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HomeMy WebLinkAboutSHX2010-00032 JARPA - SHX Permit / Conditions - 6/9/2010 SON-STATE MASON COUNTY �P ��c DEPARTMENT OF COMMUNITY DEVELOPMENT - o A U n Planning Division r o T z P O Box 279, Shelton, WA 98584 N (360)427-9670 OJ �O 1864 Exemption from Shoreline Management Act Case No.: SHX2010-00032 Substantial Development Permit Requirement The Proposal By: RODNEY K. POLSON TO BE KEPT IN THE 4625 S 289TH PT HE WA 98001 PARCEL FILE To undertake the following development: New fixed wooden dock extending 28 feet into Haven Lake; 4.5 ft. wide by 12 ft long section at shore and 12 ft. wide by 16 ft. long section farther into the lake. Within HAVEN LAKE 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 H-dock Please contact Allan Borden at ext 365 if you have any clue$tions. Issued: 6/9/2010 Expires: 6/9/2012 Authorized Local Government Official cc: APPLICANT WDFW USACOE WDOE TRIBAL COUNCIL .i y< f i . .. &!" f ��� ,�> a��' � � ��°��,g$�. �m��Ej: tom•' • '. r JGIY,y CO. �'' ! i �' i, •' W F"� a4 +{tiA {.r {�.3y4,', }y1� '� .l. a ' __ �..a :�tw '�4.�.R' rti T.� '.��.p !-fCL' K4 F M �y si Aft �t 4 � ��. �• '� {P,�.... n �M 4 VKJI �, it ���, `; t, { � E a �l: *~ `�d �� ��F✓'�%► "�� ♦ �j�^ � � L Kt �" `� r7g� ., E �S•: ��s„�.a' plt. Rr�` + ,? i'4 � �`a i �t�.�. $iAA K o;' .. �+���/��4��gi�• � �' sr'�"a �Y,i� ,,.� .ns ' +�`�_' `��s,���'v�s+�t 4`4 ,,..k k � 4..t' ^� '� � � y� �9t"• � +ems b�� +' --Xsx' u i A +' 4 tti'" jb f � lit ® s a � xAV r s k ? 'ob 1 /11 :1 J / fxjjw .. 'i SF '. 4, e • 4 10�or I off qpa lb R a t • 1 too AT 1 111 w# o 1'23 2 Jf: r+ • 1 30 4-1*b, 1 111 C M At T A tw � 1 ■ 1 /11 At MASON r ` { 1 111 1 Ago f. r 4f 1 1 111 ap a s i ✓ r e 1'Y , RECE Property Layout: 1rED PLANNING _ Rodney & Donita Polsony: (mailing address: 4625 S. 289th PI. Auburn, Wa. 98001 ) MASON COUNTY 24' 170 NE Lake Drive, Tahuya Wa. 98588 Lot 174 Tax Parcel #223305000174 Neighboring dock to the North Lot #176 !� RECEIVED � Haven CO Lake , SON "®LINTY well 125' 34' 70' Property Line—�230 Feet ° Proposed ------------------------------------------------ Dock Driveway 28' a� Sep is Mo n.,ds °' t� �c 1 16' � p -' Reserve Septic Property Line——250 Feet 20 � ' Neighboring dock to the south Lot#173 Feet 25 50 75 100 125 150 175 200 225 25 60' 10' 20' 35' 34' 90, Property Layout: Kam`, 1 20 Rodney & Donita Polson 4625 to MASON COUNT ( S. 289 PI. Auburn, Wa. 98001 ) Y 170 NE Lake Drive , Tahuya Wa. 98588 Lot 174 Tax Parcel #223305000174 N No NG ,. Feet 25 50 75 100 125 150 175 200 225 250 Se is Mounds Shed Existin 6' House Proposed Haven Dock Lake S eptic 12' �Tan High Water Line '- k � 28' Normal Water Line 60' 10' 20' 35' 34' 90' J Rodney & Donita Polson (mailing address: 4625 S. 289th PI. Auburn, Wa. 98001) Top View 170 NE Lake Drive, Tahuya Wa. 98588 i*--4 2 N —' Lot 174 Tax Parcel #223305000174 _Cement- - Bulkhead 2' Proposed Dock - Lot 174 Joists Treated 's On 13.5" Centers 6' > > Posts Treated 4X4's 12' • Main Platform is 12 x16 (192 sq. ft.) Beam Treated4X6x41/2' • Dock Walkway is 4 1/2'x12' (54 sq. ft.) Trex Composite4Beams Decking 1.25"x6" 1 • Total Dock is 246 sq. ft. w/coated Deck Screws — � 28' Note: Ordinary high water mark Posts Treated 6X6's61/2' remains fairly constant. Haven Beams Treated 6X6X12' �r }I Lake water level is controlled by a 2"x8"Treated Blocking Betwee - Dam at the North end of lake. Joists above beams �- _ Simpson Tie Clips from Joist toI 6 1/2' Joists Treated 2X8X16's on 16" Centers 4"x4"Treated Post/4"x6"Beam 4"x4"BC4 Simpson Brkt 6"x6"Treated Post/Beam 18" &Simpson Tie Clips on Joists 6"x6' BC6 Simpson Brkt Trex Composite Decking 1.25"x6" Cement Trex Composite Decking 1.25"x6" w/coated Deck Screws Bulkhead w/3"coated Deck Screws Joists Treated 2X8X16's End View 3"Coated Screws (Existing) Side View on 16"Centers Go thur to joist Ordinary \4 A Simpson Tie Clips on Joist High Water _ a r MarktOHWI ---.. _.____ ._. 20" 24 — — Dee. —. __ _ _ _.— __ —.—.—.—._.—._._. Ordinary Low P Posts Treated 6X6's Optional Water Mark 5 Beams Treated 6X6X12' 5' Pilings (OLW) Cross Tie's Deep w Mean Lower Lo ement Pier Footings -. __ Deep Treated 2X4 Water Mark Mow 16"Square y — Ground Level - --- --- ---- ( ) Simpson Brkt Cement Pier Footings Ground Level EPB44HDG 12"Round x 15"high (Overhang Cement Piers (Overhang 16" " 18" 16" Simpson Brkt Imo— 6' —►N---e' r I e'—►I r 7--il N-►I 20 Round H-.+ I i 6'--►I i� CPB66HDG Is, I� 10'--+I by 12"high 21" 21" I 28' N--►��---8 1/2'—►N—N I� 12'--►I Si4x Zo i o --600�z ----------------- y, ------------- O 2009 r AGENCY USE ONLY Y WASHINGTON STATE US Army Corps llaterece 1 of Engineers. c i , Seattle Distrid ' Joint Aquatic Resources PermitE �� Application (DARPA) Form hl i MASON COUNTY Agency re MASON # f 1 USE BLACK OR BLUE INK TO ENTER ANSWERS IN WHITE SPACES BELOW. Tax Parcel#(s): Part 1—Project Identification Unique project information that makes it easy to identify. hei -----------------------------------; 1a. Unique Project Identifier Number(UPI #) Lgipi • Don't have one yet?Get'one at httpa/www.epermittinq.wa:gov or call the Washington Governor's Office of Regulatory Assistance at(800)917-0043. 1 b. Project Name (Examples:Smith's Dock or Seabrook Lane Development) hel Q61;5onl S -Doe,k Part 2—Applicant The person or organization legally responsible for the project. 2a. Name (Last, First, Middle)and Organization (if applicable)' �O��On oCx(1 V(e.,+ 6c, ,?O�son , �pn 2bc Mailing Address (Street or PO Box) L} 15 S. 2c. City, State, Zip 2d Phone(1) 2e. Phone(2) A Fax 2 E-mail (253 ) qql-(Pa7Y (206 ) L4O6-153 ( ) roAn also,,(_&�rrisn. Cam 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.) Ebpipi 3a. Namel(Last, First,Middle)and Organization (if applicable) 3b. Mailing Address (Street or Po Box)' 3c. City, State, Zip 3d. Phone(1) 3e. Phone(2) 3f. Fax 3g. E-mail JARPA 2009 Page 1 of 11 Part 4—Property Owner(s) nel rCon ct information for people or organizations owning the property(ies)where the project will occur. pi 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 use 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 4 . E-mail Part 5—Project Location(s) Identifying information about the property or properties where the project will occur. hel ❑ There are multiple properties or project locations (e.g., linear projects). Complete the section below and use JARPA Attachment B for each additional property. 5a. Street Address (Cannot be a PO Box. If there is no address, provide other location information in 5n.) heI I ID N. L L."t 'kqe, 5b. City, State, Zip(If the project is not in a city or town,provide the name of the nearest city or town.) hel 5c. County hLgM lAas0 A 5d. Provide the section, township, and range for the project location. hLeM '/4 Section Section Township Range DOCK O_S Z"L 3 3 5e. Provide the latitude and longitude of the project location. hf eM • Example:47.03922 N lat./-122.89142 W long g 7 . Z 7 Z Z 9`1 1J, L*T-/I Z Z . 5 9 I © q (0 VJ - t... hq . 5f. List the tax parcel number(s)for the project location. h[ em • The local county assessor's office can provide this information. 223 --?)C)SbO0 %Iq 5g. Indicate the type of ownership of the property. (Check all that apply.) [bpjpj ❑ State Owned Aquatic Land ❑ Tribal Private ❑ Other publicly owned (federal,state, county, city,special districts like schools,ports,etc.) JARPA 2009 Page 2 of 11 5h. Contact information for all adjoining property owners, lessees, etc. (If you need more space,use JARPA Attachment C.) h[ eM Name Mailing Address Tax Parcel #(if known) �abby �o�ce Sv on ----TV Ow Nt 1-xkt -D2, z2-330S000lRo \J�Pr Cj$'SN-9(o) zz33o5b0o 1-75 I2.(Q (p0+"` Sf .ZZ33U b001ZZ -51eA1t\Jue, 22--j3050901-7 5i. Is any part of the project area within a 1 00-year flood plain? heI ❑ Yes ❑ No Don't know 5j. Briefly describe the vegetation and habitat conditions on the property. [Lei pl CIL)e-; rem s 5k. Describe how the property is currently used. h[ eip �-- 51nlIe 51. Describe how the adjacent properties are currently used. LtLeM fro, -Fa re s�dv v���s JARPA 2009 Page 3 of 11 5m. Describe the structures (above and below ground)on the property, including their purpose(s). h[ eM 'A s�rc�le, resk6eNue' )l�owse- �tDC'C CA `70 �eea f3.� Cy- Sin ed \0 C'C'Ae-6 159 -�e A OVA -Inc Sh o�'elan e� 5n. Provide driving directions from the closest highway to the project location, and attach a map. hei G b No e- C,, J o Am, 13e[ Ti4 h" 064 c)N+7 NE (+?,je-•l�cu�.. T � on RE H-uve,- Like-1J2,,ue r-i k4- o, -Ta h Ly&- ` ,P c'iC5;r,,4tA- �Ld. o Part 6—Project Description 6a. Summarize the overall project. You can provide more detail in 6d. Eeipj 6b. Indicate the project category. (Check all that apply.) h[ elp] ❑ Commercial ❑ Residential ❑ Institutional ❑ Transportation 216ecreational ❑ Maintenance ❑ Environmental Enhancement 6C. Indicate the major elements of your project. (Check all that apply.) h[ ele] ❑ Aquaculture ❑ Culvert ❑ Float ❑ Road ❑ Bank Stabilization ❑ Dam/Weir ❑ Geotechnical Survey ❑ Scientific Measurement ❑ Boat House ❑ Dike/ Levee/Jetty ❑ Land Clearing Device ❑ Boat Launch ❑ Ditch ❑ Marina / Moorage ❑ Stairs ❑ Boat Lift 5j?6ock/ Pier ❑ Mining ❑ Stormwater facility ❑ Bridge ❑ Dredging ❑ Outfall Structure ❑ Swimming Pool ❑ Bulkhead ❑ Fence ❑ Piling ❑ Utility Line ❑ Buoy ❑ Ferry Terminal ❑ Retaining Wall (upland) ❑ Channel Modification ❑ Fishway ❑ Other: JARPA 2009 Page 4 of 11 6d. Describe how you plan to construct each project element checked in 6c. Include specific construction methods and equipment to be used. hf eM • Identify where each element will occur in relation to the nearest waterbody. • Indicate which activities are within the 100-year flood plain. 6- A S-ku�'�Vr, r,c+6 J �-er wood sf a r-L :,V 1- 4ve,7 L-ou", Pour- b,-acfze-4 CP86A tf DC .i✓s e/%d Puce {oo�,.iy s i:✓�a L R ke. TA.#STa!/ Pre d,,-J1e,C 46-4 POSTS 11.`1 4e,1,Ly /j"k.-fS S�1ST� J2QI►Zf i�c6, o,a 4. P-S6 uSiny CiG (c s�•u�Daon 6rttcEeY4, rNsr�oc�/ 2--Rx /o' {,ref -7-o s-Is 74, 6e&-,,,s us,A',' ..r;JS,-r-a// Goy„�or,'•/t c�e�E,ie� 7� fois�t uSi.r.� -3 c%�k Scres✓s. lt,a1� w Joss-6 ,cam c I-WAe-A 74, a� e.t is� ✓� vac y'x z , cee, ��Ikheap( Jar 6e. What are the start and end dates for project construction? (month/year) hC • 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: Sf DI U End date: C` c7<A Ser 20 i o ❑ See JARPA Attachment D 6f. Describe the purpose of the work 11k and why you want or need to perform it. CJ hel Ck� - q 6g. Fair market value of the project, including materials, labor, machine rentals, etc. hel N00 )pc.3eo� a n 6h. Will any portion of the project receive federal funding? h[ eM • If yes, list eac Lagency 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. tLeM Not applicable ` 1 4 Z'b- 354- I 91 JARPA 2009 Page 5 of 11 7b. Will the pro je t impact wetlands? [bgjpj ❑ Yes No ❑ Don't know 7c. Will the project impact wetland buffers? h[ eM ❑ Yes JK No ❑ Don't know 7d. Has a wetland delineation report been prepared? hel • If yes,submit the report, including data sheets,with the JARPA package. ❑ Yes KNo 7e. Have the wetlands been rated using the Western Washington or Eastern Washington Wetland Rating System? gipj • 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? hem • If yes,submit the plan with the JARPA package. ❑ Yes No ❑ Not applicable 7g. Use the table below to list the type and rating of each wetland that will be impacted; the extent and duration of the impact; and the type and amount of compensatory mitigation proposed. If you are submitting a compensatory mitigation plan with a similar table, you may simply state (below)where we can find this information in the mitigation plan. i,el Activity causing Wetland type Impact area Duration Proposed Wetland impact (fill, and rating (sq. ft. or acres) of impact2 mitigation mitigation area drain, excavate, category' type (sq. ft. or acres) flood, etc. 'Ecology wetland category based on current Western Washington or Eastern Washington Wetland Rating System. Provide the wetland rating forms with the JARPA package. 2 Indicate the time(in months or years,as appropriate)the wetland will be measurably impacted by the activity. Enter"permanent"if applicable. 3 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: 71h. For all filling activities identified in 7g., 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[ elpl 7i. For all excavating activities identified in 7g., describe the excavation method, type and amount of material in cubic yards you will remove, and where the material will be disposed. h� eM JARPA 2009 Page 6 of 11 7j. Summarize what the compensatory mitigation plan is meant to accomplish, and describe how a watershed approach was used to design the plan. of elpl 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.) [Lpjpj ❑ 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. h[ elpl El Not applicable / ( /^ l evl S Iti'u_C-f O- ct0 C L cl cur (1 of 04"Nisyl ei.N / Z I%e ee eC SS it ry 5:&Fpen+ r-reere a�i-r ( a e • J. �e r ��s a y//oz✓eoQ 6 5/i�'� 8b. Will your project impact a waterbody or the area around a waterbody? Lie,,,,)] ®Yes ❑ No 8c. Summarize impact(s)to each waterbody in the table below. heI Activity causing Waterbody Impact Duration Amount of material Area (sq. ft. or impact (clear, name location' of impact2 to be placed in or linear ft.) of dredge, fill, pile removed from waterbody drive, etc.) waterbody directly affected SO -Do C.K OAvtvt L xke- XA-1 �r,,+�owe�,f 2 q& sr 2 y tc s�= 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. z Indicate the time(in months or years,as appropriate)the waterbody will be measurably impacted by the work. Enter"permanent"if applicable. 8d. Have you prepared a mitigation plan to compensate for the project's adverse impacts to non-wetland waterbodies? Lgjpj • If yes,submit the plan with the JARPA package. ❑ Yes tZ No ❑ Not applicable 8e. Summarize what the compensatory mitigation plan is meant to accomplish. Describe how a watershed approach was used to design the plan. • If you already completed 7j.,you do not need to restate your answer here. h[ elp] JARPA 2009 Page 7 of 11 8f. For all activities identified in 8c., 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. tg1pJ W OCD C� cQ n c� 0.� l x e� �'d C.- c C� b wt k l�e�-ol �. 01 Aof4-Lx pro PR",- t «e . 8g. For all excavating or dredging activities identified in 8c., describe the method for excavating or dredging, type and amount of material you will remove, and where the material will be disposed. hel Part 9—Additional Information Any additional information you can provide helps the reviewer(s) understand your project. 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 r4ASon a"-, -A 3�o 107-100 ►tl14 7 '2-e 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? hf gipl • 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/programs/wq/303d/. ( Yes ❑ No 5e e C, c�teo� 9c. What U.S. Geological Survey Hydrological Unit Code (HUC) is the project in? [Lpipl • Go to http://cfpub.el)a.gov/surf/locate/index.cfm to help identify the HUC./_ 9d. What Water Resource Inventory Area Number(WRIA#) is the project in? h[ elpl • Go to http://www.ecy.wa.gov/services/gis/maps/wria/wria,htm to find the WRIA#. WP- JARPA 2009 Page 8 of 11 9e. Will the in-water construction work comply with the State of Washington water quality standards for turbidity? hel • Go to http://www.ecy.wa.goy/programs/wq/swgs/criteria,htmi for the standards. [W Yes ❑ No ❑ Not applicable 9f. If the project is within the jurisdiction of the Shoreline Management Act, what is the local shoreline environment designation? hf el • If you don't know, contact the local planning department. • For more information,go to: http://www.ec�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? hf eM • Go to http://www.dnr.wa.gov/BusinessPermits/Topics/ForestPracticesApplications/Pages/fp watertypinq.aspx for the Forest Practices Water Typing System. ❑ S ❑ F ❑ Np ❑ Ns !i e,Vl 9h. Will this project be designed to meet the Washington Department of Ecology's most current stormwater manual? nei • If no, provide the name of the manual your project is designed to meet. Yes ❑ No Name of manual: 9i. If you know what the property was used for in the past, describe below. hf eIN RE S i C 6_41.�i� 9j. Has a cultural resource (archaeological) survey been performed on the project area? Lie! • If yes,attach it to your JARPA package. ❑ Yes X 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. [LpjpJ 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. hem JARPA 2009 Page 9 of 11 Part 10—Identify the Permits You Are Applying For Use the resources and checklist below to identify the permits you are applying for. • Online Project Questionnaire at http://apl)s.ecy.wa.gov/ol)as/. • Governor's Office of Regulatory Assistance at (800) 917-0043 or helpaora.wa.gov. 10a. Compliance with the State Environmental Policy Act(SEPA). (Check all that apply.) Lqpjpj • For more information about SEPA,go to www.ecv.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 (lead agency). The expected decision date is aCrO . ❑ I am applying for a Fish Habitat Enhancement Exemption. (Check the box below in 10b.) • Submit the Fish Habitat Enhancement Project form with this application. The form can be found at http://www.epermitting.wa.gov/Portals/ JarpaResourceCenter/images/default/fishenhancement.doc ❑ 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. hel 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): Ae jow -F ,es 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 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 2009 Page 10 of 11 Part 11—Authorizing Signatures Signatures required before submitting the JARPA package. 11 a. Applicant Signature (required) hf gjpj 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. lekV (initial) /ter/ A .2-V / D Applicant Date 11 b. Authorized Agent Signature [Lel 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 Date 11 c. Property Owner Signature (if not applicant) [b9jpJ 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 Own 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 JARPA 2009 Page 11 of 11 MASON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT Building III—426 west Cedar Street P.O.Box 186, Shelton, WA 98584 (360)427-9670—Ext. 352 SHORELINE PERMIT APPLICATION PERMIT NO. SHORELINE SUBSTANTIAL DEVELOPMENT SHORELINE VARIANCE DATE RECEIVED SHORELINE CONDITIONAL USE SHORELINE EXEMPTION 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 $5,718.00 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 my further describe the proposed development. Incomplete applications will be returned. APPLICANT: Cl it'0..�OlSon ADDRESS: 410 a 5 1'tt�10 U f h (street) NMI (city) ''11 (state) (zip) TELEPHONE: 0 53 ) q' l—(P�1`,7 Cad(o) (home) (business) AUTHORIZED REPRESENTATIVE: ADDRESS: (street) (city) (state) (zip) TELEPHONE: PROPERTY DESCRIPTION: General location(include property address,water body and associated wetlands—identify the name of the shoreline): 7 0 N E - Lake -Dt^k JC-� , i h LLV CA- �4 S 9IS- 516 t-o+ +�Vlq on 1-yiwen 1..c.&e Legal description (include section, township, and range to the nearest quarter, quarter section or latitude and longitude to the nearest minute. Projects located in open water areas away from land shall provide a longitude location)—include all parcel numbers: �ti yoL, 1--c. fit-. 1`1 4 ( 2.2 3 3 0 5 Ooo nj4) OWNERSHIP: Contract Applicant k Owner Lessee Purchaser (Identify) Other Owner: '�ZOG` e- (city) (state) (zip) DEVELOPMENT DESCRIPTON Development(identify and describe the proposed project, including the type of materials to be used,construction methods,principle dimensions,and other pertinent information): 5JTW t owe L -shu.o e- 01-4 t�Z x I�� wc�kwc (� \Z) 4- Use(identify current use of property with exist improvements: houses c� A0-o uyNe d S\Me_A Reason for requesting development: X ALY-k i& rea u kr e-A -�p moor a IJ00-1 on nL�-( ACKOWLEDGEMENT I hereby declare,to the best of my knowledge and belief,the forgoing information and all attached information is true and correct. DD 174A�.�I-' vi/l (' /D (apIlUnt or authorized representative) te) I:\PLANNINGICHARELL&RENEE/SHORELINEPERMIT.APP REVISED: 01-05-2005 I Publication cost is the responsibility of the applicant. Final permit processing will not occur until advertising fees have been paid to the newspaper by the applicant. The Shelton-Mason County Journal will bill the applicant directly. I /WE understand that I /WE must sign and date the attached acknowledgment indicating and that I / WE understand that is MY/ OUR responsibility. I /WE must submit the signed page as part of application in order for it to be considered as complete. c� (F , ;�_C, to DATE �ftt PetVV_,,. OWNER Y �Utv')� APPLICANTV LIST OF ADJACENT PROPERTY OWNERS' MAILING ADDRESSES WITHIN 300 FEET OF YOUR PROPERTY BOUNDARIES Addresses are to be obtained from the Mason County Assessor's Office, Bldg. 1, Second Floor. Legal Description Parcel Number Owner Name Owner Address Site Address Across the Street: HAVEN LAKE TR.275 N 1/2 Parcel number:223305000275 DAVID S LONG 627 N CARR ST TACOMA WA 98403-3010 HAVEN LAKE TR.276 EX S 1/2 Parcel number:223305000276 RICARDO R COOPER 1740 NE TAHUYA BLACKSMITH TAHUYA WA 98588-9453 HAVEN LAKE TR.277 Parcel number:223305000277 JOYCE E STRATTON 182 NE LAKE DR 181 NE LAKE DR TAHUYA TAHUYA WA 98588-9629 HAVEN LAKE TR.278 Parcel number:223305000278 HOFF,ROBERT L&DIANE L PO BOX 1022 MERCER ISLAND WA 98040-1022 HAVEN LAKE TR.279 Parcel number:223305000279 FITCH,BYRON N&KERRI L PO BOX 68268 SEATTLE WA 98168-0268 HAVEN LAKE TR.280 Parcel number:223305000280 LAYNE LV TR,JOHN&CAROL PO BOX 2042 111 NE LAKE DR TAHUYA BELFAIR WA 98528-2042 Lake Side of the Street: North HAVEN LAKE TR.180 Parcel number:223305000180 RICHARD M BLAKELEY ET AL KATHERINE R BLAKLEY 11208 SE 74TH ST NEWCASTLE WA 98056-1041 HAVEN LAKE TR.179 Parcel number:223305000179 VAN FOSSEN,GERALD M& 1729 NW SILVER ST DIANNE L BREMERTON WA 98311-9090 HAVEN LAKE TR.178 Parcel number:223305000178 JUANITA L MOUNSEY 2926 S 152ND ST SEATTLE WA 98188-2030 HAVEN LAKE TR 177 Parcel number:223305000177 LARRY O OTTESON 190 NE LAKE DR 190 NE LAKE DR TAHUYA TAHUYA WA 98588-9629 HAVEN LAKE TR.176 Parcel number:223305000176 JOYCE E STRATTON 182 NE LAKE DR 182 NE LAKE DR TAHUYA TAHUYA WA 98588-9629 HAVEN LAKE TR.175 Parcel number:223305000175 JOYCE E STRATTON 182 NE LAKE DR 182 NE LAKE DR TAHUYA TAHUYA WA 98588-9629 Our Home HAVEN LAKE TR.174 Parcel number:223305000174 4625 S 289TH PL 170 NE LAKE DR TAHUYA POLSON RODNEY K&DONITA AUBURN WA 98001-2832 South HAVEN LAKE S 27/238 TRS 172& 173-DPC#07-26 Parcel number:223305000172 FINNIGAN,MATTHEW P& 12636 SE 60TH ST 150 NE LAKE DR TAHUYA ISARAH P IBELLEVUE WA 98006-3962 HAVEN LAKE S 27/238 TR.171 Parcel number:223305000171 FINNIGAN,MATTHEW P& 12636 SE 60TH ST SARAH P BELLEVUE WA 98006-3962 HAVEN LAKE TR 170 Parcel number:223305000170 FITCH,BYRON N&KERRI L PO BOX 68268 SEATTLE WA 98168-0268 HAVEN LAKE TR. 169 Parcel number:223305000169 FITCH,BYRON N&KERRI L PO BOX 68268 SEATTLE WA 98168-0268 HAVEN LAKE TR. 168 Parcel number:223305000168 KENNETH M COX PO BOX 797 MARYSVILLE WA 98270-0797 HAVEN LAKE TR.167 Parcel number:223305000167 NELSON,BRIAN M&RUTH A 13511 BINGHAM AVE E 102 NE LAKE DR TAHUYA TACOMA WA 98446-4231 Viewer Frame Page 1 of 1 search legend lavers fi n$Y Home Page Mason Cottrity GIS Help Disclaimer MIN Boundaries&Places 'Parcels C&' k ............ 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Lnwe Jr. E OFF I """"""Iff t--'20 ft Contours(White)Cam' J DAerial Photos """"'0005 DNR Aerial Photos 1006 NAIP Aerial Photos i L `"'"""'"""""�2009 NAIP Aerial Photos Refresh Map L l�� 110 AJC Auto Refresh A/c 1p A Closed group,clHe to.open. o Zoom to.... Zoom Factor: 1 25% Zoom to Point �An open group,click to close. 1 Zoom In M0110 Overview In Out Full Map Back Pan Identify Measure Units Select Line Clear Print Help http://mapmason.co.mason.wa.us/website/mason/viewer.htm?Query=PIN=%27223305000174%27&QueryZoom=Yes 1/27/2010