describe. No
(fte-p yrL9 e��i es ha t/� bui /f �xf ns� �e 1or�,1rA1
r- p �o r rd �'jeft gar ro erh, s .
eye a r e, adduce � f � � � �
2
TO BE COMPLETED BY APPLICANT EVALUATION FOR
AGENCY USE ONLY
e. Describe the purpose, type, and approximate
quantities of any filling or grading proposed.
Indicate source of fill.
��a� 1 �-o giant" 1oea..s� E�g(ori
e.
� C�c
f. Could erosion occur as a result of clearing,
construction, or use? If so, generally describe.
No
g. About what percent of the site will be covered with
impervious surfaces after project constructions
(for example, asphalt or buildings)? glG11c
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.
N0Ile—
b. Are there any off-site sources of emissions or odor
that may affect your proposal? If so, generally
describe.
H/A
C. Proposed measures to reduce or control emissions or
other impacts to air, if any:
H/A
3
TO 'BE COMPLETED BY APPLICANT EVALUATION FOR
AGENCY USE ONLY
3. WATER:
&. 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, stae what stream or
river it flows into.
�faoc r►a l
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.
Ste..plWL-A
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.
Sce��la,n
4) Will the proposal require surface water withdrawals or
diversions? Give general description, purpose, and approximate
quantities if known. N U
5) Does the proposal lie within a 100-year floodplain? If so,
note location on the site plan.
Lin=}- V t()LU
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. N d
4
TO BE COMPLETED BY APPLICANT E`►ALUATION FOR
AGENCY USE ONLY
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. N(j
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 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. ( nt—
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 water flow
into other waters? If so, describe. NUbjt
2) Could waste materials enter ground or surface waters? If so
generally describe. No
d. Proposed measures to reduce or control surface; ground, and
runoff water impacts, if any: N )h
4. PLANTS:
a. Check or circle types of vegetation found on the
site: None_U)I i�ve-' )0egldl
deciduous tree: alder, maple, aspen, other
evergreen tree: fir, cedar, pine, other
shrubs
grass
pasture
crop or grain
wet soil plants: cattail, buttercup, bullrush, skunk cabbage,
others
water plants: water lily, eelgrass, vilfoil, other
5
TO BE COMPLETED BY APPLICANT EVALUATION FOR
AGENCY USE ONLY
b. What kind and amount of vegetation will be removed
or altered? N011C_
C. List threatened or endangered species known to be
on or near the site. Vxl0v_)
d. Proposed landscaping, use of native plants, or
other measures to preserve or enhance vegetation on
the site, if any: VqC, Wi(I +rt Cund 1.L5e,TeMau
1MA I. wc CIO Vielf a-rotuld SQl Wd6r'
d hel �oritrol etro9i nY, �5U0 aS,' ro • 80,+e ncus+tr, graSSP,S efe"
S. 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: hawk, eron, eagle, songbirds, other
mammals: deer, _bear, elk, beaver, other
fish: bass, sal om n rout herring, shellfish other
b. List any threatened or endangered species known to
be on or near the site. �J bmif_salrwri
NQod c&y A,) 5umrnL1- c�LwmJ U G
c. Is the site part of a migration route? If so,
explain. '
do n+ vho(.v
d. Proposed measures to preserve or enhance wildlife,
(�
if any: yAr &IOU-)
i. 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.
N/A
6
TO BE CGVLL'M BY APPLICANT EVALUATION FOR
AGL7CY USE ORLY
b. Mould you project affect the potential use of solar
energy by adjacent properties? If so, generally
describe.
N/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:
N/A
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. U.l r4f_rlf ma I;tnr rt ' S���fQ oT At ( oP GCij
1) describe special emergency services that might
be required. TAiDylf,,
N/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 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
hours noise would come from the site. MO 11
�1
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TO BE COMPLETED BY APP'LICART EVALUATION FOR
AGENCY USE ONLY
3) Proposed measures to reduce or control noise
impacts, if any: Mco(t_
8. LAND AND SHORELINE USE:
a. What is the current use of the site and adjacent (
properties?ca�e � Y
1I�YrtC Sub� �P2 '��� �t�g11c nG �rvm s rL
5; K� �arnt � m rii�►��� (1
b. Has the site been used for agriculture? If so,
describe. NO
C. Describe any structures on the sit
knie, with efa ed Sara '
favn;)q iomc (t)►th e-�acG>ed r'a
d. Will any structure be demolished? If so, at?
RO
e. What is the current zonin classification of the
site? 1. 4"WCL) VC-5i deyi?,e0. 1 L vY t , 5&CxeS
a r carat rest,den f,o-I - 1 u cS
nit' r 5 au"
f. What is the current compre ens ve plan designation
of the site? J, VLA-ra e-Sc e ri1i..) r �j • l u,rl i t pe.rr -54c.r'll's
o?. ru ra-1 re9 den-Nod - l wm�f ))e r'- 5 au cs
g. If applicable, what is the current shoreline master
program designation of the site? U.1'b4ui
h. Has any part of the site been classified as an
'environmentally sensitive' area? tI/f so, specify.
10 to
i. Approximately how many people would reside or work
in the completed project?
N/A
J. Approximately how may people would the completed
project displace?
N/A
8
TO BE CORPLETED BY APPLICANT EVALUATION FOR
AGENCY USE ONLY
k. Proposed measures to avoid or reduce displacement
impacts, if any:
N/A
ale. 04r-O. Mrt. owe'vi
1. Proposed_measures. to_ensure the proposal is compatible
with existing and projected land uses and plans, if any:
9. HOUSING:
a. Approximately how may units, if any, would be
provided? Indicate whether high, middle, or low-
income housing.
N/A
b. Approximately how many units, if any, would be
eliminated? Indicate whether high, middle, or low-
income housing.
N/A
C. Proposed measures to reduce or control housing
impacts, if any:
N/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?
b. What views in the immediate vicinity would be
altered or obstructed? RoriC--
c. Proposed measures to reduce or control aesthetic
impacts, if any:
11. LIGHT AND GLARE:
a. What type of light or glare will the proposal
produce? What time of day would it mainly occur?
N/A
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TO BE COMPLETED BY APPLICANT EVALUATION FOR
AGENCY USE ONLY
b. Could light or glare from the finished project be a
safety hazard or interfere with viers?
N/A
C. What existing off-site sources of light or glare
may affect your proposal:
N/A
d. Proposed measures to reduce or control light and
glare impacts, if any:
N/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.
N c
C. Proposed measures to reduce or control impacts on
recreation, including recreation opportunities to
be provided by the project or applicant, if any:
r4vYtt-
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. N b
b. Generally describe any landmark or evidence of
historic, archaeological, scientific, or cultural
importance known to be on or next to the site. N CI'Le_
C. Proposed measures to reduce or control impacts, ifll�
any:
10
1
TO HE COIKPLETED BY APPLICANT EVALUATIOIN FOR
AGENCY USE ONLY
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. LA's gitua' to
b. Is site currently served by public transit? If
not, what is the approximate distance to the
existing street system. Show on site plans, if
any.
N/A
C. How many parking spaces would the completed project
have? How many would the project eliminate?
N/A
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).
N/A
e. Will the project use (or occur in the immediate
vicinity of) water, rail, or air transportation?
If so generally describe.
N/A
f. How many vehicular trips per day would be generated
by the completed project? If known, indicate when
peak volumes would occur.
N/A
g. Proposed measures to reduce or control
transportation impacts, if any:
N/A
11
-- 1
TO BE COMPLETED BY APPLICANT EVALUATION FOR
AGENCY USE ONLY
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.
N/A
b. Proposed measures to reduce or control direct
impacts on public services, if any:
N/A
16. UTILITIES:
a. Circ utilities currentlyavailable ite:
--�-- �ee-g
- at—the--�ctricit natural gas, se_�rvic4,
_ ___elephone sanitNry—sever, s _syste 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 vicinitywhich might
g be needed.
17. 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.
y -
Signature: + 'fC_,,a
w
0 _ l
Date Submitted:
I
12
RFCEI VF
Oct D
426 1 aw
ESA LISTED SALMONIDS CHECKLIST W�CEOAR Sr
Applicant Information Project Information
�. Name S1R Al L= L. M&V- r► ). Name A M E P,, N A;9T I q
Phone(36o) $7?-'g1155 Location u L;vJa.4� �f� 4�5`
a AYyy�� (�lQSi-ter Babb) -IM-bbib Description ; pt L3
aA/A),Q 5frT-7 &J--k Dr
:Bile—) Lot 11
This worksheet was designed to help project proponents and
government agencies identify when a project needs further
analysis regarding adverse effects on ESA (Endangered Species
Act) listed salmonids . Salmonids are salmon, trout and chars,
e.g. bull trout. For our purposes, "ESA listed salmonids" is
defined as fish species listed as endangered, threatened or
being considered for listing.
If ESA listed species are present or ever were present in the watershed where your project
will be located, your project has the potential for affecting them, and you need to comply
with the ESA. The questions in this section will help determine if the ESA listings will
impact your project.
The Fish Program Manager at the appropriate Department of Fish and Wildlife (DFW)
regional office can provide information for the following two questions
1 . Are ESA listed salmonids currently present in the watershed
in which your project will be located?
Yes INo
Please describe. NdcA eAVLO,A 3WVWVkLe-(- &Ww,
bull'Ci'ou-�
2 . Has there ever been an ESA listed salmonid stock present in
this watershed? Yes No Uncertain
Please describe . ff�
f-1t)CA (2.a..n cJ 5L vytjxt r Cat wvh
WA I tY,cJ�
If you answered "yes" to either of the above questions, you
should complete the remainder of this checklist.
September 1999 1
PROJECT SPECIFICS: The questions in this section are specific to •
the project and vicinity.
1 . Name of watershed: cl y��J
2 . Name of nearest waterbody: _H onA L11a l
3 . What is the distance from this project to the nearest body of
water?
Often a buffer between the project and a stream can reduce the chance of a
negative impact to fish.
4 . What is the current land use between the project and the
potentially affected water body (parking lots, farmland, etc)
SW i vv. rn ne�, -�S S�tt Yl� , boad-ina
5 . Is the project above a:
• natural permanent barrier (waterfall) Yes Now
• natural temporary barrier (beaver pond) Yes Now_
• man-made barrier (culvert, dam) Yes No_$_
• other (explain) :
6. If yes, are there any resident salmonid populations above the
blockage? Yes No1Z. Don' t know
7 . What percent of the project will be impervious surface
(including pavement & roof area) ? �bh�
September 1999 2
FISH MIGRATION: The following questions will help determine if
this project could interfere with migration of adult and
juvenile fish.
Both increases and decreases it water flows can affect fish migration.
1 . Does the project require the withdrawal of :
i . Surface water? Yes Now
Amount
Name of surface water body
ii . Ground water? Yes Now
Amount
From where
Depth of well
2 . Will any water be rerouted? Yes No
If yes, will this require a channel change?
3 . Will there be retention or detention ponds? Yes No_x_
If yes, will this be an infiltration pond or a surface
discharge to either a municipal storm water system or a
surface water body?
If. to a surface water discharge, please give the name of the
waterbody.
4 . Will this project require the building of new roads?
Yes No_x_ Increased road mileage may affect the timing of water
reaching a stream and may impact fish habitat.
5 . Are culverts proposed as part of this project? Yes No,x__
6 . Will topography changes affect the duration/direction of
runoff flows? Yes No-)�— If yes, describe the changes .
7 . Will the project involve any reduction of the floodway or
floodplain by filling or other partial blockage of flows?
Yes No
If yes, how will the loss of flood storage be mitigated by your project?
September 1999 3
• c
WATER QUALITY: The following questions will help determine if
this project could adversely impact water quality. Such impacts
can cause problems for listed species.
Water Quality can be made worse by runoff from impervious surfaces, altering water
temperature, discharging contaminants, etc.
1 . Do you know of any problems with water quality in any of the
streams within this watershed? Yes No.
If yes, describe.
2 . Will your project either reduce or increase shade along or
over a waterbody? Yes No 71K_
Removal of shading vegetation or the building of structures such as docks or
floats often result in a change in shade.
3 . Will the project increase nutrient loading or have the
potential to increase nutrient loading or contaminants
(fertilizers, other waste discharges, or runoff) to the
waterbody? Yes Now
4 . Will turbidity be increased because of construction of the
project or during operation of the project? Yes Now
In-water or near water work will often increase turbidity.
5 . Will your project require long term maintenance, i.e. bridge
cleaning, highway salting, chemical sprays for vegetation
management, clearing of parking lots?
Yes No _X_ If yes, please describe.
September 1999 4
VEGETATION: The following questions are designed to determine .
if the project will affect riparian vegetation, thereby,
adversely impacting salmon.
1. Will the project involve the removal of any vegetation from
the stream banks? Yes Now
If yes, please describe the existing conditions, and the
amount and type of vegetation to be removed.
2 . If any vegetation is removed, do you plan to re-plant?
Yeses_ No If yes, what types of . plants will you use?
uxkt ne ct r 1�P�i ckes an�.d Sa,Ltc,Da e r:
rn
grasses
September 1999 5
RESOURCES
Washington Department of Fish and Wildlife Website
www.wa.gov/wdfw/
This site has useful information on fish habitat.
Washington Department of Ecology Website
www.wa.gov/ecoloav/
Click on the Water Quality button on the left side of this page .
National Marine Fisheries Services Website
Evolutionarily Significant Unit (ESU) maps can be found at
www.nwr.noaa.gov Go to this site and then click on the ESA Salmon
button.
NOTE: Most applicants should have the information necessary to
answer most of the questions in this checklist. Additional
information will need to be obtained by local and state agencies
if it appears that the project is likely to affect ESA listed
species.
September 1999 r 6
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ry:•.�i:>i:iii;:.:.:...i.i Y.JARPA FORM OCT 21 2002
O
(for use in Washington State)
PLEASE TYPE OR PRINT IN BLUE OR BLACK INK 426 ••�/: CEDAR STi
Based on the preceding checldist,1 am sending copies of this application to the following: (check all that apply)
Local Government for shoreline: ❑ Substantial Development ❑Conditional Use ❑Variance tJ Exemption,or,if applicable
❑ Floodplain Management ❑Critical Areas Ordinance
.0 • Washington Department of Fish and Wildlife for HPA
A Washington Department of Ecology for. t]Approval to Allow Temporary Exceedance of Water Quality Standards
[P 401 Water Quality Certification Nationwide Permits
❑, Washington Department of Natural Resources for:❑Aquatic Resources Use Authorization Notification
Corps Engineers for: Section 404 ® Section 10 permit
❑ Coast Guard for: ❑Section 9 Bridge Permit
SECTION A -Use for all permits covered by this application. Be sure to also complete Section C(Signature Block)for all permit
applications.
1.APPLICANT 1. 7f}N
02. A11710- M. t. eIES+e'
MAILING ADDRESS ). .240 M. yl " I I
a, 15o4 AMloothSt,, 5eele,, Wl4 IUJ7 -,5yo1
WORK PHONE A p) HOME PHONE 97 7— p-q 55 FAX#
If an agent is acting for the applicant during the permit process,complete#2.
2.AUTHORIZED AGENT f kmyl Met'-
MAILING ADDRESS /a F QQ / 4 D
Kir-K.Icin4, WA gS6,34
WORK PHONE HOME PHONE FAX#
C4.20 Pd!- 7590
3.RELATIONSHIP OF APPLICANT TO PROPERT� OWNER ❑PURCHASER ❑LESSEE ❑OTHER:
�16t1 owntr
4.NAME,ADDRESS,AND PHONE NUMBER OF PROPERTY OWNER(S),IF OTHER THAN APPLICANT:
5.LOCATION(STREET ADDRESS,INCLUDING CITY,COUNTY AND ZIP CODE,WHERE PROPOSED ACTIVITY I TS OR WILL OCCUR)
I. � o � .ach N. A o�lG C fir. �.;�,L.,WRwP� WA. 9�5.�,5�
a, a r. 1-i,U
WATERBODY `1 TRIBUTARY OF
HQ� L w
1/4 SECTION TOWNSHIP RANGE GOVERNMENT LOT SHORELINE DESIGNATION
ZONING DESIGNATION
V'U ` c.
TAX PARCEL NO../ 25 Q O IV J DNR STREAM TYPE,IF KNOWN
�Z3�3 v 3 50 010 ��
Application Page 1 of 4
L J
FTHE
DESCRIBE
CURRENT USE OF THE PROPERTY.AND STRUCTURES OOSTING ON THE PROPERTY. IF ANY PORTION OF THE PROPOSED AC11Vfiy IS ALREADY COMPLETED `
.INDICATE MONTH AND YEAR OF COMPLETION.
n�l� -Fa.m( I� homes with Saraje6 wna.444ke4
GRICULTURAL LAND?❑YESARE YOU A USDA PROGRAM
YES
PROPONo
SED�w OR COMPLETE PLANS AND SPEGFICATTONS SHOULD BE PROVIDED FOR ALL WO K WATERWARD OF TE ORDIINARYPHIGH WATER AOR
e a1`Cac �d
7b.DESCRIBE THE PURPOSE OF THE PROPOSED WORK.
'To pre-tjexvt- -FUT�ltll r,ros(nrn o� ,)alet4roki h e-� �'g—T�re en; -
brti, doe l 10,Pi
FPOTENTIAL IMPACTS TO CHARACTERYSIIC USES OF THE WATER BODY. THESE USES MAY INCLUDE FISH AND AQUATIC LIFE,WATER QUALITY,WATER
EATION,and AESTHETICS. IDENTIFY PROPOSED AC11ONS TO AVOID,MINIMIZE,AND MITIGATE DETRIMENTAL IMPACTS,AND PROVIDE PROPER PROTECTION
WINGS: SEE APPENDIX A-SAMPLE DRAWINGS AND CHECKLIST FOR COMPLETING THE DRAWINGS. ONE SET OF ORIGINAL OR GOOD QUALITY
WINGS MUST BE ATTACHED. NOTE: APPLICANTS ARE ENCOURAGED TO SUBMIT PHOTOGRAPHS OF THE PROJECT SITE,BUT THESE DO NOT SUBSTITUTE
FOR DRAWINGS. THE CORPS OF ENGINEERS ANO COAST GUARD
AGENCIES REQUIRE DRAWINGS ON 8-112 X 11 INCH SHEETS. LARGER DRAWINGS MAYBE REQUIRED BY OTHER
8.WILL THE PROJECT BE CONSTRUCTED IN STAGES?
PROPOSED STARTING GATE: ❑YES x NO
ESTIMATED DURATION OF ACTIVITY:
9.CHECK IF ANY STRUCTURES WILL Be PLACED e /��y� /� I /�/� 1'y+
J,WATERWARD OF THE ORDINARY HIGH WATER MARK OR LINE FOR FRESH OR TIDD�AAL�ATERS ANDIOR U)at r V"�yr r (J���\ I`i%�lu 1 Q1
WATERWARO O THE MEAN HIGH WATER LINE IN TIDAL WATERS `� U/dGGG1 SS r r��/ •�/i� � f(J. WA
10.WILL FILL MATERIAL(ROCK,FILL,BULKHEAD,PILINGS OR OTHER MATERIAL)BE PLACED,
I',`/7
,,,fff
[ WATERWARD O THE ORDINARY HIGH WATER MARK OR LINE FOR FRESH WATERS? -
I` IF YES,VOLUME(CUBIC YARDS) EA (ACRES
WATERWARD O THE MEAN HIGHER HIGH WATER FOR TIDAL WATERS? YI
11.WILL MATERIAL 8E PLACED IN WETLANDS? IF YES,VOLUME(CUBIC YARDS) W14RE
IF YES:
❑YES Jq NO
A.IMPACTED AREA IN ACRES:
8 HAS A DELINEATION BEEN COMPLETED?jF YES,PLEASE SUBMIT WITH APPLICATION.
❑YES p NO
C.HAS A WETLAND REPORT BEEN PREPARED? IF YES,PLEASE SUBMIT WITH APPLICATION
❑YES ❑NO
D TYPE AND COMPOSITION OF FILL MATERIAL(E.G,SAND,ETC.):
E.MATERIAL SOURCE
F.UST ALL SOIL SERIES(TYPE OF SOIL)LOCATED AT THE PROJECT SITE,8 INDICATE IF THEY ARE ON THE COUNTYS LIST OF HYDRIC SOILS. SOILS INFORMATION CAN BE
OBTAINED FROM THE NATURAL RESOURCES CONSERVATION SERVICE(MRCS):
12.WILL PROPOSED ACTIVITY CAUSE FLOODING OR DRAINING OF WETLANDS?
❑YES I�NO
APPPlication Page 2 of 4
IF YES,IMPACTED AREA IS _ACRES
13,WILL EXCAVATION OR DREDGING BE REQUIRED IN WATER OR WETLANDS? ❑YES ,tj NO
w v
IF YES:
A.VOLUME:_(CUBIC YARDS)/AREA_(ACRES)
B.COMPOSITION OF MATERIAL TO BE REMOVED.
C.DISPOSAL SITE FOR EXCAVATED MATERIAL.
D.METHOD OF DREDGING:
14.LIST OTHER APPLICATIONS,APPROVALS,OR CERTIFICATIONS FROM OTHER FEDERAL,STATE OR LOCAL AGENCIES FOR ANY STRUCTURES,CONSTRUCTION,DISCHARGES,
OR OTHER ACTIVITIES DESCRIBED IN THE APPLICATION(I.E.,PRELIMINARY PLAT APPROVAL,HEALTH DISTRICT APPROVAL,BUILDING PERMIT,SEPA RFVIFW,FSRC LIC--NSE,
FOREST PRACTICES APPLICATION,ETC.)ALSO INDICATE WHETHER WORK HAS BEEN CONIPI_ETED AND INDICATE ALL EXISTING WORK ON DRAWINGS.
TYPE OF APPROVAL ISSUING AGENCY IDENTIFICATION NO. DATE OF APPLICATION DATE APPROVED COMPLETED?
n
rl'a-
-5ech,on 10
SEPA LEAD AGENCY SEPA DECISION. SEPA DECISION DATE:
15. HAS ANY AGENCY DENIED APPROVAL FOR THE ACTIVITY DESCRIBED HEREIN OR FOR ANY ACTIVITY DIRECTLY RELATED TO THE ACTIVITY
DESCRIBED HEREIN?❑YES NO NO IF YES,EXPLAIN: �
SECTION 8 - Use for Shoreline and Corps of Engineers permits only:
16. TOTAL COST OF PROJECT. THIS MEANS THE FAIR MARKET VALUE OF THE PROJECT,INCLUDING MATERIALS,LABOR,MACHINE RENTALS,ETC.
17. LOCAL GOVERNMENT WITH JURISDICTION.
18. FOR CORPS,COAST GUARD,i44D DNR PERMITS,PROVIDE NAMES,ADDRESSES,AND TELEPHONE NUMBERS OF ADJOINING PROPERTY OWNERS,LESSEES,ETC.PLEASE
NOTE: SHORELINE MANAGEMENT COMPLIANCE MAY REQUIRE ADDITIONAL NOTICE-CONSULT YOUR LOCAL GOVERNMENT.
NAME ADDRESS PHONE NUMBER
' as A 'LL; —5 kl77-::5-yrq
L10 kuDta
111'�"�� h ?him L, 1- 1J12 W4S rYaD -5ya
Application Page 3 of 4
SECTION C -This section MUST be completed for any permit covered by this application.
19. 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 TO START WORK ONLY AFTER ALL NECESSARY PERMITS HAVE BEEN RECEIVED.
NATURE OF APPLICANT OR AUTHORIZED AGENT
DATE '
f.�.
I HEREBY DESIGNATE
TO ACT AS MY AGENT IN MATTERS RELATED TO THIS APPLICATION FOR PERMfT(S), I UNDERSTAND THAT IF A FEDERAL PERMIT IS ISSUED,I MUST SIGN THE PERMIT
4
I NATURE OF PP C DATE
SIGNATURE OF LANDOWNER(EXCEPT PUBLIC ENTrrY LANDOWNERS,E.G.DNR) DATE
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)unsdiction 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
haudulent statement or entry,shall be fined not more than$10,000 or imprisoned not more than 5 years
rs or both.
COMPLETED BY LOCAL j FF11CIAL
A Nature of the existing shoreline. (Describe type of shoreline, such as marine, sti earn lake, l�agonn, rnarsh,77777
s`,varnp, #tUod
plain, ftoddway, defia;gyps of beach,such as acceetion, erosion, high bank, iOW b;an or dike; matolial such as sand, gf a'1
rtiUd,clay, rock, riprap,>>,and extent and type of Wkheadincg if any.)
B, 3n the evert ttlat any of ttie proposed buildings or structures Will exceed a height of thirty-five feet above the average giade
level, indicate approxirrlate i0cation of and number of residential Units, existing anb potential, that will have an cbstrLJrtetl
View
3f#hu a mica*:on involves a Wndiiidn l usc,of varianoe, Sat forth in full tt3at portuan 6€ttte rt..4.;✓✓r pragfam which provides that
the pruposed use may be a conitionai use, or, in the casAf a aarlarae, froiavhich�ltha�iatianc isi Being scaught
0 3�L t 1 , , pc s��L1ev�1}S,nrrtertt
E Fka xfw �90C1 ar F7txxli l tat 5tX dealfea adfriairt U.lx i u4%t^tYArn �a FEW FIWA Cottutturity-panel Numaef
; tk; .Uj f kx-Kjilt{#411 a7de;YtY}%(3rt(H tifroh ntnn4tsf W lh,?-L}�-mkipnrmrtl f l is At�ei%. ..
7fi -F utsf"Sit 10 building eie,/,AK;:
Bulldlnq and Gpr)sttuction Oocumentation
�Cor7;fs�ation#�csgiliraei _._._ _ Certif+ca8inn�er-ervnd __ _ SUrvs�urJ�rchitczcUt;nf}increry—,
Fkxx3 5 rc oG�g r ParrQculsu nrtt a 3�c s;f ottsirurt �n
Li�rated�u:;crdy .a. ..._.�.y.: f'r><r:C,cxlsitucticn ._ f'r�€f C�rns#rttc#ian
A#w ald)n k,Wcitosw Y_ .........
—These A — — —
les are Equal O g�rc n end 4 rfnetltro
pportu Action
h1' employers,
amp! ye
For special accommodaUon needs,please contact the approprfare agency from Appendix B.
Application Page 4 of 4