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Home My WebLink AboutSHX2021-00030 JARPA Replace Log Bulkhead with Rock Bulkhead - SHX Permit / Conditions - 7/6/2021 j AEG � � 3 RECEIVE. ;A LL, MASON COUNTY JUL 0 1202i COMMUNITY SERVICES 615 W. Alder Street Building,Planning,Environmental Health,Community Health 615 W.Alder St.—Bldg.8,Shelton,Wa 98584 Phone:(360)427-9670 ext.352 ♦ Fax:(360)427-7798 PERMIT NO.:SU:1 . ..-(1'`t W SHORELINE PERMIT APPLICATION "VI A il`41) rk" tj E SHORELINE PERMITS CONDITIONAL USE* SUBSTANTIAL DEVELOPMENT VARIANCE* EXEMPTION X 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: Frank Dahl ADDRESS: 22 Dale Court (street) Massapequa, NY 117587327 (city) (state) (zip) TELEPHONE: 516-761-6820 (home) (business) AUTHORIZED REPRESENTATIVE: Jennifer Rotsten of Sealevel Bulkhead Builders,Inc. ADDRESS: Po Box 375 (street) Kingston, WA 98346 (city) (state) (zip) TELEPHONE: 360-297-2401 PROPERTY DESCRIPTION: General location (include property address, water body and associated wetlands—identify the name of the shoreline): 830&890 Dewatto Beach Dr Tahuya,WA 98588,Hood Canal Rev. March 1, 2018 Include all parcel numbers: Projects located in open water areas, away from land shall provide latitude/longitude. 32328-31-00110 & 32328-31-00080 OWNERSHIP: Contract Applicant Owner x Lessee Purchaser (Identify) Other Owner: Frank Dahl 22 Dale Court Massapequa,NY 117587327 (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): Replace existing log bulkhead with a rock bulkhead, total +/-88'. Existing Use(identify current use of property with exist improvements): SFR and undeveloped lot Reason for requesting development: The old log bulkhead has reached the point of needing to be replaced in order to continue to protect the exisitng home on the property (830 NE Dewatto). See geotechnical report for more detail. 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. ACKOWLEDGEMENT: I hereby declare, to the best of my knowledge and belief, the forgoing information and all attached information is true and correct. lie 7/6/2021 pplicant or Authorized Representative) (date) .-.............................................................................................................-- AGENCY USE ONLY 3 Date Received: WASHINGTON STATE o E.gireera�s D�—O�^� ' Joint Aquatic Resources Permit Agency reference#: _�'__ Application (DARPA) Form '°2 Tax Parcel#(s): USE BLACK OR BLUE INK TO ENTER ANSWERS IN THE WHITE SPACES BELOW. 3e7 fj-31 -000g0 :_.................................................................................................................: Part 1 - Project Identification 1. Project Name (A name for your project that you create. Examples:Smith's Dock or Seabrook Lane Development) hel Dahl Bulkhead Replacement Part 2 - Applicant The person and/or organization responsible for the project. hf elpl 2a. Name (Last, First, Middle) Dahl, Frank 2b. Organization (if applicable) 2c. Mailing Address (Street or PO Box) 22 Dale Court 2d. City, State, Zip Massapequa, NY 117587327 2e. Phone (>) 2f. Phone(2) 2g. Fax 2h. E-mail ( 516 ) 761-6820 ( ) ( ) rubedahl@hotmail.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. • If your project might affect species listed under the Endangered Species Act,you will need to fill out a Specific Project Information Form(SPIF)or prepare a Biological Evaluation. Forms can be found at htt[):Hwwvo.nws.usace.army.mil/Missions/CivilWorks/Regulatory/PermftGuidebook/EndangeredSt)ecies.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. =To access an online JARPA form wth(help]screens,go to htti)://www.ei)ermitting.wa.gov/site/alias resourcecenter/iarpa iarva form/9984/iarpa form.aspx. For other help,contact the Govemor's Office for Regulatory Innovation and Assistance at(800)917-0043 or helpaoria.wa.gov. ORIA-revised 02/2020 Page 1 of 15 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.) nei 3a. Name (Last, First, Middle) Rotsten Jennifer 3b. Organization (if applicable) Sealevel Bulkhead Builders, Inc. 3c. Mailing Address (Street or PO Box) PO Box 375 3d. City, State, Zip Kingston, WA 98346-0375 3e. Phone (1) 3f. Phone (2) 3g. Fax 3h. E-mail ( 360 ) 297-2401 ( 360 ) 710-0899 ( 360 ) 297-2308 Jenny@sealevelbb.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. LnLel ® Same as applicant. (Skip to Part 5.) ❑ Repair or maintenance activities on existing rights-of-way easements. (Skip to Part 5.) ❑ There are multiple upland property owners. Complete the section below and fill out iARPA 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 .IARPA Attachment E to apply for the Aquatic Use Authorization. 4a. Name (Last, First, Middle) Dahl, Frank 4b. Organization (if applicable) 4c. Mailing Address (Street or PO Box) 22 Dale Court 4d. City, State, Zip Massapequa, NY 117587327 4e. Phone (1) 4f. Phone (2) 4g. Fax 4h. E-mail ( 516 ) 761-6820 ( ) ( ) rubedahl@hotmail.com ORIA-revised 02/2020 Page 2 of 15 Part 5 - Project Location(s) Identifying information about the property or properties where the project will occur. hf elal ❑ 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.)lbpjo ® 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.)JtgjPJ 830 & 890 Dewatto Beach Dr, 5c. City, State, Zip (If the project is not in a city or town,provide the name of the nearest city or town.) hel Tahuya, WA 98588 5d. County hLela] Mason 5e. Provide the section, township, and range for the project location. L,ei 1/4 Section Section Township Range 28 23 N 03 W 5f. Provide the latitude and longitude of the project location. [nel • Example:47.03922 N lat./-122.89142 long. (Use decimal degrees-NAD 83) 47.452 /-123.073 5g. List the tax parcel number(s)for the project location. nei • The local county assessor's office can provide this information. 32328-31-00110, 32328-31-00080 5h. Contact information for all adjoining property owners. (If you need more space, use JARPA Attachment C.) hL elpl Name Mailing Address Tax Parcel#(if known) George Neely 8347 Vashon Dr Ne 323283100070 ........................................................................................................................................ Lacey, WA 98516 Frank Dahl 22 Dale Court 323283100160 ........................................................................................................................................ Massapequa, NY 117587327 .....................--................................................................................................................ ORIA-revised 02/2020 Page 3 of 15 5i. List all wetlands on or adjacent to the project location. Lr,ei N/A 5j. List all waterbodies (other than wetlands) on or adjacent to the project location. Jnei Hood Canal 5k. Is any part of the project area within a 100-year floodplain? ❑ Yes ❑ No ® Don't know 51. Briefly describe the vegetation and habitat conditions on the property. Trees, shrubs, landscaped yard. Please review attached HMP/HA 5m. Describe how the property is currently used. SFR/Undeveloped 5n. Describe how the adjacent properties are currently used. SFR 5o. Describe the structures (above and below ground) on the property, including their purpose(s) and current condition. ,heipl Owner's home, patio, bulkhead 5p. Provide driving directions from the closest highway to the project location, and attach a map. nei From Holly, follow NE Dewatto Holly Rd South to Dewatto Beach Dr, end at site. ORIA-revised 02/2020 Page 4 of 15 Part 6 - Project Description 6a. Briefly summarize the overall project. You can provide more detail in 6b. This proposal includes the replacement of the existing wooden log bulkhead at the site with a new granite rock bulkhead. The rock bulkhead will extend across the slide area for a total of+/-88'. All armor rock will be delivered by land, dumped onto the beach on the north side of the house, The spalls will be delivered to the area above the slide and lowered to the beach for use. Base rocks in the bulkhead will be 4-5 man sized with top rocks ranging from 2-4 man. The base rocks will be keyed into the substrate +/-3' or to refusal, whichever is reached first, with the above grade height to remain approximately the same as the existing wood bulkhead. The spalls will be placed behind the armor rock with filter fabric installed between the bank and the spalls. 6b. Describe the purpose of the project and why you want or need to perform it. The existing log bulkhead is in need of being replaced to protect the home and property. 6c. Indicate the project category. (Check all that apply.) n ❑ Commercial ® Residential ❑ Institutional ❑ Transportation ❑ Recreational ❑ Maintenance ❑ Environmental Enhancement 6d. Indicate the major elements of your project. (Check all that apply.) hei ❑ 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 ❑ Boat Lift ❑ Dock/ Pier ❑ Marina / Moorage Measurement Device ❑ Bridge ❑ Dredging ❑ Mining ❑ Stairs ❑ Bulkhead ❑ Fence ❑ Outfall Structure ❑ Stormwater Facility ❑ Buoy ❑ Ferry Terminal ❑ Piling / Dolphin ❑ Swimming Pool ❑ Channel Modification ❑ Fishway ❑ Raft ❑ Utility Line ❑ Other: ORIA-revised 02/2020 Page 5 of 15 6e. Describe how you plan to construct each project element checked in 6d. Include specific construction methods and equipment to be used. LhLel • Identify where each element will occur in relation to the nearest waterbody. • Indicate which activities are within the 100-year floodplain. The footing for the bulkhead will be excavated out behind the existing bulkhead alignment, base rocks installed, and then the remaining rocks stacked on top. The old bulkhead will then be removed. This will result in a net gain of habitat and no net loss. 6f. What are the anticipated start and end dates for project construction? (Month/Year) • If the project will be constructed in phases or stages, use JARPA Attachment C)to list the start and end dates of each phase or stage. Start Date: 09/06/2021 End Date: 09/17/2021 ❑ See JARPA Attachment D 6g. Fair market value of the project, including materials, labor, machine rentals, etc. 73,245.00 6h. Will any portion of the project receive federal funding? • If yes, list each agency providing funds. ❑ Yes ❑ No ® Don't know Part 7 - Wetlands: Impacts and Mitigation ❑ Check here if there are wetlands or wetland buffers on or adjacent to the project area. (If there are none, skip to Part 8) 7a. Describe how the project has been designed to avoid and minimize adverse impacts to wetlands. nel� ❑ Not applicable ORIA-revised 02/2020 Page 6 of 15 7b. Will the project impact wetlands? ❑ Yes ❑ No ❑ Don't know 7c. Will the project impact wetland buffers? ❑ Yes ❑ 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 ❑ No 7e. Have the wetlands been rated using the Western Washington or Eastern Washington Wetland Rating System? "helgl • 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? h[ elpl • 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. 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. ORIA-revised 02/2020 Page 7 of 15 Activity (fill, Wetland Wetland type Impact Duration Proposed Wetland drain, excavate, Name' and rating area (sq. of Impact3 mitigation mitigation area flood, etc.) category2 ft. or type4 (sq. ft. or 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. z Ecology wetland category based on current Western Washington or Eastern Washington Wetland Rating System.Provide the wetland rating forms with the JARPA package. Indicate 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: 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. `�elpi 7J'. For all excavatingactivities 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.) M 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. ORIA-revised 02/2020 Page 8 of 15 i helpl ❑ Not applicable The replacement bulkhead will be installed landward of the existing bulkhead to result in a net gain of habitat. 8b. Will your project impact a waterbody or the area around a waterbody? ❑ Yes ® No 8c. Have you prepared a mitigation plan to compensate for the project's adverse impacts to non-wetland waterbodies? Lhel • 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 ❑ Not applicable 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. hel No net loss 8e. Summarize impact(s) to each waterbody in the table below. �elpj Activity (clear, Waterbody Impact Duration Amount of material Area (sq. ft. or dredge, fill, pile name' location2 of impact3 (cubic yards) to be linear ft.) of drive, etc.) placed in or waterbody removed from directly affected waterbody Excavation (footing) Hood Canal Adjacent Permanent +/-53 cy +/-88' ORIA-revised 02/2020 Page 9 of 15 If no official name for the waterbody exists,create a unique name(such as"Stream I")The name should be consistent with other documents provided. z 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. 3 Indicate 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. iLLIL There will not be any fill placed in the waterbody. The replacement bulkhead will be installed landward. 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. Excavation will include the removal of material behind the existing bulkhead to install the footing rock. This will include +/-53 cy. This material will be placed on the beach for nourishment or upland of the bulkhead, based on approvals. 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 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? hL eM • If Yes,list the parameter(s)below. • If you don't know, use Washington Department of Ecology's Water Quality Assessment tools at: hftr)://www.ecy.wa.-.,_)v/programs/wq/303d/. ORIA-revised 02/2020 Page 10 of 15 ❑ Yes ❑ No 9c. What U.S. Geological Survey Hydrological Unit Code (HUC) is the project in? jhei, • Go to .epa.goy/surf/locate/index.cfm to help identify the HUC. 17110019 9d. What Water Resource Inventory Area Number(WRIA#) is the project in?Lbgipj • Go to ttr)://www.ecy.wa.gov/services/gis/maps/wd 3/wria.htm to find the WRIA#. 17 9e. Will the in-water construction work comply with the State of Washington water quality standards for turbidity? jULel • Go to http://www.ecy.wa.�, programs/wq/sw, ritena.html 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? 'help] • If you don't know, contact the local planning department. • For more information,go to: http//www.ecy.wa.goy/programs/sea/sma/laws rules/173 226/211 designations.html. ® Rural ❑ Urban ❑ Natural ❑ Aquatic ❑ Conservancy ❑ Other: 9g. What is the Washington Department of Natural Resources Water Type? [hel • Go to http://www.dnr.wa.gov/BusinessPermitsfTopics/ForestPracticesApplications/Pages/fp watertyping.asp for the Forest Practices Water Typing System. ® 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? h[ elp • If No, provide the name of the manual your project is designed to meet. ® Yes ❑ No Name of manual: 9i. Does the project site have known contaminated sediment? • If Yes,please describe below: ❑ Yes ® No ORIA-revised 02/2020 Page 11 of 15 9j. If you know what the property was used for in the past, describe below. 1hei N/A 9k. Has a cultural resource (archaeological) survey been performed on the project area? • If Yes,attach it to your JARPA package. ❑ Yes ® 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. (helpl Marbeld murrelet, spotted owl, chinook salmon, steelhead, killer whale, humpback whale, gray wolf 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. h( eIR1 Habitat: Puget Sound Nearshore Species: Pacific Lamprey, River Lamprey,White Sturgeon,Pacific Herring,Longfin Smelt,Surfsmelt,Bull Trout/ Dolly Varden,Chinook Salmon,Chum Salmon,Coastal Res./Searun Cutthroat,Coho,Pink Salmon,Rainbow Trout/ Steelhead/ Inland Redband Trout,Pacific Cod,Pacific Hake,Walleye Pollock,Black Rockfish,Bocaccio Rockfish Brown Rockfish,Copper Rockfish,Greenstriped Rockfish,Quillback Rockfish,Redstripe Rockfish,Tiger Rockfish Yellowtail Rockfish,Lingcod,Pacific Sand Lance,English Sole,Rock Sole,Western Toad,Pacific Pond Turtle, Common Loon,Common Murre,Marbled Murrelet,Tufted Puffin,Western grebe,W WA nonbreeding concentrations of: Loons, Grebes, Cormorants, Fulmar, Shearwaters, Storm-petrels, Alcids W WA breeding concentrations of: Cormorants, Storm-petrels, Terns, Alcids, Great Blue Heron,Brant,Cavity-nesting ducks: Wood Duck, Barrow's Goldeneye, Common Goldeneye, Bufflehead, Hooded Merganser,Western Washington nonbreeding concentrations of: Barrow's Goldeneye, Common Goldeneye, Bufflehead,Harlequin Duck,Trumpeter Swan,Waterfowl Concentrations ,Bald Eagle Peregrine Falcon,Mountain Quail,Sooty Grouse,"W WA nonbreeding concentrations of:Charadriidae, Scolopacidae, Phalaropodidae "Band-tailed Pigeon Yellow-billed Cuckoo, Vaux's Swift,Pileated Woodpecker Purple Martin,Dall's Porpoise,Humpback Whale,Gray Whale,Sperm Whale,Harbor Seal,Orca (Killer Whale) Pacific Harbor Porpoise,California Sea Lion,Steller (Northern) Sea Lion,Roosting Concentrations of: Big-brown Bat, Myotis bats, Pallid Bat,Townsend's Big-eared Bat,Keen's Long-eared Bat (formerly Keen's Myotis) Columbian Black-tailed Deer,Pinto (Northern) Abalone,Geoduck ,Butter Clam,Native Littleneck Clam Manila Clam,Olympia Oyster,Pacific Oyster,Dungeness Crab,Pandalid shrimp (Pandalidae),Puget Blue ORIA-revised 0212020 Page 12 of 15 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(a2oria.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.) JLPjPJ • For more about SEPA,go to www.ecy.wa.gov/programs/sea/sepa/e-review.htmi ❑ 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 9/1/2021 ❑ I am applying for a Fish Habitat Enhancement Exemption. (Check the box below in 10b) Lhel ❑ 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. 101b. Indicate the permits you are applying for. (Check all that apply.) h! e 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. Do not send cash. Washington Department of Ecology: ❑ Section 401 Water Quality Certification ❑ Non-Federally Regulated Waters FEDERAL AND TRIBAL GOVERNMENT United States Department of the Army 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: For projects or bridges over waters of the United States,contact the U.S.Coast Guard at: d13-pf-d13bddges@uscg.mil ❑ Bridge Permit ❑ Private Aids to Navigation (or other non-bridge projects) ORIA-revised 02/2020 Page 13 of 15 United States Environmental Protection Agency: ❑ Section 401 Water Quality Certification (discharges into waters of the U.S.)on tribal lands where tribes do not have treatment as a state (TAS) Tribal Permits: (Check with the 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-revised 02/2020 Page 14 of 15 Part 11 - Authorizing Signature Signatures are required before submitting the JARPA package. the JARPA package includes the JARPA form, project plans, photos, etc. hei p 11 a. Applicant Signature (required) hf el 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. (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. (Initial) Frank Dahl See attached authorization of agent Applicant Printed Name Applicant Signature Date 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. Jennifer Rotsten lee-e�- 7/6/2021 Authorized Agent Printed Name A60orizedkgent Signature Date 11 c. Property Owner Signature(if not applicant). h( el 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. Frank Dahl 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 of agency of the United States knowingly falsifies,conceals,or covers up any trick,scheme,or devise 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 Govemor'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 ORIA-revised 02/2020 Page 15 of 15