HomeMy WebLinkAboutSHR2022-00013 ATF Bulkhead, Pier, Dock JARPA - SHR Application - 8/21/2022 RECEIVED
RECEIVED:
MASON COUNTY AUG 31 2L22
r COMMUNITY SERVICES 615 W. Alder Street
Budding,Planning,Ervironmental HeAl},comm❑nity He'
-4 615 W.Alder St.—Bldg.8,Shelton,Wa 98584
Phone:(360)427-9670 ext.352 ♦Fax:(360)427-7798 3
PERMIT NO.: D Z!}ZZ-QQO
SHORELINE PERMIT APPLICATION PLANNING
SHORELINE PERMITS
CONDITIONAL USE* SUBSTANTIAL DEVELOPMENT
VARIANCE* ❑ EXEMPTION ❑
ACCESSORY DWELLING UNIT* ❑
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 $7,047.00 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 may further describe the proposed development.
Incomplete applications will be returned.
*Shoreline Variances and Conditional uses require public hearings and have additional pages that shall be
attached to this application.
APPLICANT: WaVn e 4- RD loin Jo hi l'jcm ADDRESS: 27Q� (p N1I (,Anjph (-(-i( ( RJ
Redvnd�� (� eet� a5��
(city) (state)
(Zip)
TELEPHONE: 14?, . Ll jz o, bLe9 Z
(home)
f (business)
AUTHORIZED REPRESENTATIVE: J,,(U1r1 �Q (/AA M,[� l �jInOY`2(i y1e ��lu�'l�lS (.l.0
ADDRESS: 9i01
d e r��treet) , ,l�V�
(city) j W (state)
(Zip)
TELEPHONE: __ ZQ(p � ) ZOO
PROPERTY DESCRIPTION: (L,o
General location (include property address vl ater body and associated wetlands—identify the name of the shoreline):
Rev. Nov. 30, 2021
Include all parcel numbers: Projects located in open water areas, away from land shall provide latitude/longitude.
z033d• 570 .00153
OWNERSHIP:
C� Contract
Applicant
Owner C✓� Lessee F--] purchaser (Identify) Other
Owner: Way/N if 44— RPib l v� Jd h 1150V1
2-1a 1(P IJ E .t,✓l 4-611 rZd , e�mXlO( , WA It 5 ft
(street) (city) (state) (Zip)
DEVELOPMENT DESCRIPTON:
Development proposal (identify and describe the proposed project, including the type of materials to be used, construction
methods, principle dimensions, and other pertinent information):
i
dY}� h� rep �aczw- ��,-rig "V 3to "
Existing Use (identify current use of property with exist improvements):
Reason for requesting development:
PM- f�r rn" c41hd re&g4cvh',�Yiovl
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Estimated Fair Market Value of Project to Closest$1,000: 15►UG
The Applicant shall provide, at a minimum, the following information:
a. SITE PLAN -drawn to scale and including:
i. The boundary of the parcel(s)of land upon which the development is proposed;
ii. The ordinary high water mark (OHWM). This may be an approximate location provided, that for any development
where a determination of consistency with the applicable regulations requires a precise location of the OHWM the
mark shall be located precisely and the biological and hydrological basis for the location as indicated on the plans
shall be included in the development plan. Where the OHWM is neither adjacent to or within the boundary of the
project, the plan shall indicate the distance and direction to the nearest OHWM of a shoreline;
iii. Where appropriate, the proposed land contours using five-foot intervals in water area and ten-foot intervals on
areas landward of OHWM, if development involves grading, cutting, filling, or other alteration of land contours;
iv. The dimensions and location of existing structures which will be maintained,-
v. The dimensions and locations of proposed structures, parking and landscaping;
vi. The location of proposed utilities, such as sewer, septic tanks and drain fields, water, gas and electricity;
vii.The location, source, composition, and volume of fill material;
viii. The location, composition and volume of any extracted materials, and proposed disposal area;
b. CROSS SECTION, drawn to scale including:
i. The existing ground elevations;
ii. The proposed ground elevations,-
iii. The location and height of existing structures,-
iv. The location and height of proposed structures;
V. The OHWM.
c. VICINITY MAP, including:
i. The location of subject parcel using natural points of reference (roads, state highways, prominent landmarks,
etc.).
ii. If the development involves the removal of any soils by dredging or otherwise, identify the proposed disposal
site on the map. If disposal site is beyond the confines of the vicinity map, provide another vicinity map
showing the precise location of the disposal site and its distance to nearest city or town.
iii. On the map, or separately, give a brief narrative description of the vicinity of the proposed project including
identification of the adjacent uses, structures and improvements, intensity of development and physical
characteristics.
d. ADJACENT LANDOWNERS. Provide names and mailing addresses of all real property owners within 300
feet of property line boundaries where development is proposed as mailing labels or pre-addressed
envelopes.
ACKOWLEDGEMENT:
I hereby declare, to the best of my knowledge and belief, the forgoing information and all attached information is true and
correct.
GC�n I Ve_
(Applicant or Authorized Representative) (date)
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AGENCY USE ONLY
��IWASHINGTON STATE of Army Corps Date received:
of Engineers �
Seattle District
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Joint Aquatic Resources Permit
t
Agency reference#:
Application (JARPA) Form','
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USE BLACK OR BLUE INK TO ENTER ANSWERS IN THE WHITE SPACES BELOW. Tax Parcel#(s):
t
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t t
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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
Johnson Dock and After-The Fact Bulkhead
Part 2-Applicant
The person and/or organization responsible for the project.
2a. Name (Last, First, Middle)
Johnson, Wayne & Robin
2b. Organization (If applicable)
2c. Mailing Address (Street or Po Box)
27816 NE Union Hill Rd
2d. City, State, Zip
Redmond, WA 98053
2e. Phone(i) A Phone (2) 2g. Fax 2h. E-mail
425-466-6692 Robinjohnson52@yahoo.com
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.
• 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
hftp://www.ePermltting.wa.gov/Site/alias resourcecenter/iarpa iarpa form/9984/iarpa form.aspx.
For other help,contact the Governor's Office for Regulatory Innovation and Assistance at(800)917-0043 or help(a)oria.wa.gov.
ORIA-16-011 Page 1 of 11
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.)
3a. Name (Last, First, Middle)
McDonald, Leann
3b. Organization (if applicable)
Shoreline Solutions LLC
3c. Mailing Address (Street or Po Box)
9784 NE Lafayette Avenue
3d. City, State, Zip
Bainbridge Island, WA 98110
3e. Phone(1) 3f. Phone(2) 3g. Fax 3h. E-mail
206-300-2678 leannm@mac.com
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.
❑x Same as applicant. (Skip to Part 5.)
❑ Repair or maintenance activities on existing rights-of-way or easements. (Skip to Part 5.)
❑ There are multiple upland property owners. Complete the section below and fill out JARPA Attachment A for
each additional property owner.
❑ Your project is on Department of Natural Resources (DNR)-managed aquatic lands. If you don't know, contact
the DNR at (360) 902-1100 to determine aquatic land ownership. If yes, complete JARPA Attachment E to
apply for the Aquatic Use Authorization.
4a. Name (Last, First, Middle)
4b. Organization (If applicable)
4c. Mailing Address (Street or Po Box)
4d. City, State, Zip
4e. Phone(1) 4f. Phone(2) 4g. Fax 4h. E-mail
ORIA-16-011 Page 2 of 11
Part 5—Project Location(s)
Identifying information about the property or properties where the project will occur. hf elpl
❑ 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.)
❑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.)
1480 NE Tahuya Blacksmith Rd
5c. City, State, Zip(If the project is not in a city or town, provide the name of the nearest city or town.)
Tahuya, WA 98588
5d. County
Mason
5e. Provide the section, township, and range for the project location.
1/4 Section Section Township Range
30 16 2W
5f. Provide the latitude and longitude of the project location.
• Example: 47.03922 N lat. /-122.89142 W long. (Use decimal degrees- NAD 83)
47.453981 N lat. / -122.988767 W long
5g. List the tax parcel number(s) for the project location.
• The local county assessor's office can provide this information.
1924069081
5h. Contact information for all adjoining property owners. (If you need more space, use JARPA Attachment C.)
Name Mailing Address Tax Parcel # (if known)
N: Colby & Janice Blackstrom 40940 State Route 20
........ ......... ........................................................................._._.._.._..................._................. 223305000154
Concrete, WA 98237
S: Julie Gurrad et al 1927 163rd St SE
....... .....................-1._............................................................................................................ 223050000152
Mill Creek, WA 98112
5i. List all wetlands on or adjacent to the project location.
n/a
5j. List all waterbodies (other than wetlands) on or adjacent to the project location.
ORIA-16-011 Page 3 of 11
Have Lake
5k. Is any part of the project area within a 100-year floodplain?
❑ Yes 9 No ❑ Don't know
51. Briefly describe the vegetation and habitat conditions on the property.
Lawn, trees, bushes
5m. Describe how the property is currently used.
Single family residential
5n. Describe how the adjacent properties are currently used.
Single family residential
5o. Describe the structures (above and below ground) on the property, including their purpose(s) and current
condition.
Secondary residence, Hood condition, existing cinderblock bulkhead
5p. Provide driving directions from the closest highway to the project location, and attach a map.
From Shelton, follow WA-3 southeast to Belfair. Turn left onto WA-300. Take NE Belfair Tahuya Rd
and NE Haven Way to NE Tahuya Blacksmith Rd. 1482 is on the right.
Part 6—Project Description
6a. Briefly summarize the overall project. You can provide more detail in 6b.
Construct new 8' x 36' pier supported by six in-water piling and a landward concrete abatement.
After-the-fact application to legally permit the retaining wall block bulkhead and lake access
(stairway).
6b. Describe the purpose of the project and why you want or need to perform it.
The dock will be used for moorage and enjoyment of water related activities. The retaining wall block
bulkhead replaced a timber bulkhead 20 years ago, and the stairway provides access to the shore and lake.
6c. Indicate the project category. (Check all that apply)
❑ Commercial Lx Residential ❑ Institutional ❑ Transportation ❑x Recreational
❑ Maintenance [Z Environmental Enhancement
6d. Indicate the major elements of your project. (check all that apply)
❑ 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 ❑x Dock / Pier ❑ Marina / Moorage ❑ Stairs
❑ Bridge ❑ Dredging ❑ Mining ❑ Stormwater facility
❑x Bulkhead ❑ Fence ❑ Outfall Structure ❑ Swimming Pool
ORIA-16-011 Page 4 of 11
❑ Buoy ❑ Ferry Terminal ❑ Piling/Dolphin ❑ Utility Line
❑ Channel Modification ❑ Fishway ❑ Raft
❑ Other:
6e. Describe how you plan to construct each project element checked in 6d. Include specific construction
methods and equipment to be used. hei j
• Identify where each element will occur in relation to the nearest waterbody.
• Indicate which activities are within the 100-year floodplain.
1. Install new piling for pier
2. Install structural members and decking
6f. What are the anticipated start and end dates for project construction? (MonthNear)
• 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: Fall 2022 End Date: 2-3 days ❑ See JARPA Attachment D
6g. Fair market value of the project, including materials, labor, machine rentals, etc.
$12,500
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
❑ 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.
❑x Not applicable
7b. Will the project impact wetlands?
❑ Yes ❑x No ❑ Don't know
7c. Will the project impact wetland buffers?
❑ Yes ❑x No ❑ Don't know
7d. Has a wetland delineation report been prepared?
• If Yes, submit the report, including data sheets,with the JARPA package.
❑ Yes ❑x No
7e. Have the wetlands been rated using the Western Washington or Eastern Washington Wetland Rating
System? If Yes, submit the wetland rating forms and figures with the JARPA package.
❑ Yes Z No ❑ Don't know
7f. Have you prepared a mitigation plan to compensate for any adverse impacts to wetlands?
• If Yes, submit the plan with the JARPA package and answer 7g.
ORIA-16-011 Page 5 of 11
• If No, or Not applicable, explain below why a mitigation plan should not be required.
❑ Yes ❑x No ❑ Don't know
7g. Summarize what the mitigation plan is meant to accomplish, and describe how a watershed approach was
used to design the plan.
n/a
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. Lhel
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
category' 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
Page number(s) for similar information in the mitigation plan, if available:
7L 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.
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.
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.)
❑x 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.
❑ Not applicable
Replacement of an existing dock. Decking will include grated for light penetration.
81b. Will your project impact a waterbody or the area around a waterbody?
x. Yes ❑ No
8c. Have you prepared a mitigation plan to compensate for the project's adverse impacts to non-wetland
waterbodies?
• 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 ® No ❑ Don't know
ORIA-16-011 Page 6 of 11
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 impact' (cubic yards) to be linear ft.) of
drive, etc.) placed in or removed waterbody
from waterbody directly affected
Six piling Haven Lake In-water 2 hours Less than 2 sf
'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.
2 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.
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.
No fill material
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. [Lel
No dredging.
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.
Agency Name Contact Name Phone Most Recent
Date of Contact
Mason County Julie Lewis 360-427-9670 ext 357 May 2022
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: https://ecologV.wa.gov/Water-
Shorelines/Water-quality/Water-improvement/Assessment-of-state-waters-303d.
❑ Yes ❑x No
9c. What U.S. Geological Survey Hydrological Unit Code (HUC) is the project in?
• Go to http://cfl)ub.epa.goy/surf/locate/index.cfm to help identify the HUC.
17110017
9d. What Water Resource Inventory Area Number (WRIA#) is the project in?
• Go to https://ecolociy.wa.gov/Water-Shorelines/Water-supply/Water-availability/Watershed-look-up to find the WRIA#.
WRIA 14
ORIA-16-011 Page 7 of 11
9e. Will the in-water construction work comply with the State of Washington water quality standards for
turbidity?
• Go to https://ecology.wa.govANater-Shorelines/Water-quality/Freshwater/Surface-water-quality-standards/Criteria for the
standards.
❑ Yes ❑ No ❑ Not applicable
9f. If the project is within the jurisdiction of the Shoreline Management Act, what is the local shoreline
environment designation?
• If you don't know, contact the local planning department.
• For more information, go to: https://ecology.wa.gov/Water-Shorelines/Shoreline-coastal-management/Shoreline-coastal-
planning/Shoreline-laws-rules-and-cases.
El Urban ❑ Natural ❑x Aquatic ❑ Conservancy ❑ Other:
9g. What is the Washington Department of Natural Resources Water Type?
• Go to http://www.dnr.wa.gov/forest-practices-water-typing 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? If No, provide the name of the manual your project is designed to meet.
❑x Yes ❑ No
Name of manual: Most recent manual
9i. Does the project site have known contaminated sediment? If Yes, please describe below.
Yes ❑ No
9j. If you know what the property was used for in the past, describe below. j
Residential
9k. Has a cultural resource (archaeological) survey been performed on the project area?
• If Yes, attach it to your JARPA package.
❑ Yes 0 No
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.
None known.
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.
None known.
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 help(aboria.wa.gov.
ORIA-16-011 Page 8 of 11
• 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.)
• For more information about SEPA, go to httos://ecology.wa.-gov/regulations-permits/SEPA-environmental-review.
❑ A copy of the SEPA determination or letter of exemption is included with this application.
® A SEPA determination is pending with Mason County (lead agency). The expected decision date is
Fall 2022
❑ I am applying for a Fish Habitat Enhancement Exemption. (Check the box below in 10b.)
❑ 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.
10b. Indicate the permits you are applying for. (Check all that apply.)
LOCAL GOVERNMENT
Local Government Shoreline permits:
® Substantial Development ❑ Conditional Use ❑ Variance
❑ Shoreline Exemption Type (explain):
Other City/County permits:
❑ Floodplain Development Permit ❑ Critical Areas Ordinance
STATE GOVERNMENT
Washington Department of Fish and Wildlife:
® Hydraulic Project Approval (HPA) ❑ Fish Habitat Enhancement Exemption —Attach Exemption Form
Washington Department of Natural Resources:
❑ Aquatic Use Authorization Complete JARPA Attachment E and submit a check for$25 payable to the Washington
Department of Natural Resources.
Washington Department of Ecology:
❑ Section 401 Water Quality Certification
FEDERAL AND TRIBAL GOVERNMENT
United States Department of the Army (U.S. Army Corps of Engineers):
❑ Section 404 (discharges into waters of the U.S.) ❑ Section 10 (work in navigable waters)
United States Coast Guard:
❑ General Bridge Act Permit ❑ Private Aids to Navigation (for non-bridge projects)
United States Environmental Protection Agency:
❑ Section 401 Water Quality Certification (discharges into waters of the U.S.) on tribal lands where tribes do
not have treatment as a state (TAS)
ORIA-16-011 Page 9 of 11
Tribal Permits: (Check with the tribe to see if there are other tribal permits, e.g.,Tribal Environmental Protection Act, Shoreline
Permits, Hydraulic Project Permits,or other in addition to CWA Section 401 WQC)
❑ Section 401 Water Quality Certification (discharges into waters of the U.S.)where the tribe has treatment
as a state (TAS).
ORIA-16-011 Page 10 of 11
Part 11—Authorizing Signatures
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. WJ (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. WJ (initial)
Wayne Johnson tVk91W U4-- y June 6, 2022
Applicant Printed Name Applicant Signature Date
11 b. Authorized Agent Signature
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.
Leann Ebe McDonald Lea vt w Ebe.,Mc ay a &
June 6, 2022
Authorized Agent Printed Name Authorized Agent Signature Date
11c. Property Owner Signature (if not applicant)
Not required if project is on existing rights-of-way or easements (provide copy of easement with JARPA).
I consent to the permitting agencies entering the property where the project is located to inspect the project site
or any work. These inspections shall occur at reasonable times and, if practical, with prior notice to the
landowner.
Property Owner Printed Name Property Owner Signature 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: ORIA-16-011 rev.09/2018
ORIA-16-011 Page 11 of 11
AFFIDAVIT OF POSTING NOTICE
STATE OF WASHINGTON )
) ss:
COUNTY OF MASON )
RE: (Parcel#or Address of Site): f ` E ToLov, 81,LAsm;A K\ (.? 3 O'SO-
0o'b3)
I, Julie Lewis , Planner for Mason County, do hereby certify that I have posted 1 copies
of the attached:
Notice of Application On this— S /�day of /-tA�ti� , 2023, in ID, conspicuous
places as follows:
o One at The Site
o One at The Mason County Building One's Public Bulletin Board [411 N 5th St—Shelton,WA]
o One at
In witness whereof,the party has signed this Affidavit of Posting Notice this y day of
Al2r- , 20 :13
Signed by Julie Lewis
Mason County Community Services Department
615 W. Alder St—Shelton,WA 98584
Subscribed and sworn before me this \4*-` day of IRPY \
20 23 , 1 certify that 3Ux\1e LeW�s signed this document.
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o�;�d' NOTARY PUBLIC in and for the State of Washington,
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My Commission Expires: Wwem\otr '60, 2024-
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