HomeMy WebLinkAboutSHX2016-00003 - SHX Permit / Conditions - 2/3/2016 ' �,t$STATE.0
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STATE OF WASHINGTON
DEPARTMENT OF ECOLOGY
PO Box 47775 • Olympia, Washington 98504-7775 • (360) 407-6300
711 for Washington Relay Service • Persons with a speech disability can call 877-833-6341
January 31, 2019
Paul and Marla Morgan
PO Box 1309
Allyn, WA 98524
Re: Mason County Permit SHR2018-00014 - Approved
Paul and Marla Morgan-Applicant
Shoreline Substantial Development Permit (SDP)#3978
Dear Paul and Marla Morgan:
On January 29, 2019,the Department of Ecology received notice that Mason County approved
your application for an SDP. Your permit is to convert an existing garage into an accessory
• dwelling unit within shoreline jurisdiction of Puget Sound.
By law, local governments must review all SDPs for compliance with:
• The Shoreline Management Act(Chapter 90.58 RCW)
• Ecology's Substantial Development Permit approval criteria (Chapter 173-27-150 WAC)
• The Mason County Local Shoreline Master Program.
Local governments, after reviewing SDPs for compliance, are required to submit them to
Ecology. Your approved SDP has been received by Ecology.
What Happens Next?
Before you begin activities authorized by this permit,the law requires you wait at least 21 days
from January 29, 2019, the "date of filing." This waiting period allows anyone (including you)
wh6 disagrees with any aspect of this permit to appeal the decision to the state Shorelines
Hearings Board. You must wait for the conclusion of an appeal before you can begin the
activities authorized by this permit.
We recommend contacting the Shorelines Hearings Board at(360) 664-9160 before be Wing
permit activities to ensure that no appeal has been filed. Information on appeals is also posted at
http://www.eluho.wa.gov/Decision/Search Cases. Select"Shorelines Hearings Board" from the
drop down menu labeled "Board" and enter "Search." The most current appeal will appear on
top.
If you want to appeal this decision,you can find appeal instructions (Chapter 461-08 WAC) at
the Shorelines Hearings Board website above. They are also posted on the website of the
Washington State Legislature at: http://apps.leg.wa.gov/wac.
L-%WL-1 V Lam.L-f
FEB 0 5 2019
b15 W. Alder Street
Paul and Marla Morgan
January 31,2019
Page 2 of 2
Other federal, state, and local permits may be required in addition to this shoreline permit.
If you have any questions about this letter,please contact Donna Joblonski at(360) 407-7058.
Sincerely,
C on M 4b&rw'&�
Donna Joblonski, Administrative Assistant
Shorelands and Environmental Assistance Program
cc: Ron Buckholt, Mason County
Py0N_STgr�O MASON COUNTY
C ft DEPARTMENT OF COMMUNITY DEVELOPMENT
o n o N Planning Division
o T Z 426 W Cedar St, Shelton, WA 98584
P N Y Y (360)427-9670
OJ �O
1864
Exemption from Shoreline Management Act
Case No.: SHX2016-00003 Substantial Development Permit Requirement
The Proposal By: M& P MORGAN REPLACEMENT BULKHEAD
C/O PACIFIC NW BULKHEAD INC
P O BOX 11477
OLYMPIA,WA 98508
To undertake the following development:
Replace failing concrete bulkhead in front of residence with rock bulkhead in same alignment;
108 ft. length and 7 ft. height.
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 Allan Borden at ext 365 if you have any questio s.
Issued: 2/3/2016 Z/3 ZU(6
Expires: 2/3/2018 Authorized Local Government Official
cc: APPLICANT WDFW USACOE WDOE TRIBAL COUNCIL
RECEIV j 1---------------------------------------
' AGENCY USE ONLY '
t eo 0 7 1 m *7ED
Y � AA"/"1�!!! 1 Date received:
US Anny
WASHINGTON STATE s- IAp 17 201
Joint Aquatic Resources Permit Agency reference#: v�I X2616' 3;
Application (DARPA) Form1,2 hel Tax Parcel#(s): 1�aa�i- So ®��►`1
1
USE BLACK OR BLUE INK TO ENTER ANSWERS IN THE WHITE SPACES BELOW.
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Part 1—Project Identification
1. Project Name (A name for your project that you create.Examples:Smith's Dock or Seabrook Lane Development) fhelpl
M & P morgan replacement bulkhead
Part 2—Applicant
The person and/or organization responsible for the project. hel
2a. Name (Last, First, Middle)
Pacific NW Bulkhead Inc
2b. Organization(If applicable)
2c. Mailing Address (Street or Po Box)
Po box 11477
2d. City, State, Zip
Olympia wa 98508
2e. Phone(1) 2f. Phone(2) 2g. Fax 2h. E-mail
( 3608886357 ) ( ) ( ) pacificnwbulkhead@comcast.net
Additional forms may be required for the following permits:
• If your project may qualify for Department of the Army authorization through a Regional General Permit(RGP),contact the U.S.Army Corps of
Engineers for application information(206)764-3495.
• If your project might affect species listed under the Endangered Species Act,you will need to fill out a Speck Project Information Form(BPIF)or
prepare a Biological Evaluation. Forms can be found at
http://www nws usace army mil/Missions/CiviiWorks/Regulatory/PermitGuidebook/EndanaeredSpecies.aspx.
• Not all cities 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.
2To access an online JARPA form with[help]screens,go to
http://www.epermifting.wa.gov/site/alias resourcecenter/iarpa iarpa form/99B4/iarpa form.aspx.
For other help,contact the Govemor's Office for Regulatory Innovation and Assistance at(800)917-0043 or helper-oria.wa.gov.
JARPA Revision 2015.1 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 11 b of this
application.) it eM
3a. Name (Last, First, Middle)
Kaufman kim
3b. Organization (If applicable)
3c. Mailing Address (Street or Po Box)
Po box 11477
3d. City, State, Zip
Olympia wa 98508
3e. Phone(1) 3f. Phone(2) 3g. Fax 3h. E-mail
3608886357 ( ) ( ) pacificnwbulkhead@comcast.net
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. [Help]
❑ 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 DARPA 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 (Last, First, Middle)
Morgan marla & paul
4b. Organization (If applicable)
4c. Mailing Address (street or Po Box)
7710 e grapeview loop road
4d. City, State, Zip
Allyn wa 98524
4e. Phone(1) 4f. Phone(2) 4g. Fax 4h. E-mail
( ) ( ) ( ) Mmm1962002@yahoo.com
JARPA Revision 2015.1 Page 2 of 14
Part 5—Project Location(s)
Identifying information about the property or properties where the project will occur. hel
❑ 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.) hel
x❑ 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 E)
5b. Street Address (Cannot be a PO Box. If there is no address, provide other location information in 5p.) [help]
7710 a grapeview loop rd
5c. City, State, Zip(If the project is not in a city or town, provide the name of the nearest city or town.) [hpipi
Allyn wa 98524
5d. County hf eipl
Mason
5e. Provide the section, township, and range for the project location. hl elpl
%Section Section Township Range
0 29 22n R1 w
5f. Provide the latitude and longitude of the project location. hel
• Example:47.03922 N lat./-122.89142 W long. (Use decimal degrees-NAD 83)
47.374558 -122.829591
5g. List the tax parcel number(s)for the project location. hf elpl
• The local county assessor's office can provide this information.
12229-50-02019
5h. Contact information for all adjoining property owners. (if you need more space,use JARPA Attachment C.) hL elA
Name Mailing Address Tax Parcel #(if known)
Steadman stuart I & kathery 1 7720 a grapeview loop rd allyn wa 98524 12229-50-02018
Parks jr ex ux Lawrence a 7700 a grapeview loop rd allyn wa 98524 12229-50-02021
JARPA Revision 2015.1 Page 3 of 14
51i. List all wetlands on or adjacent to the project location. hei
none
5j. List all waterbodies (other than wetlands) on or adjacent to the project location. hf eye]
North bay
5k. Is any part of the project area within a 100-year floodplain? hei
❑ Yes ❑ No x❑ Don't know
51. Briefly describe the vegetation and habitat conditions on the property. hei
Typical shoreline vegetation shrubs grass sand gravel various size rocks. Typical shoreline habitat song birds
fish deer
5m. Describe how the property is currently used. hei
Single family residence
5n. Describe how the adjacent properties are currently used. hei
Single family residence
5o. Describe the structures (above and below ground) on the property, including their purpose(s) and current
condition. [help
Built 1960, quality 2.0-fair, condition 3.0—average, frame siding metal,1 story, carport, detached garage, wood
deck, bedrooms 3, bathrooms 2
5p. Provide driving directions from the closest highway to the project location, and attach a map. hei
See attached map and directions
JARPA Revision 2015.1 Page 4 of 14
Part 6—Project Description
6a. Briefly summarize the overall project. You can provide more detail in 6b. hel
Replace failing concrete with rock (270 ton) 108' long 7' tall
6b. Describe the purpose of the project and why you want or need to perform it. hel
Huge sink holes forming behind failing wall.
6c. Indicate the project category. (Check all that apply) hel
❑ Commercial x❑ 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 ❑ 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
x❑ Other:
replacement bulkhead
JARPA Revision 2015.1 Page 5 of 14
6e. Describe how you plan to construct each project element checked in 6d. Include specific construction
• methods and equipment to be used. hel
• Identify where each element will occur in relation to the nearest waterbody.
• Indicate which activities are within the 100-year floodplain.
See attached site plan for rock placement in water. All rock coming from upland quarry. Barge will enter corridor
per HPA instructions. All work will be done by excavator from grounded barge.
6f. What are the anticipated start and end dates for project construction? (Month/Year) hem
• If the project will be constructed in phases or stages, use to list the start and end dates of each phase or
stage.
Start date:now End date: 10 days from start date ❑ See JARPA Attachment D
6g. Fair market value of the project, including materials, labor, machine rentals, etc. hel
$31,000-00
6h. Will any portion of the project receive federal funding?
• If yes, list each agency providing funds.
❑ Yes x❑ No ❑ Don't know
Part 7—Wetlands: Impacts and Mitigation
x❑ 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. [
❑ Not applicable
7b. Will the project impact wetlands? h[ gid
JARPA Revision 2015.1 Page 6 of 14
❑ Yes ❑ No ❑ Don't know
7c. Will the project impact wetland buffers? hf eM
❑ Yes ❑ No ❑ Don't know
7d. Has a wetland delineation report been prepared? heI
• If Yes, submit the report, including data sheets,with the JARPA package.
❑ Yes ❑ No
7e. Have the wetlands been rated using the Western Washington or Eastern Washington Wetland Rating
System? [help]
• If Yes, submit the wetland rating forms and figures with the JARPA package.
❑ Yes ❑ No ❑ Don't know
7f. Have you prepared a mitigation plan to compensate for any adverse impacts to wetlands? heI
• If Yes, submit the plan with the JARPA package and answer 7g.
• If No, or Not applicable,explain below why a mitigation plan should not be required.
❑ Yes ❑ No ❑ Not applicable
7g. Summarize what the mitigation plan is meant to accomplish, and describe how a watershed approach was
used to design the plan. hel
I
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. [ )
Activity (fill, Wetland Wetland Impact Duration Proposed Wetland
drain, excavate, Name' type and area (sq. of impact3 mitigation mitigation area
flood, etc.) rating ft. or type' (sq. ft. or
categoryz Acres) acres)
If no official name for the wetland exists,create a unique name(such as"Wetland 1"). The name should be consistent with other project documents,such
as a wetland delineation report.
2 Ecology wetland category based on current Western Washington or Eastern Washington Wetland Rating System. Provide the wetland
rating forms with the JARPA package.
3Indicate the days,months or years the wetland will be measurably impacted by the activity.Enter"permanent"if applicable.
°Creation(C),Re-establishment/Rehabilitation(R),Enhancement(E), Preservation(P),Mitigation Bank/In-lieu fee(B)
JARPA Revision 2015.1 Page 7 of 14
Page number(s) for similar information in the mitigation plan, if available:
7i. For all filling activities identified in 7h, describe the source and nature of the fill material, the amount in cubic
yards that will be used, and how and where it will be placed into the wetland. [Leipj
7j. For all excavating activities identified in 7h, describe the excavation method, type and amount of material in
cubic yards you will remove, and where the material will be disposed. hel
Part 8—Waterbodies (other than wetlands): Impacts and Mitigation
In Part 8, "waterbodies" refers to non-wetland waterbodies. (See Part 7 for information related to wetlands.) hey
❑ 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.
Lel
x❑ Not applicable
Replace failing existing concrete. Large sink holes forming behind wall.
81b. Will your project impact a waterbody or the area around a waterbody? hel
❑ Yes x❑ No
JARPA Revision 2015.1 Page 8 of 14
� I
8c. Have you prepared a mitigation plan to compensate for the project's adverse impacts to non-wetland
waterbodies? h[ eAi
• If Yes, submit the plan with the JARPA package and answer 8d.
• If No, or Not applicable,explain below why a mitigation plan should not be required.
❑ Yes ❑x No ❑ Not applicable
replacement
8d. Summarize what the mitigation plan is meant to accomplish. Describe how a watershed approach was used
to design the plan.
• If you already completed 7g you do not need to restate your answer here. [ ]
8e. Summarize impact(s) to each waterbody in the table below.
Activity (clear, Waterbody Impact Duration Amount of material Area (sq. ft. or
dredge, fill, pile name' location of impact3 (cubic yards) to be linear ft.) of
drive, etc.) placed in or waterbody
removed from directly affected
waterbody
0 North bay 270 ton 108'
a,
i
If no official name for the waterbody exists,create a unique name(such as"Stream 1")The name should be consistent with other documents provided.
2Indicate whether the impact will occur in or adjacent to the waterbody. If adjacent, provide the distance between the impact and the waterbody and
indicate whether the impact will occur within the 100-year flood plain.
3Indicate the days,months or years the waterbody will be measurably impacted by the work. Enter"permanent"if applicable.
8f. For all activities identified in 8e, describe the source and nature of the fill material, amount (in cubic yards)
you will use, and how and where it will be placed into the waterbody. h[ eM
270 ton rock coming from upland quarry. See attached site plan for rock placement in water
JARPA Revision 2015.1 Page 9 of 14
8g. For all excavating or dredging activities identified in 8e, describe the method for excavating or dredging,
type and amount of material you will remove, and where the material will be disposed. Neel
Failing concrete disposed to upland source
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. heI
Agency Name Contact Name Phone Most Recent
Date of Contact
9b. Are any of the wetlands or waterbodies identified in Part 7 or Part 8 of this JARPA on the Washington
Department of Ecology's 303(d) List?
• If Yes, list the parameter(s) below.
• If you don't know, use Washington Department of Ecology's Water Quality Assessment tools at:
htto://www.egy.wa.gpy/prp_gra /w M3d/.
❑ Yes x❑ No
I
9c. What U.S. Geological Survey Hydrological Unit Code (HUC) is the project in? h[ elo
• Go to http://cfpub.epa.gov/surf/locate/index.cfm to help identify the HUC.
9d. What Water Resource Inventory Area Number (WRIA#) is the project in? heI
• Go to http://www.ecy.wa.gov/services/gis/maps/wria/wria.htn to find the WRIA#.
14
JARPA Revision 2015.1 Page 10 of 14
9e. Will the in-water construction work comply with the State of Washington water quality standards for
turbidity? Frei
• Go to nttp://www.ecy.wa.gov/programs/wq/swgs/criteria.html for the standards.
x❑ Yes ❑ No ❑ Not applicable
9f. If the project is within the jurisdiction of the Shoreline Management Act, what is the local shoreline
environment designation? h[ elpl
• If you don't know, contact the local planning department.
• For more information, go to: hftp://www.ecy.wa.gov/programs/sea/sma/laws rules/173-26/211 designations.htm 1.
❑ Rural tTUrban ❑ Natural ❑ Aquatic ❑ Conservancy ❑ Other
9g. What is the Washington Department of Natural Resources Water Type? ['7elp]
• Go to hftp://www.dnr.wa.gov/forest-practices-water-typin for the Forest Practices Water Typing System.
x❑ Shoreline ❑ Fish ❑ Non-Fish Perennial ❑ Non-Fish Seasonal
9h. Will this project be designed to meet the Washington Department of Ecology's most current stormwater
manual? [hel
• If No, provide the name of the manual your project is designed to meet.
x❑ Yes ❑ No
Name of manual:
9i. Does the project site have known contaminated sediment?
• If Yes, please describe below.
❑ Yes x❑ No
9j. If you know what the property was used for in the past, describe below. hel
l Y P P Y
Single family residence
9k. Has a cultural resource (archaeological) survey been performed on the project area? [?el-pi
• If Yes, attach it to your JARPA package.
❑ Yes x❑ No
JARPA Revision 2015.1 Page 11 of 14
91. 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. �hel
Bull trout Chinook none affected by work
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. hel
Part 10—SEPA Compliance and Permits
Use the resources and checklist below to identify the permits you are applying for.
• Online Project Questionnaire at http://apps.oria.wa.gov/opas/.
• Governor's Office for Regulatory Innovation and Assistance at (800) 917-0043 or helper-oria.wa.gov.
• For a list of addresses to send your JARPA to, click on agency addresses for completed JARPA.
10a. Compliance with the State Environmental Policy Act (SEPA). (check all that apply.) h[ elp]
• For more information about SEPA, go to www.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 mason co (lead agency). The expected decision
date is
❑ I am applying for a Fish Habitat Enhancement Exemption. (Check the box below in 1 ob.) h[ pjA
x❑ This project is exempt (choose type of exemption below).
❑ Categorical Exemption. Under what section of the SEPA administrative code (WAC) is it exempt?
Shoreline exemption
❑ Other:
❑ SEPA is pre-empted by federal law.
JARPA Revision 2015.1 Page 12 of 14
10b. Indicate the permits you are applying for. (Check all that apply.) Lqgld
LOCAL GOVERNMENT
Local Government Shoreline permits:
❑ Substantial Development ❑ Conditional Use ❑ Variance
❑ Shoreline Exemption Type (explain): replacement
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
You must submit a check for $150 to Washington Department of Fish and Wildlife, unless your project qualifies
for an exemption or alternative payment method below. Do not send cash.
Check the appropriate boxes:
❑$150 check enclosed. Check#
Attach check made payable to Washington Department of Fish and Wildlife.
❑ My project is exempt from the application fee. (Check appropriate exemption)
❑ HPA processing is conducted by applicant-funded WDFW staff.
Agreement #
❑ Mineral prospecting and mining.
❑ Project occurs on farm and agricultural land.
(Attach a copy of current land use classification recorded with the county auditor, or other proof of current land use.)
❑ Project is a modification of an existing HPA originally applied for, prior to July 10, 2012.
HPA#
Washington Department of Natural Resources:
❑ Aquatic Use Authorization
Complete.ARPA Attachment E and submit a check for$25 payable to the Washington Department of Natural Resources.
Do not send cash.
Washington Department of Ecology:
❑ Section 401 Water Quality Certification
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:
❑ Private Aids to Navigation (for non-bridge projects)
JARPA Revision 2015.1 Page 13 of 14
jac floc �vavv wk-w- rwRu >
Part-11-Authorizing Signatures natures -3ub - 6N2_;> -UN
Signatures are required before submitting the JARPA package. The JARPA package includes the JARPA form,
project plans, photos, etc. (_ ._
11 a. Applicant Signature (required) )
I certify that to the best of my knowledge and belief, the information provided in this application is true, complete,
and accurate. I also certify that I have the authority to carry out the proposed activities, and I agree to start work
only after I have received all necessary permits.
I hereby authorize the agent named in Part 3 of this application to act on my behalf in matters related to this
application. tNk (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 entering the property where the project is located to inspect the project site or any work
related to the project. _N�N (initial)
Pacific Northwest Bulkhead Inc
Applicant Printed Name Apolicant Signature Date
11 b. Authorized Agent Signature hf eM
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.
Kim Kaufman 7 Y
Authorized Agent Printed Name Authoriz Agent Signat!:01Date
11 c. Property Owner Signature (if not applicant) G i J
Not required if project is on existing rights-of-way or easements.
I consent to the permitting agencies entering the property where the project is located to inspect the project site
or any work. These inspections shall occur at reasonable times and, if practical, with prior notice to the
landowner.
Marla Morgan _
Property Owner Printed Name Property Owner gignaWre Date
18 U.S.0 §1001 provides that:Whoever, in any manner within the jurisdiction of any department or agency of the United States knowingly
falsifies, conceals, or covers up by any trick, scheme, or device a material fact or makes any false, fictitious, or fraudulent statements or
representations or makes or uses any false writing or document knowing same to contain any false, fictitious, or fraudulent statement or
entry, shall be fined not more than $10,000 or imprisoned not more than 5 years or both.
If you require this document in another format,contact the Governor's Office for Regulatory Innovation and Assistance(ORIA)at(800)
917-0043. People with hearing loss can call 711 for Washington Relay Service. People with a speech disability can call (877)833-6341
ORIA publication number: ENV 019 09 rev. 09/2015
JARPA Revision 2015.1 Page 14 of 14