HomeMy WebLinkAboutSHX2011-00029 JARPA Cancelled Replace Culvert - SHX Permit / Conditions - 7/18/2011 PyoN_srgTFO MASON COUNTY
C DEPARTMENT OF COMMUNITY DEVELOPMENT
o A o (APlanning Division
_ o N Z P O Box 279, Shelton, WA 98584
T
7 N y ti (360)427-9670
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1864
Exemption from Shoreline Management Act
Case No.: SHX2011-00029 Substantial Development Permit Requirement
The Proposal By: WA ST DEPT OF TRANSPORTATION
�D
P O BOX 47417Ya-
OLYMPIA,WA 98504-7417
-- M S
To undertake the following development: 0
WA DOT project is to replace a failing 36-inch diameter culvert that provides conveyance for a
non-fish bearing creek under HWY 101. The creek drains into Hood Canal but the project is not
within the 200-foot shoreline jurisdiction. The existing culvert will be plugged and abandoned.
The stream will be re-aligned where it enters and leaves the culvert. A Habitat Management Plan
proposes 5340 square feet area to be planted with native species. Additional mitigation includes
rerouting the access road to avoid needing to cut 3 large trees.
Within STREAM/HOOD CANAL 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 Rebecca Hersha at ext 287 if you have an i uest' S.
Issued: 7/18/2011
Expires: 7/18/2013 Authorized Local Government Official
cc: APPLICANT WDFW USACOE WDOE TRIBAL COUNCIL
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US Army Corps ' �
WASHINGTON STATE Sof etteDsttnct JUN 2 7 2011
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Joint Aquatic Resources Permit Agencyrefer4vM
Application (JARPA) Form' Tax Parcel#(s): '
USE BLACK OR BLUE INK TO ENTER ANSWERS IN 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) h[ pel f
US Highway 101, South of Beacon Point— Major Drainage
Part 2-Applicant
The person or organization responsible for the project. [help]
2a. Name (Last, First, Middle)and Organization(if applicable)
Sawyer, Jeff B., Washington State Department of Transportation
21b. Mailing Address (Street or PO Box)
P. O. Box 47417
2c. City, State, Zip
Olympia, WA 98504-7417
2d. Phone(1) 2e. Phone(2) 2f. Fax 2g. E-mail
(360) 570-6700 (350) 570-6701 (360) 570-6697 sawyerj@wsdot.wa.gov
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.) [help]
3a. Name (Last, First, Middle) and Organization (if applicable)
31b. Mailing Address (Street or PO Box)
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
http://www.nws.usace.army.mil/PublicMenu/Menu.cfm?sitename=REG&pagename=mainpage_ESA
• If you are applying for an Aquatic Resources Use Authorization you will need to fill out and submit an Application for Authorization to Use State-
Owned Aquatic Lands form to DNR,which can be found at http://www.dnr.wa.gov/Publications/aqr_use_auth_app.doc
• Not all cities and counties accept the JARPA for their local Shoreline permits.If you think you will need a Shoreline permit,contact the appropriate
city or county government to make sure they will accept the JARPA.
2To access an online JARPA form with[help]screens,go to
http://www.epermitting.wa.gov/site/alias_resourcecenter/jarpajarpa_form/9984/jarpa_form.aspx.
For other help,contact the Governor's Office of Regulatory Assistance at 1-800-9174043 or help@ora.wa.gov.
JARPA 2010 v1 3/30/2010 Page 1 of 12
3c. City, State, Zip
3d. Phone(1) 3e. Phone(2) ±31. Fax 3g. E-mail
Part 4—Property Owner(s)
Contact information for people or organizations owning the property(ies)where the project will occur. 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 property owners. Complete the section below and fill out JARPA Attachment A for each
additional property owner.
4a. Name (Last, First, Middle)and Organization (if applicable)
4b. Mailing Address (street or PO Box)
4c. City, State, Zip
4d. Phone(1) 4e. Phone(2) 4f. Fax 4g. E-mail
Part 5—Project Location(s)
Identifying information about the property or properties where the project will occur. [help]
❑ 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.) h[ elpl
❑ State Owned Aquatic Land (If yes or maybe,contact the Department of Natural Resources(DNR)at(360)902-1100)
❑ Federal
® Other publicly owned (state,county, city,special districts like schools, ports,etc.)
❑ Tribal
❑ Private
5b. Street Address (Cannot be a PO Box. If there is no address,provide other location information in 5p.) [help]
US Highway 101, Mile Post 316.06 to Mile Post 316.26
5c. City, State, Zip(If the project is not in a city or town, provide the name of the nearest city or town.) [help]
Lilliwaup, WA 98555
5d. County bLeel ]
Mason
JARPA 2010 v1 3/30/2010 Page 2 of 12
5e. Provide the section, township, and range for the project location. [help]
% Section Section Township Range
NW 12 24 North 3 West
5f. Provide the latitude and longitude of the project location. [help)
• Example:47.03922 N lat./-122.89142 W long.(NAD 83)
47.587464 N Latitude/-123.002289 W Longitude
5g. List the tax parcel number(s)for the project location. [help]
• The local county assessor's office can provide this information.
32412-00-60000
5h. Contact information for all adjoining property owners. (If you need more space, use JARPA Attachment C.) [help]
Name Mailing Address Tax Parcel # (if known)
P.O. Box 900961
......._ _._.........---..._......................._......_.....................
Totem Girl Scout Council Seattle, WA 98109-9561 32412-00-63000
..................__.........._._..._............................_.__.__......_...............................----.__.---......._.....__....._............_...._...
5i. List all wetlands on or adjacent to the project location. hel
There are three Ecology Category III wetlands identified within the project area. Two wetlands
(A & C) are emergent wetlands and one wetland (13) is scrub-shrub wetland. See attached
drawings.
5j. List all waterbodies (other than wetlands) on or adjacent to the project location. [held
Unnamed Creek on project site. Hood Canal is adjacent to the project approximately 400-ft plus.
5k. Is any part of the project area within a 100-year flood plain? [hell)]
❑ Yes ® No ❑ Don't know
51. Briefly describe the vegetation and habitat conditions on the property. [help]
The entire project lies within the western hemlock vegetation zone of western Washington
(Franklin & Dyrness 1988). Vegetation is generally dominated by needle-leaved, evergreen tree
species such as Douglas Fir, western hemlock, and western red cedar. Other plant species in
the direct vicinity of the project are big-leaf maple, red alder, salmonberry, lady fern, giant
horsetail, creeping buttercup, trailing blackberry & sword fern (Wetland Assessment Report dated
1212010. Author: Paul Dreisbach, WSDOT, Olympic Region). The unnamed stream was determined
to be non-fish bearing in 2009 by WA Dept. of Fish & Wildlife. Woody vegetation is dominated
by western hemlock, western red-cedar and big leaf maple. Dominant shrubs in the action area
are elderberry, Indian plum and salmonberry. Herbaceous vegetation is dominated by sword
fern, grasses and native forbs. The west side of the highway has been recently logged & only a
few scattered conifer and deciduous trees still remain outside the WSDOT right-of-way. Listed
Species & their critical habitat will not be susceptible to negative impacts related to project
activities (No Effect Letter to FHWA dated 211612011 by Eric Gower, WSDOT project biologist).
JARPA 2010 v1 3/30/2010 Page 3 of 12
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5m. Describe how the property is currently used. net ]
US Highway 101 provides a transportation corridor for commercial and private motor vehicles.
5n. Describe how the adjacent properties are currently used. Inelpi
Adjacent properties are currently used for recreation (camping, hiking, fishing and hunting).
5o. Describe the structures (above and below ground) on the property, including their purpose(s). heM
N/A- There are no existing structures within the project limits.
5p. Provide driving directions from the closest highway to the project location, and attach a map. [Lei )
US Highway 101 cuts through the project limits. To travel to the project site, proceed from the City of
Shelton, Washington north on US Highway 101. Travel through the towns of Potlatch and Hoodsport to
the town of Lilliwaup. Travel 10.9 miles north from Lilliwaup to reach the project site. (See attached
map).
JARPA 2010 v1 3/30/2010 Page 4 of 12
Part 6—Project Description
6a. Summarize the overall project. You can provide more detail in 6d. [help]
This Major Drainage project will utilize a "trenchless" method to install a new culvert under US Highway
101. The existing cross culvert, located in a deep roadway fill, is failing. Work will include "trenchless
installation" of a 108 linear foot, 36-inch diameter, steel casing culvert pipe through the roadway fill,
slope work, plug and abandon the existing culvert pipe, minor stream re-alignment, and guardrail
installation on both sides of the roadway.
6b. Indicate the project category. (Check all that apply) [help]
❑ Commercial ❑ Residential ❑ Institutional ® Transportation ❑ Recreational
❑ Maintenance ❑ Environmental Enhancement
6c. Indicate the major elements of your project. (Check all that apply) [help]
❑ Aquaculture ® Culvert ❑ Float ❑ Road
❑ Bank Stabilization ❑ Dam /Weir ❑ Geotechnical Survey ❑ Scientific
❑ Boat House ❑ Dike / Levee / Jetty ❑ Land Clearing Measurement Device
❑ Boat Launch ❑ Ditch ❑ Marina / Moorage ❑ Stairs
❑ Boat Lift ❑ Dock/ Pier ❑ Mining ❑ Stormwater facility
❑ Bridge ❑ Dredging ❑ Outfall Structure ❑ Swimming Pool
❑ Bulkhead ❑ Fence ❑ Piling ❑ Utility Line
❑ Buoy ❑ Ferry Terminal ❑ Retaining Wall
❑ Channel Modification ❑ Fishway (upland)
❑ Other:
6d. Describe how you plan to construct each project element checked in 6c. 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 flood plain.
The new 108 linear foot, 36-inch diameter culvert will be installed through the roadway fill from the west
side (upland side) of US Highway 101 using a trenchless method. WSDOT prefers to utilize this method
to install the culvert to preserve the integrity of the existing fill slopes, the vegetation and roadway
prism. To accomplish this work, the contractor will excavate an "insertion pit" approximately 15-foot by
30-foot and up to 4-foot deep. Excavation of the "insertion pit'will require removal of approximately 70
cubic yards of material. The "pipe insertion" equipment will be placed in the completed "insertion pit." A
temporary stream bypass pipe and the existing culvert will continue to convey the unnamed creek while
the new, culvert is "inserted" through the roadway fill. On the east side (downslope side) of US Highway
101, grading will be performed to provide an access road to the culvert outlet area. Fill will be utilized at
the culvert outlet to give the roadway slope "extra integrity" for the "insertion" operation. Approximately
90 cubic yards of rip rap and 70 cubic yards of new select borrow will be placed. The new culvert inlet
will be offset 25-feet from the existing culvert inlet. The new culvert outlet will be directly above the
existing culvert outlet. The new culvert will use the same streambed at the discharge point. Fill will be
utilized to redirect the unnamed stream to the new culvert inlet. Once the new culvert is conveying the
waters of the unnamed creek, the existing culvert will be plugged and abandoned. Work to complete the
project will consist of minor stream re-alignment, slope work, replanting and guardrail installation on
both sides of the highway. Project limits are not within the 100-yr flood plain. See attached plan sheets.
JARPA 2010 v1 3/30/2010 Page 5 of 12
6e. What are the start and end dates for project construction? (month/year) [help]
• 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: June 2012 End date: August 2012 ❑ See JARPA Attachment D
6f. Describe the purpose of the project and why you want or need to perform it. [help]
The purpose of this major drainage project is to replace an existing 36-inch diameter culvert that
provides conveyance for a perennial, non-fish bearing unnamed creek that drains into Hood Canal. The
existing culvert is located in a deep roadway fill. The culvert is failing due to joint separation and
collapsing of the pipe. Failure of the culvert could cause the downslope fill to destabilize. Therefore it is
necessary to install a new 108-foot, 36-inch diameter steel casing culvert, using the trenchless method
through the roadway fill from the west side of the highway.
6g. Fair market value of the project, including materials, labor, machine rentals, etc. (help]
$756,133.00
6h. Will any portion of the project receive federal funding? [help]
• If yes, list each agency providing funds.
® Yes ❑ No ❑ Don't know
Federal Highway Administration
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.)[help]
7a. Describe how the project has been designed to avoid and minimize adverse impacts to wetlands. [hell)]
❑ Not applicable
The project has been designed to avoid and minimize adverse impacts to wetlands within the project
limits by utilizing the trenchless method of installing the new culvert. Using this method eliminates the
need for a detour road which would impact all three wetlands within the project limits. The trenchless
method of installing the new culvert will permanently impact one wetland (Wetland B).
7b. Will the project impact wetlands? he►
® Yes ❑ No ❑ Don't know
7c. Will the project impact wetland buffers? [help]
® Yes ❑ No ❑ Don't know
7d. Has a wetland delineation report been prepared? [help]
• 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? h[ eip
• If yes, submit the wetland rating forms and figures with the JARPA package.
® Yes ❑ No ❑ Don't know
JARPA 2010 v1 3/30/2010 Page 6 of 12
7f. Have you prepared a mitigation plan to compensate for any adverse impacts to wetlands? h(�el
• 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
Three small Ecology Category III wetlands were identified within the project area. Wetlands A and C are
emergent wetlands and will not be impacted. Wetland B is a 130 square foot, scrub-shrub wetland which
will be completely impacted. The impacts at Wetland B will be from fill that is necessary for stream
realignment.
7g. Summarize what the mitigation plan is meant to accomplish, and describe how a watershed approach was
used to design the plan. hel
In order to mitigate for the impacts to Wetland B; Wetlands A and C (total of 1155 square feet) will be
enhanced with Rubus spectabillis (salmonberry), Carex obnupta (slough sedge), and Juncus ensifolius
(dagger-leaved rush). This is over the mitigation ratio of 8:1 that is in the Wetland Mitigation in
Washington— Part 1: Agency Policies and Guidance document (Ecology et al, 2006). The riparian areas
along the new stream channel will be restored by planting native trees and shrubs.
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. [help]
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)
Fill Wetland B PSS, III 130 sq. ft. permanent (E) Wetlands A&C
0.027 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.
4 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: N/A
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. h(�el j
Fill will be contractor supplied from a WSDOT approved source. The nature of the fill will be both native
and select borrow. The total amount of fill is 217 cubic yards placed by excavator. The amount of fill
placed over Wetland B will be approximately 17 cubic yards.
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
None — No excavation activity
JARPA 2010 v1 3/30/2010 Page 7 of 12
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.) [help]
® 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.
[help]
❑ Not applicable
The existing culvert will be utilized to maintain stream flow of the unnamed creek during the installation
of the new culvert. A temporary stream dam and bypass pipe will be utilized to divert the unnamed
stream to the existing culvert. When the new culvert is in place, the unnamed creek will be redirected to
the new culvert utilizing a new creek channel. Erosion will be controlled by preparation and
implementation of a Temporary Erosion and Sedimentation Control Plan using Best Management
Practices. See attached drawings.
8b. Will your project impact a waterbody or the area around a waterbody? help]
® Yes [:1 No
8c. Have you prepared a mitigation plan to compensate for the project's adverse impacts to non-wetland
waterbodies? help]
• 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
A Riparian planting plan has been created to compensate the projects' adverse impacts to existing
unnamed creek channel. Please see updated JARPA drawings.
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. hLelp]
See completed section 7g.
8e. Summarize impact(s) to each waterbody in the table below. hel
Activity (clear, Waterbody Impact Duration of Amount of material Area (sq. ft. or
dredge, fill, pile name' location' inrl to be placed in or linear ft.) of
drive, etc.) removed from waterbody
waterbody directly affected
Fill Unnamed Crk. Upstream Permanent 38 cy 338 sq. ft.
(Exist. Channel) Not within
floodplain
Fill Unnamed Crk. Downstream Permanent 1 cy 78 sq. ft.
(Exist. Channel) Not within
floodplain
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.
3 Indicate the days,months or years the waterbody will be measurably impacted by the work. Enter"permanent"if applicable.
JARPA 2010 v1 3/30/2010 Page 8 of 12
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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. [help]
Fill within unnamed creek will be supplied by the contractor from an approved WSDOT site. Type of fill
will be both native and select borrow. Approximate quantity of material placed will be 38 cubic yards. Fill
will be placed into the waterbody using an excavator.
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. heel
There are no excavation impacts to the existing unnamed creek channel.
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. [help]
Agency Name Contact Name Phone Most Recent
Date of Contact
Mason County Allen Borden (360) 427-9670, X365 March 9, 2011
Community
Development
9b. Are any of the wetlands or waterbodies identified in Part 7 or Part 8 on the Washington Department of
Ecology's 303(d) List? heel i
• If yes, list the parameter(s)below.
• If you don't know, use Washington Department of Ecology's Water Quality Assessment tools at:
http://www.ecy.wa.gov/proq[qM§/w_q/303d/.
❑ Yes ® No
9c. What U.S. Geological Survey Hydrological Unit Code (HUC) is the project in? [help]
• Go to http://cfpub.epa.gov/surf/locate/index.cfm to help identify the HUC.
17110018
9d. What Water Resource Inventory Area Number (WRIA#) is the project in? hql
• Go to http://www.ecy.wa.gov/services/gis/maps/wria/wria.htm to find the WRIA#.
16 Skokomish - Dosewallips
JARPA 2010 v1 3/30/2010 Page 9 of 12
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9e. Will the in-water construction work comply with the State of Washington water quality standards for
turbidity? [help]
• Go to http://www.ecy.wa.gov/programs/wq/swgs/criteria.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.gov/programs/sea/sma/laws rules/173-26/211 designations.html.
❑ Rural ❑ Urban ❑ Natural ❑ Aquatic ❑ Conservancy ❑ Other
9g. What is the Washington Department of Natural Resources Water Type? [help]
• Go to http://www.dnr.wa.gov/BusinessPermits[Topics/ForestPracticesAi)plications/Pages/fp watertyping.aspx 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�ei ]
• If no, provide the name of the manual your project is designed to meet.
❑ Yes ® No
Name of manual: WSDOT Highway Runoff Manual M31-16.02 (May 2010)
9i. If you know what the property was used for in the past, describe below. help]
This property has been and continues to be used as a transportation corridor.
9j. Has a cultural resource (archaeological) survey been performed on the project area? [help]
• If yes, attach it to your JARPA package.
® Yes ❑ No
9k. Name each species listed under the federal Endangered Species Act that occurs in the vicinity of the project
area or might be affected by the proposed work. [help]
Federal Endangered Species Act listed:
• Puget Sound bull trout [Puget Sound Distinct Population Segment (DPS)] (threatened)
• marbled murrelet (threatened)
• northern spotted owl (threatened)
• Chinook salmon [Puget Sound Evolutionarily Significant Unit (ESU)] (threatened)
• chum salmon (Hood Canal Summer Run ESU) (threatened)
• steelhead [Puget Sound DPS] (threatened)
91. Name each species or habitat on the Washington Department of Fish and Wildlife's Priority Habitats and
Species List that might be affected by the proposed work. [help]
Washington Department of Fish and Wildlife's Priority Habitats and Species list:
• Pandion haliaetus osprey
JARPA 2010 v1 3/30/2010 Page 10 of 12
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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.ecy.wa.gov/opas/.
• Governor's Office of Regulatory Assistance at (800) 917-0043 or help(a-�ora.wa.gov.
• For a list of agency addresses to send your application, click on the "where to send your completed
JARPA" at http://www.epermitting.wa.gov.
10a. Compliance with the State Environmental Policy Act (SEPA). (Check all that apply.) [help]
• For more information about SEPA,go to www.ecy.wa. oq v/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 WSDOT (lead agency). The expected decision date is
4/1/2011.
❑ 1 am applying for a Fish Habitat Enhancement Exemption. (Check the box below in 1 ob.)[help]
❑ 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.) [help]
LOCAL GOVERNMENT
Local Government Shoreline permits:
❑ Substantial Development ❑ Conditional Use ❑ Variance
❑ Shoreline Exemption Type (explain):
Other city/county permits: Mason County
❑ Floodplain Development Permit ® Critical Areas Ordinance
STATE GOVERNMENT
Washington Department of Fish and Wildlife:
® Hydraulic Project Approval (HPA) ❑ Fish Habitat Enhancement Exemption
Washington Department of Ecology:
® Section 401 Water Quality Certification
Washington Department of Natural Resources:
❑ Aquatic Resources Use Authorization
FEDERAL GOVERNMENT
United States Department of the Army permits (U.S. Army Corps of Engineers):
® Section 404 (discharges into waters of the U.S.) ❑ Section 10 (work in navigable waters)
United States Coast Guard permits:
❑ General Bridge Act Permit ❑ Private Aids to Navigation (for non-bridge projects)
JARPA 2010 v1 3/30/2010 Page 11 of 12
Part 11—Authorizing Signatures
Signatures are required before submitting the JARPA package. The DARPA package includes the JARPA form,
project plans, photos, etc. fheipl
11 a. Applicant Signature (required) help]
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 enterin the property where the project is located to inspect the project site or any work
related to the project. — S (initial)
�-� S G�W ` �►� (0 2 f � II
Applicant Printed Name Apolicgnf Signature VDate
11 b. Authorized Agent Signature [help]
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.
Authorized Agent Printed Name Authorized Agent Signature Date
11 c. Property Owner Signature (if not applicant). [help]
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.
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 of Regulatory Assistance(ORA). People with hearing loss
can call 711 for Washington Relay Service. People with a speech disability can call(877)833-6341.
ORA publication number: ENV-019-09
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