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HomeMy WebLinkAboutSDP2013-00046 • UDC CONSISTENCY REVIEW Project Planner: Master#MLA13-00150 Review Type Project Description SDP13-00046 MOORING BUOY IN MYSTERY BAY,SDP Primary: THOMAS C ROSE Site Address: SUSAN M ROSE 7180 FLAGLER RD PO BOX 233 NORDLAND WA, 98358 NORDLAND WA 983580233 Project Location: Parcel Number: 976 200 401 Site Address: 7180 Flagler Rd Nordland S-T-R: 33 30N 1E Parcel Number: 976200401 S-T-R: 33-30N-01 E Total Acreage 1 Legal Description NORDLAND BLK 4 TAX I,56,65(ENLGD BY N20'OF TX Land Use: 1100 7)SUBJ/REST COVT 562115/563749 Flood District: Fire District: 1 Planning Area: 3 Flood Map(FIRM)Panel No: .chool D 49 Zoning: COMP PLAN DESIGNATION: COMMUNITY PLAN: UGA: UGA Trans [ ] Plot plan states "property line" [ ] Assessor's Map(Property lines on submitted plot plan must match the property lines as identified on the Assessor's 1/4 map) [ ] Legal Access to Property YEV NO [ ] Parcel Tags or Scanned Documents YES NO [ ] ESA's: Special Reports Nearby YES NO [ ] Designated Ag YES NO [ ] Shoreline Designation: ) NO PTjtigX,c, [ ] Shoreline Slope Stability: YES N Stream Type:YES N9/ - FWHCA: YF NO 4 ,1. MAN 1"i h 1.41141111 Anil Wetlands: YES N Rare Plants:. N� Seismic: 0 0,, NOS Landslide: �Y Flood: NO VL M U J P� p �yv�/ �- �C Yv 00{1V 9u, Erosion: YES N9,' Aquifer Recharge Area:YES NQ SIPZ: none At Risk 'gh Ris Coastal 11,iMKUP r f..U ' Bi CMZ: n e- High Risk Mod- . - iskDisconnected CMZ Stormwater site plan submitted: YesNo [ ] Forest Lands: YES N9 Adjoining Forest Lands: Commercial/ Rural/ Inholding [ ] Mineral Lands: YES N9- [ ] Agricultural Lands: YES ■7 [ ] Archaeology: YES 10 [ ] No Shooting Zone: YES N7" [ ] Stormwater: New Impervious Surface n10 Land Disturbing Activity d n ESA's Stormwater Req's:Min Req#2 Min Req#1 thru#5 Min Req#1 thru#10 Engineering [ ] Notice Provisions/Disclosure:Airport YES N.9/ MRL YES N0/ Forest Lands YES [ ] Landscaping Required: Yes lye' [ ] Parking Spaces Required N/ 2 Other 1 Building Height: 35' UBC Standard VV I . [ ] Impervious Surface coverage percentage: Resource Lands&Public: 10% Rural Residential: 25% Rural Industrial: Per UDC Sec 6.7 Rural Commercial: 60% Area of Building Coverage:60%in Rural Industrial Lands only [ ] Total Building(s) Size: RVC:20,000 SF CC:5,000 SF NC:7,500 SF GC: 10,000 SF All others:subject to septic&water constraints/None specified [ ] Setbacks: Front: Left Side: Right Side: Rear: Shoreline Setback: LSHA Setback: [ ] Road Classification: Road Approach: EXISTING NOT REQ'D RAP • [ ] SEPA Required: YES EXEMP L [ ] Flood Certificate: [ ] Existing Case(s)&Condition(s): Violations: Yes No [ ] Recorded Date of Subdivision: AFN Over 5yrs=UDC Plat Conditions: <5yrs=Plat Conditions on plat or Old Ordinance [ ] Lots/Require Declaration of Restrictive Covenant YES NO, submitted: YES NO [ ] UGA No Protest Agreement YES NO, submitted: YES NO [ ] Site Visit conducted YES NO [ ] Require Final Zoning Approval YES NO [ ] ADMIN: Setbacks entered in Permit Plan case N/A YES New Parcel Tags entered in Permit Plan N/A YES Special Reports Scanned N/A YES Title Notes Updated Parcel tags found for parcel 976200401 1.) WSRC Coaching- 2011-02-15,CZ 8/29/13 Other Parcel tags found for parcel 976200401 2.) WSRC Coaching- no date,CZ 9/3/13 Other Parcel tags found for parcel 976200401 3.) WSRC Coaching- 2013-11-29,CZ 11/6/13 Other 4 4 Associated CASES status issued finaled description 976200401 BLD07-00241 F 5/18/2007 4/21/2008 A/G 120 GAL PROP TANK,WALL HEATER&GAS PIPE SEP72-00099 C 7/21/1972 Now filed w/SEPI1-19 BLD94-00856 F 12/21/1994 12/23/1994 Fuel Tank Remove(2) XMP95-00062 A 11/9/1995 repair existing bulkhead BLD96-00679 F 11/1/1996 11/3/1997 propane tank installation FEP12-00141 ACT 3/13/2013 MLA11-00046 P RJ 11-00045 P SDP11-00010 A 4/18/2011 SHORELINE EXEMPTION FOR SEPTIC APPLICATION SEP11-00019 F 4/29/2011 11/29/2011 System serves the Store-7180 Flagler Rd,Home-42 Beveridge Ln. and ADU-62 Beveridge Ln. SEP72-99&SEP82-I62 no longer valid and filed here MLA11-00055 PRJ11-00051 P CONVERT EXISTING PERMITTED GARAGE TO ADU(UNPERMITTED) RAP11-00015 F 5/16/2011 11/1/2011 RAP&911 -Beveridge Ln BLD11-00065 F 5/16/2011 3/20/2012 CONVERT EXISTING PERMITTED GARAGE TO ADU(UNPERMITTED) MLA13-00150 SDP13-00046 P MOORING BUOY IN MYSTERY BAY,SDP OTH11-00007 CLS 1/24/2012 WET SEAS EVAL RAP11-00019 F 5/16/2011 11/1/2011 RAP&911 FOR ADU-Beveridge Ln SOM72-00099 RCR 2/7/2013 serves Nordland Store-7180 Flagler Rd,main res.-#42 Beveridge Ln,ADU-#62 Bev.Ln SEP82-00162 C 3/18/1982 3/18/1982 Now filed w/SEP11-19 Incinerating toilet no longer in the building USR11-00044 F 10/5/2011 DECOMMISSION WELL ADDRESS WAS LISTED AS 7180 FLAGLER RD-NORLAND JEFFERSON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT UNIFIED DEVELOPMENT CODE TYPE I LAND USE PERMIT SHORELINE SUBSTANTIAL DEVELOPMENT PERMIT EXEMPTION WASHINGTON STATE SHORELINE MANAGEMENT ACT(RCW 90.58) PROPONENT: THOMAS C ROSE SUSAN M ROSE PO BOX 233 NORDLAND WA 983580233 DATE ISSUED: May 25, 2014 DATE EXPIRES: May 25, 2015 MLA NUMBER: MLA13-00150 CASE NUMBER:SDP13-00046 PROJECT PLANNER: Donna Frostholm PROJECT DESCRIPTION: MOORING BUOY IN MYSTERY BAY, Shoreline Exemption Permit and Flood Development Permit WATERBODY AND/OR ASSOCIATED WETLANDS: MYSTERY BAY PROJECT LOCATION: Parcel Number: 976 200 401 Site Address: 7180 Flagler Rd Nordland S-T-R: 33 30N 1 E FINDINGS: 1.) The Administrator finds that this application complies with applicable provisions of the Unified Development Code, all other applicable ordinances and regulations, and is consistent with the Jefferson County Comprehensive Plan and Land Use map. 2.) The applicant is proposing to install a mooring buoy in Mystery Bay, within the aquatic shoreline designation. The adjacent upland is designated as Conservancy. This proposal is subject to the Mystery Bay Management Plan. 3.) This application was sent to federal, state, and tribal agencies for review. DCD did not receive any comments on this application. 4.) The application was reviewed by the Jefferson County Department of Community Development staff for the potential presence of Critical Areas under the provisions of the Unified Development Code (UDC). After an initial Geographic Information Systems mapping review, the following Critical Areas were confirmed to be present on the subject property: fish and wildlife habitat conservation areas(listed species in marine water); frequently flooded areas; and seawater intrusion protection zones(high-risk). This application requires federal and state permits, which will be reviewed for potential impacts to species and habitats of concern. DCD assumes that if federal and state permits are issued, there will be no negative impact to fish and wildlife species and habitats as a result of implementing this proposal; therefore, no Special Report has been requested. It is further assumed that the FEMA BiOp requirements have been met once a federal permit is issued. This application is not expected to adversely affect seawater intrusion protection zones; therefore, no Special Report has been requested. 5.) The proposed project will be located in Mystery Bay, in an area that is mapped on the Federal Emergency Management Agency Flood Insurance Rate Map(Panel 530069 0190 B) as Zone A. The proposal is subject to the requirement for a flood development permit, which is incorporated into this decision. The proposal meets the definition for development but not structure, as per JCC 15.15.050. 6.) The proposed project will not result in any increase in flood levels during the occurrence of base flood discharges. 7.) Jefferson County determined that this proposal is categorically exempt from review under the State Environmental Policy Act(SEPA) pursuant to WAC 197-11-800(24)(f). 8.) The site plan, as submitted with the shoreline exemption application on November 19, 2014, has been reviewed for consistency under the UDC, and has been approved by Jefferson County Department of Community Development. Any modifications, changes, and/or additions to the stamped, approved site plan dated May 25, 2014 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 9.) This approval is for shoreline exemption and flood development permits for installation of a mooring buoy only. Any future permits on this site are subject to review for consistency with applicable codes and ordinances and does not preclude review and conditions which may be placed on future permits. 10.) The parcel has been designated as Convenience Crossroads (CC) under the Jefferson County Comprehensive Land Use Map effective August 28, 1998. One house and one accessory dwelling unit are located on this parcel. 11.) The Development Review Division finds that this proposal is consistent with the Shoreline Master Program (JCC 18.25.090(11))and is consequently exempt from the substantial development permit (SDP) requirements. Exemptions from the substantial development permit requirements do not exempt a proposed development from compliance with the applicable policies and standards of the Shoreline Master Program or other applicable Federal, State, or local permit or license requirements. 12.) NOTICE: This permit does not excuse the proponent from complying with other local, state, and federal ordinances, regulations, or statutes applicable to the proposed development, but consistent with RCW 90.58. Development pursuant to this permit shall be undertaken subject to the applicable policies and performance standards of the Jefferson County Shoreline Management Master Program and the Jefferson County Unified Development Code. If during excavation or development of the site an area of potential archaeological significance is uncovered, all activity in the immediate area shall be halted, and the Administrator shall be notified at once. The Federal Endangered Species Act rules to protect threatened Chinook and Summer-run Chum salmon became effective on January 8, 2001. Bull trout have been listed as threatened since early 2000. Under the ESA, any person may bring lawsuit against any individual or agency that"takes" listed species (defined as causing harm, harassing, or damaging habitat for the listed species). In addition, the National Marine Fisheries Service can levy penalties. Portions of Jefferson County, including the marine environment, are included as "critical habitat"for a listed species. Development of property along any marine shoreline, freshwater shoreline, or floodplains could harm habitat if protective measures are not taken. To minimize the potential to damage habitat, all property owners developing adjacent to marine shoreline, freshwater shoreline, or floodplains are advised to do the following: -All development activities should avoid unstable slopes, wetlands, and forested areas near surface waters -Remove minimal vegetation for site development, especially large trees -Allow trees that have fallen into surface waters to remain there - Infiltrate stormwater from buildings and driveways onsite through drywells rather than discharging directly into surface waters or roadside ditches The Federal Bald and Golden Eagle Protection Act requires landowners within 660 feet(1/8th of a mile)of an eagle nest to consult with the US Fish and Wildlife Service. This Eagle Act prohibits anyone from"taking" bald eagles. This federal law defines the term "take" and describes the possible legal consequences when a"take" occurs. Among other actions, "take" includes a disturbance of bald eagles or their habitat. Under federal law a permit may still be required for activities that impact bald eagles or their habitat. Contact the US Fish and Wildlife Service (http://www.fws.gov/pacific/eagle/)to learn more about how this law affects your project. Any individual, group, or agency can bring suit for a listed species"taking", even if you are in compliance with Jefferson County development codes. The risk of a lawsuit against you can be reduced by consulting with a professional fisheries habitat biologist, and following the recommendations for site development provided by the biologist. For more information, contact the National Marine Fisheries Service in Seattle, or the U.S. Fish and Wildlife Service. CONDITIONS: 1.) Flood hazard reduction measures are to be used as required by the Jefferson County Flood Damage Prevention Ordinance 07-0515-06 (Jefferson County Code Chapter 15.15). 2.) Construction Materials and Methods of Construction to Reduce Flood Hazard: (i)All new construction and substantial improvements shall be constructed with materials and utility equipment resistant to flood damage; and (ii)All new construction and substantial improvements shall be constructed using methods and practices that minimize flood damage. 3.) To show compliance with the FEMA Biological Opinion, work on this project shall not begin until all applicable federal permits have been issued. 4.) The applicant shall adhere to the Mystery Bay Management Plan, including but not limited to: (1)the owner of the mooring buoy must have a residence directly upland of the mooring buoy so a home toilet can easily be used; and (2)the owner shall not discharge wastewater or other substances ito Mystery Bay and will properly dispose of waste in an upland sewage system or boat pump-out location. For DOH to consider exempting boats from the marina threshold count, the applicant shall return the attached Mooring Buoy Affidavit form to DCD. FAILURE TO RETURN THIS FORM IN A TIMELY MANNER MAY RESULT IN THE PROJECT BEING OUT OF COMPLIANCE WITH THE MYSTERY BAY MANAGEMENT PLAN. 5.) The project shall adhere to the Best Management Practices (BMPs)to control stormwater, erosion and sediment during construction. BMPs shall address permanent measures to stabilize soil exposed during construction, and in the design and operation of stormwater and drainage control systems. 6.) Prior to commencing development activity, proponent is responsible for informing the Washington Department of Fish and Wildlife (WDFW) in order for WDFW to determine whether this action is subject to the Washington State Hydraulic Code(Chapter 220-10 WAC). Hydraulic Project Approval (HPA) is required for all hydraulic projects, which are defined as construction or performance of other work that will use, divert, obstruct, or change the natural flow or bed of any of the salt or fresh waters of the state. 7.) In addition to Jefferson County permit conditions, the project proponent shall comply with all conditions set forth by the Washington Department of Fish and Wildlife through Hydraulic Project Approval. 8.) Prior to commencing development activity, the proponent is responsible for informing the US Army Corps of Engineers(COE) in order for COE to determine whether a Department of the Army permit or review is required. Generally, review is required for construction and dredging in or around navigable waters of the US and for work or fill in hydrologically connected wetlands. Contact the US Army Corps of Engineers, Seattle District Regulatory Branch, PO Box 3755, Seattle WA 98124, (206) 764-3495, for more information. 9.) Work within the jurisdiction of the Shoreline Master Program other than as described above shall receive separate review from this Department. 10.) Construction shall be in substantial compliance with the site plan submitted on November 19, 2013 as it exists now or is hereafter amended by Jefferson County and/or the Washington Department of Ecology. 11.) No fill or other material may be placed in the waters or intertidal areas of Jefferson County. 12.) This permit constitutes permission to place a mooring buoy and ground tackle only. Permission to place floats is not authorized. 13.) The buoy shall be permanently marked with the proponent's name, address, and telephone number and the permit number. 14.) No more than two (2) boats shall be secured by a mooring buoy. 15.) The mooring buoy shall not be rented or leased. 16.) Boats that are occupied shall not be permitted to moor at private docks, piers, and floats longer than three (3) days unless pump-out facilities are available in the immediate vicinity. 4111G .A► eurrtm-nt of Communi %evelopment Staff c: Department of Ecology, Shorelands Office, Rick Mraz Washington State Department of Fish &Wildlife, ' Washington State Department of Natural Resources, Bridget Kaminski-Richardson u•S :WI h Cz^f vsof 4 /A,3, S0 6"'")°'`` '' \\tidemark\data\forms\F_SDP_Exemption_U.rpt 5/25/2014 rvy- 44, 7180 Fiagicr Rd, Marrowstene. WA 98338, U 2oi Coogge earth feet meters '200 800 vRo?osED gos. "bk.101 LAT 4T. 059.1- Lot.16.: 1092 Cc) APPROVED SITE PLAN C,I , m , NOV ;:,m3 mg 2 5 2014 J JEFFERSON COUNTY JEFFERSON COUNTY D' -"` C UNITY DEVELOPMENT DEPT OF COMM'iNITY DEVELOPMENT 1 1 . • P'' -0 37 Ro SE a . 91., • r . . - - - - - . P 1,T . . 114 Ip - - - W $51.: tt■7It4Ya t t' V5 I(1 . 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L_.._..GEPT.PF i 0",gi�tt°dITY OPNNT - - - .• 1 1 Tag#_ ITO MINIa SCata of W.astrington ) S gays ` tr County of Jefferson ,residing at blainOttittitilyteitain on oath deposes and yam. sue:ttt Own mooring buoy in Mystery Bay with thhfollowi d iptl*nr lira' Latitude f Longitude •l DesetifItiotof boat us Ily s t ' hA tr . ��;' = l $inboat_ aeckCnek_ i cif t1 ova flie boat t 4• e E.., l a 4in k witty adyetablet 1 � toi.lQt I oaritiy urider.penaltskidf perjury thatany boat moored.tothis taut/will • Not hake.overn' giants • Not trischaripearygtoilet waste into Mystery Bay • Not allow gray w (from showers,laundry or kitchen)or otheE4.4stapt, S,to-drain irito te Mystery gay Dispose of all toilet waste end gray water properly In upland seiivaget-sySternSor at a boat pump-outstation Data., Name* I cart*that I knee'. 5ati to ei'idence that is the { person whO:a Vi rile,and is the owner of the mooting buoy deorxibed above.F further furthtf FF certify titat mid persttekockno4miledgell the foresail/le-statement to-be tile free and volunta y-actnf Po. said person. 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HPU‘A fiNGNg- . . - U .L •4l GIPfib1 ..-= IfOt , . - • . . - . . . . . . . . . . �� i .z • • . . . . . . . • . . . . ,.,t - - . . . . . . . . . . . . 41 ‘1..: . . . . . . . . . . . . . . . . . . . . . . . N*1.1 X ANC rr-Piz:, • - - - " - N H$' 05'{2 . . . . . . . . . . W MIL' 4,41 26 . IL); , 1. F -KgERSON COUNTY- ( . I "LPT.GF C i t�:rIU�11TY DE;«I OAM 4T - i Donna Frostholm From: Gardiner, Joanne L NWS [Joanne.L.Gardiner @usace.army.mil] Sent: Tuesday, May 13, 2014 7:01 AM To: Donna Frostholm Subject: FW: Rose Mooring Buoy in Mystery Bay (NWS-2013-1162) (UNCLASSIFIED) Classification: UNCLASSIFIED Caveats: NONE Hi Donna, I have an application in from Mr. Rose (see below). I'm waiting for copies of his documentation before I can issue the permit verification. Thank you for the notification. Jo Jo Gardiner Fisheries Biologist, Regulatory Branch U.S. Army Corps of Engineers, Seattle District 206-764-6878 Original Message From: Gardiner, Joanne L NWS Sent: Thursday, May 01, 2014 11:39 AM To: Kaminski-Richardson, Bridget (DNR); rose @olympus.net Subject: Rose Mooring Buoy in Mystery Bay (NWS-2013-1162) (UNCLASSIFIED) Classification: UNCLASSIFIED Caveats: NONE Good morning Tom and Bridget, Tom thank you for submitting the SPIF for Mooring Buoys to me. I'm glad to hear that the other agencies have approved your project. The Corps just needs written approval from DOH, the County, WDFW, and DNR before we can issue our permit verification so I'll need copies of the County SDP and the HPA from WDFW - it's OK to send these to me via email. I've included Bridget Kaminski-Richards on this email to give her a heads up that I'll be contacting her. Here at the Corps, I'm waiting for Section 106 consultation (under the National Historic and Preservation Act) and the Tribal consultations to close. Please feel free to contact me if you have any questions. Regards, Jo Jo Gardiner Fisheries Biologist, Regulatory Branch U.S. Army Corps of Engineers, Seattle District 206-764-6878 1 A ' Classification: UNCLASSIFIED Caveats: NONE 2 c^ y JEFFERSON COUNTY " DEPARTMENT OF COMMUNITY DEVELOPMENT f(,is,,;"` 621 Sheridan Street, Port Townsend,WA 98368 Web:www.co.iefferson.wa.us/communitydevelopment Tel:360.379.4450 I Fax:360.379.4451 I Email:dcd(a?co.iefferson.wa.us SquareONE Resource Center I Building Permits&Inspections I Development Review I Long Range Planning May 2, 2014 Dear Reviewer, RE: MLA13-00150 Jefferson County has forwarded the attached application to you for review and comment because your agency is responsible for determining compliance with state and federal requirements or may otherwise be affected by the following proposal: MOORING BUOY IN MYSTERY BAY, SDP Location: Parcel Number: 976 200 401 Site Address: 7180 Flagler Rd Nordland S-T-R: 33 30N 1E Comments must be received within fourteen (14)calendar days or by May 16, 2014. If no written response has been received within fourteen (14) days, your agency will be presumed to have no comments. If necessary, the UDC administrator may grant an extension of time for comment. Please contact at(360)379-4450 if you desire an extension of time or have additional questions regarding this proposal. Thank you in advance for your attention to this matter. Sincerely, Donna Frostholm Donna Frostholm cc:RICK MRAZ, *DOE SHORELANDS OFFICE WDFW, *DAN AFOE PO BOX 47829, *WSDOH SHELFISH AND WATER PROT. - MARK TOY BRIDGET KAMINSKI-RICHARDSON, *WA STATE DNR GRETCHEN KAEHLER, *WA STATE DEPT OF ARCH & HIST PRES 31974 LITTLE BOSTON RD., PT GAMBLE S'KLALLAM TRIBE LEANN JENKINS, *JAMESTOWN S'KLALLAM TRIBE KRIS MILLER, *SKOKOMISH TRIBE RANDY N LUMPER, M.E.S., *SKOKOMISH TRIBE ALISON O'SULLIVAN, *SUQUAMISH TRIBE CYNTIA ROSSI, *POINT NO POINT TREATY COUNCIL CENWS-OD-RG ATTN: J L GARDINER, * US ARMY CORPS OF ENGINEERS \\tidemark\data\forms\F_MLT_ReviewerLtr.rpt 5/2/2014 .,1,9.0N c �` `"1 . o JEFFERSON COUNTY W��, •' '� .i.„, DEPARTMENT OF COMMUNITY DEVELOPMENT `' ` '4 621 Sheridan Street • Port Townsend • Washington 98368 360/379-4450 • 360/379-4451 Fax c www.co.jefferson.wa.us/commdevelopment Master Permit Application MLA: Ir4 1 5—C) Project Description (include separate sheets as necessary): "(Zo5e wino R1NCs -i- ‘3 oIA f iM'mot5Tep--1 ‘5641 Tax Parcel Number: 1 1 h 'LOO 4 0 Property Size: I ACRE (acres/square feet) Site Address and/or Directions to Property: `1 t it 1 L ott Cs Lta 't-D. N 0 ta-at. 14r.40 1 WW . °t t3Sg Property Owner(s)of Record: THo'AAA S -It 5vSA15 12oSE. Telephone: 3 b0 — 3141-SY n I Fax: email: Yo See olq o res.Ae♦ Mailing Address: e 0 . 'P3 0 k '2."37, P1 a P.0L tA•nsO i IA. . q t 3 sY JJ Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: 1 What kind of Permit? (Check each box that applies ❑ Lot or Road Segregation ❑Building ❑ Critical Areas Stewardship Plan ❑ Demolition Permit ❑Variance(Minor, Major or Reasonable Economic Use) Li Single Family Li Garage Attached/ Detached ❑ Conditional Use[C(a), C(d),or CI** II 0 Manufactured Home - . n Modular • • - .• ❑ Discretionary"D"or Unnamed Use Classification ❑ Commercial* ❑ Special Use(Essential Public Facilities)** O Change of Use ❑ Boundary Line Adjustment ❑ Address ❑ Road Approach_ ❑ Short Plat*" ❑ Home Business ❑Cottage Industry ❑ Binding Site Plan** ❑ Propane ❑ Long Plat** • ;_, .gig„ - - - ❑ Planned Rural Residential Development(PRRD)/Amendments"* ❑Allowed"Yes"Use Consistency Analysis ❑ Plat Vacation/Alteration** ❑ Stormwater Management ri4-16horeline Master Program Exemption/Permit Revisions** ❑ Site Plan Approval Advance Determination(SPAAD)* ❑ Shoreline Management Substantial Development** ❑Temporary Use ❑ Shoreline Management Variance 0 Wireless Telecommunication* n Camp chansive Plan/UDC/Land Use District Map Amendment IT: r'nictices Ac_ of . Y .-7.r . . :.'onion El Jefferson County Shoreline Master Program Amendment ■ * May require a Pre—Fpp icati n Conference ❑ Tree Vegetation Request **Requires a Pre-Application Conference I Please identify any other local, state or federal permits required for this proposal, if known: . V100ISR. WS J v. S. Al2 sn9 Co Kt of ENCr(NeERS 1 W PO 14 I DESIGNATION OF AGENT I hereby designate to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE Date:- By signing this application form,the owner/agent attests that the information provided herein,and in any attachments, is true and correct to the best of his, her or its knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respect to this application packet may result in this permit being null and void. , th, 7,o to :,indemnify erV2 hold harmicos Jefferson County against_.in st ail liabilities,judgments,court costs,reasonable attorney's fees and ,,�i, o A iiii;i may in any way accrue against Jc f rsoii County as a result of or In Consequence of the granting of this permit. fwthor provide access and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application review and any required later inspections. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the time of the application that he or she w is prior notice. Signature: � Date: I I— 't — I The action or actions Applicant will undertake as a result of the issuance of this permit may negatively impact upon one or more threatened or endangered species and could lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the "Endangered Species Act"or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this permit has been issued will not violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your action(s)even if you are in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-transferableilejeherin g to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below. Rinnatura- Date: I t—1 —11 • r aqt€ r Rd. Marro.w, tcn , \ < 3=, a U .ot q Vo $le earth feet ,800 meters '200 Uw '� YRot OSED L,o CsV Dt4 ¶oR ROSE 15 Q01 LAT : 4g'• °S`it L ort&: — -t.2 , 1,012 tq • ,1' d 37 Ro s E Bw y . . - - - - - POLT ; . 1 1- tot tz4vtlis.15 `( ►x. . PI-FT � lv,� tri cur-z .2 - - - . _ CH�t}3+ . .� • I POW LAN6 .SW�V$i to Pk/Tr-AV V u 25 HP ,OGN6 . . . . . • . . . . • 111; 1, •4W' GU- 4J = 1101 . . • s�a - • N Esc° 05442 W 122' (<t 26 . 1 I-,L, .,��. - • Y- s J AGENCY USE ONLY Date received: [I- us Army Corps WASHINGTON STATE of Engine Engineers Joint Aquatic Resources Permit Agency reference#: Application (JARPA) Form'2 Tax Parcel#(s): USE BLACK OR BLUE INK TO ENTER ANSWERS IN THE WHITE SPACES BELOW. 4 ti NOV 07 Part 1—Project Identification 1. Project Name (A name for your project that you create.Examples:Smith's Dock or Seabrook Lane Development) [help) Rose Family Mooring Buoy, Mystery Bay Part 2—Applicant The person and/or organization responsible for the project. [help 2a. Name (Last,First,Middle) Thomas Rose 2b. Organization(If applicable) 2c. Mailing Address (Street or PO Box) P.O. Box 233 2d. City, State, Zip Nordland, Wa. 98358 2f. Phone(2) 2 . Fax 2h. E-mail (1) 2 O 2e. Phone( ) 9 ( 360 )3795471 ( 360 )7741266 ( ) rose @olympus.net 360 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/Missions/CivilWorks/Reo ulatory/PermitGuidebook/EndanoeredSpecies.aspx. • Not all cities and counties accept the JARPA for their local Shoreline permits.If you need a Shoreline permit,contact the appropriate city or county government to make sure they accept the JARPA. 2To access an online JARPA form with[help]screens,go to http://www.eoermittinq.wa.00v/site/alias resourcecenter/Lama iarpa form/9984/iarpa form.aspx. For other help,contact the Governor's Office of Regulatory Assistance at 1-800-917-0043 or help @ora.wa.gov. JARPA Revision 2012.1 Page 1 of 16 • 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.) [help] ❑ Private ❑ Federal ❑ Publicly owned (state,county,city, special districts like schools, ports,etc.) ❑ Tribal x❑ Department of Natural Resources (DNR) — managed aquatic lands (Complete JARPA Attachment E) 5b. Street Address (Cannot be a PO Box. If there is no address,provide other location information in 5p.) [help] 5c. City, State, Zip(If the project is not in a city or town,provide the name of the nearest city or town.) [help] Nordland 5d. County [help] Jefferson 5e. Provide the section, township, and range for the project location. [help] '/�Section Section Township Range N t/ -3a 30 E 5f. Provide the latitude and longitude of the project location. [help] • Example:47.03922 N lat./-122.89142 W long.(Use decimal degrees-NAD 83) i18,05�1i Low: -taa .bca6 5g. List,the tax parcel number(s) for the project location. [help] • The`local county assessor's office can provide this information. State owned aquatic lands , cab acx)yo 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) Dov►c� btccc-ori e. t3C Cleve l L(A GO(0 a00-50A NO OLAtJU wA '8358 Richcct thicku d P,a, 60x 13 - — -- --- — gobRooLica t•. land C335B WtLLit4.% FAR% R _"1 t Gi-{ `�6.�ACrt.�.2. Cam'O_ -- !1 'Lem get, Nofko vr .) o war °tg ,SI/ JARPA Revision 2012.1 Page 3 of 16 Part 6—Project Description 6a. Briefly summarize the overall project You can provide more detail in 6b. [help[ Install a residential use mooring buoy, 18-in diameter, secured by 1 in braided line, with a subsurface float, anchored with an embedment style (helix) anchor at a depth of 14 ft.(0 tide) 6b. Describe the purpose of the project and why you want or need to perform it. [help] To provide a safe moorage for our 23 foot sailboat, convenient to our waterfront home. e.. C C es $ 5 A 01-1,4 ° G 23 k�'r . 506).-t CS dt w 14 L4 Go S o N 6c. Indicate the project category. (Check all that apply) [helps ❑ Commercial xEResidential ❑ Institutional ❑ Transportation Recreational ❑ Maintenance ❑ Environmental Enhancement 6d. Indicate the major elements of your project. (Check all that apply) [help] ❑Aquaculture ❑ Culvert ❑ Float ❑ Retaining Wall ❑ Bank Stabilization ❑ Dam /Weir n Floating Home (upland) ❑ Boat House ❑ Dike/Levee/Jetty ❑ Geotechnical Survey ❑ Road ❑ Land Clearing ❑ Scientific ❑ Boat Launch n Ditch Measurement Device ❑ Boat Lift ❑ Dock/ Pier ❑ Marina/Moorage ❑ Stairs ❑ Bridge ❑ Dredging ❑ Mining ❑ Stormwater facility ❑ Bulkhead ❑ Fence ❑ Outfall Structure El Swimming Pool x❑ Buoy ❑ Ferry Terminal ❑ Piling/Dolphin ❑ Utility Line ❑ Channel Modification ❑ Fishway ❑ Raft ❑ Other: JARPA Revision 2012.1 Page 5 of 16 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. [help] 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. [help] 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 helix anchor will be fully embedded in the sea bed, leaving only the eye at the top of the screw exposed.A mid-water float will keep the mooring line off the bottom to eliminate the possibility of disturbance of plant and animal life. The installation of the helix will be by a single diver, using manually operated tools. There is no need for removal of vegetation in the proposed location, and the potential for blocking light penetration into the water does not exist. 8b. Will your project impact a waterbody or the area around a waterbody? [help] x❑Yes ❑ No JARPA Revision 2012.1 Page 9 of 16 WT11 LA;lp!ganJ ao} spaepue;s A;llenb je eM uoJ6u►gseM Jo a eJs eqJ q M Aidwoo){aoM uogoniJsuoo aaJeM-u! aq ll!M '06 9#Vl M '#VIM eq4 pub}01.w4y•eunn/ Jnevsdaw/sib/saovues/nob"em•Aoa•MMM//:dI1q 0/00 • 6u!pefoid aye s! (#VI M) aagwnN eaay/(aoluanuf eoanosej aa;eM Je4M 'P6 61.001.LL L-pegsaa1eM punos le6nd '3HH ay;&Pep!dray o}w,}o•xapui/a1e0o1/pns/nob'eda-gndpo//:d4}y 04 00 • ldiagJ zu! 4oefoad aye Si (anH) apoa J!Un leo!6oloapAH Caning leo!6oloao 'S-f) JeLM -36 oN Jx SeA D 7 P£0£/bnn/sweabad/nob-em•Aoa•mmAr p:dpy sioo;;uewssassy A4llenrj Jele/A s;A6o1oo8 iuewpedea uo46uIyseM esn'nnouN tuop noA II • • noleq(s)ia*eweJed ay;Is!!'se), • Magi rill (p)£0£ s,/(6oloog Jo}uewpedea uoJ6u!gse/N eqL uo yd?8Kf 9}aed JO L Ped u! pa14!4uep! sa!pogaa}eM ao spuel4aM aql Jo Aue aay •q6 ( ) ( ) ( ) ;3e;uo3 Jo a;ea ;uaoaa;sow euoyd aweN;oe;uoa aweN Aoue6y Mad •Molaq wegi Isll `Joafoad s!ql uo sa!oua6e lUSWUJan06 I(us y4!M pe poM Apeeile aneq noA Jl •e6 •uogsenb a JOMSUB 4ouue3 noA J!)o s!Jl •ueo no/(se UOipes s!q Jo yonw se a}aldwa .Joafoad ano/( pueIsaapun (s)JeMalnaa sin sdieq ep!noad ueo not uoQewaoJu! leuo!J!ppe Auy uopeu 10Jui ieuomppb-6 ped V/N ldiagJ •pasodslp eq p!M leuawew aql aaagM pue `anowaa ll!M nog( leuaIew Jo}unowe pue edfq `6u16p9ap JO 6ugeneoxe JOJ poq ew ay; aglaosap `89 U! pe!J!4uep! sa!J!n!Joe 6ul6peap ao 6u!Jeneoxa pe 10d •68 • • Go to http://www.ecy.wa.gov/programs/wq/scads/criteria.html for the standards. x❑ Yes ❑ No ❑ Not applicable 91. 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. XI-1 Rural ❑ Urban ❑ Natural 1 Aquatic ❑ Conservancy n Other 9g. What is the Washington Department of Natural Resources Water Type? [help] • Go to http:/lwww_dnr.wa.gov/BusinessPermits/Topics/ForestPracticesApplications/Pagesifp watertypinq.aspx for the Forest Practices Water Typing System. x❑ Shoreline n Fish ❑ Non-Fish Perennial n Non-Fish Seasonal 9h. Will this project be designed to meet the Washington Department of Ecology's most current stormwater manual? [help] • If No,provide the name of the manual your project is designed to meet. Yes ❑ No Name of manual: 91 Does the project site have known contaminated sediment? [help] • If Yes,please describe below. n Yes x❑ No 9j. If you know what the property was used for in the past, describe below. [help] State owned Aquatic Lands 9k. Has a cultural resource (archaeological) survey been performed on the project area? [help] • If Yes,attach it to your JARPA package. ❑Yes x❑ No ,,,,,rt„ '1 n„1 Page 12 of 16 10b. Indicate the permits you are applying for. (Check all that apply.) [help] LOCAL GOVERNMENT Local Government Shoreline permits: ❑ Substantial Development x❑ Conditional Use ❑Variance El Shoreline Exemption Type (explain): w AC- ` `t — S5 o C3) Other city/county permits: El Floodplain Development Permit ❑ Critical Areas Ordinance STATE GOVERNMENT Washington Department of Fish and Wildlife: x❑ Hydraulic Project Approval (HPA) ❑ Fish Habitat Enhancement Exemption —Attach Exemption Form Effective July 10, 2012, you must submit a check for$150 to Washington Department of Fish and Wildlife, unless your project qualifies for an exemption or alternative payment method below. Do not send cash. Check the appropriate boxes: ■41 $150 check enclosed. (Check# Attach check made payable to Washington Department of Fish and Wildlife. ❑Charge to billing account under agreement with WDFW. (Agreement# ) El My project is exempt from the application fee. (Check appropriate exemption) ❑ HPA processing is conducted by applicant-funded WDFW staff. (Agreement # ) El Mineral prospecting and mining. ❑ Project occurs on farm and agricultural land. (Attach a copy of current land use classification recorded with the county auditor,or other proof of current land use.) ❑ Project is a modification of an existing HPA originally applied for, prior to July 10, 2012. (HPA# Washington Department of Natural Resources: x❑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 FEDERAL GOVERNMENT United States Department of the Army permits (U.S. Army Corps of Engineers): ❑ Section 404 (discharges into waters of the U.S.) x❑ Section 10 (work in navigable waters) United States Coast Guard permits: ❑ General Bridge Act Permit ❑ Private Aids to Navigation (for non-bridge projects) JARPA Revision 2012.1 Page 14 of 16 I. 1 AGENCY USE ONLY US E g eeerrsrps Date received: I I ° I.a ; Town WASHINGTON STATE Seattle District ❑Application Fee Received; El Fee N/A Joint Aquatic Resources Permit g New Application; ❑Renewal Application Application (JARPA) [help] Type/Prefix#: a3 ;NaturE Use Code:74q1 LM Initials&BP-#:. O i 3 Li 9 < - RE Assets Finance BP#: New Application Number: Attachment E. Trust(s): ;County: Aquatic Use Authorization on AQRPIate#(s): Gov Lot#(s): Department of Natural Resources Tax Parcel#(s): (DNR)-managed aquatic lands [help] Complete this attachment and submit it with the completed JARPA form only if you are applying for an Aquatic Use Authorization with DNR. Call (360) 902-1100 or visit www. bit.ly/dnr aquatic lease for more information. • DNR recommends you discuss your proposal with a DNR land manager before applying for regulatory permits. Contact your regional land manager for more information on potential permit and survey requirements. You can find your regional land manager by calling (360) 902-110.0 or going to http://www.dnr.wa.ctov/Publications/aqr land manager map.pdf. [help] • The applicant may not begin work on DNR managed aquatic lands until DNR grants an Aquatic Use Authorization. • Include a $25 non-refundable application processing fee, payable to the "Washington Department of Natural Resources." (Contact your Land Manager to determine if and when you are required to pay this fee.) [help] DNR may reject the application at any time prior to issuing the applicant an Aquatic Use Authorization. [help] 1. Applicant Name (Last, First,Middle) Rose, Thomas C. 2. Organization Name Of applicable) 3. Which of the following applies to Applicant? Check one and,if applicable,attach the written authority—bylaws,power of attorney,etc. [help] ❑ Corporation x❑ Individual ❑ Limited Partnership ❑ Marital Community (Identify spouse): n General Partnership ❑ Government Agency ❑ Limited Liability Company ❑ Other(Please Explain): Home State of Registration: JARPA Attachment E Revision 2012.1 Page 1 of 2 Tag# MOORING BUOY AFFIDAVIT State of Washington SS:Mystery Bay mooring County of Jefferson Ekoty VS eR t, 6- ,residing at ge p.i 1A1,-)0 "to C( 3 q. 0 Ct-vk �-t iZ 1 tU. being first duly sworn on oath deposes and says:that I own a mooring buoy in Mystery Bay with the following description: Location: Latitude Lib-0537 Longitude"'laa,bs(ab ,NAD 83 DNR Authorization No.: Description of boat usually 5,„k �o z L . moored there: I �2' f 4 D r T Type of toilet facilities on boat(check one): I have no toilet facilities on the boat ® I have a portable toilet ❑ I have a holding tank with a dye tablet ❑ I have another type of toilet I certify under penalty of perjury that any boat moored to this buoy will • Not have overnight occupants • Not discharge any toilet waste into Mystery Bay • Not allow gray water(from showers,laundry or kitchen)or other substances to drain into Mystery Bay • Dispose of all toilet waste and gray water properly in upland sewage systems or at a boat pump-out station 7 Date t - 30 1 3 Name: I certify that I know or have satisfactory evidence that T'omO3 05e. is the person who appeared before me,and is the owner of the mooring buoy described above.I further certify that said person acknowledged the foregoing statement to be the free and voluntary act of said person. fh .� SWORN AND SUBSCRIBED before me this day of Apci aol3by r z`• y, �ti*' iA 0 4 NOTARY n, Notary Public Name: li PUBIC LIC �`�9 2-1-17 In and for the State of Washington 4kthOPWAO= My Commission expires: ���` r ao)� Appendix E January 27, 2010 Page 1 of 1 SDP13-00046 SDP13-00046 *DOE SHORELANDS OFFICE *DAN AFOE RICK MRAZ WDFW PO BOX 47775 332 EAST 5TH STREET, SUITE 100 OLYMPIA,WA 98504-7775 PORT ANGELES,WA 98362 SDP13-00046 SDP13-00046 *WSDOH SHELFISH AND WATER PROT. -MARK TOY *WA STATE DNR PO BOX 47829 BRIDGET KAMINSKI-RICHARDSON OLYMPIA,WA 98504-7284 5310 EAGLEMOUNT RD CHIMACUM,WA 98325 SDP13-00046 SDP13-00046 *WA STATE DEPT OF ARCH&HIST PRES PT GAMBLE S'KLALLAM TRIBE GRETCHEN KAEHLER 31974 LITTLE BOSTON RD. 1063 S. CAPITOL WAY, SUITE 106 KINGSTON,WA 98346 OLYMPIA,WA 98501 SDP13-00046 SDP13-00046 *JAMESTOWN S'KLALLAM TRIBE *SKOKOMISH TRIBE LEANN JENKINS KRIS MILLER LJENKINS @JAMESTOWNTRIBE.ORG 80 N TRIBAL CENTER RD SKOKOMISH,WA 98584 SDP13-00046 SDP13-00046 *SKOKOMISH TRIBE *SUQUAMISH TRIBE RANDY N LUMPER, M.E.S. ALISON O'SULLIVAN 541 NORTH TRIBAL CENTER ROAD PO BOX 498 SKOKOMISH,WA 98584 SUQUAMISH,WA 98392 SDP13-00046 SDP13-00046 *POINT NO POINT TREATY COUNCIL *US ARMY CORPS OF ENGINEERS CYNTIA ROSSI CENWS-OD-RG ATTN:J L GARDINER 7999 NE SALISH LANE P 0 BOX 3755 KINGSTON,WA 98346 SEATTLE,WA 98124-3755 April 25, 2014 THOMAS C ROSE SUSAN M ROSE PO BOX 233 NORDLAND WA 983580233 RE: SITE ADDRESS: 7180 FLAGLER RD MLA#: MLA13-00150 Dear THOMAS C ROSE: Jefferson County Department of Community Development staff has reviewed the application materials for the above project proposal and has determined that the application is substantially complete. Additional information needed for project review may be requested in writing by the Director or Project Planner. Please call the Department of Community Development if you have any questions. Sincerely, Department of Community Development Staff c: File April 25, 2014 Dear Reviewer, RE: MLA13-00150 Jefferson County has forwarded the attached application to you for review and comment because your agency is responsible for determining compliance with state and federal requirements or may otherwise be affected by the following proposal: Location: Comments must be received within fourteen (14) calendar days or by May 9, 2014. If no written response has been received within fourteen (14) days, your agency will be presumed to have no comments. If necessary, the UDC administrator may grant an extension of time for comment. Please contact at(360)379-4450 if you desire an extension of time or have additional questions regarding this proposal. Thank you in advance for your attention to this matter. Sincerely, c: , \\tidemark\data\forms\F_MLT_AppSubstComplt.rpt 4/25/2014 Map Output Page 1 of 1 ArcIMS HTML Viewer Ma• imiiiiii v• v1s }sNt 3l tk2f-Va,Gac i 1 S 1.1.1relriVJ 976200302', f -._ Legend Selected Features JC_Roads "8avedtlge r_n Parcel$FI ' � 2919 Aerial Photos 97620040# s , 8 976200406 976200401, ' 976200405 .,„ ? if' m #1711 0 4 976200402 Nnr,. •: •. Cur: Ca• „cr rxa Gl:, r � M _.. FOR INFORMATIONAL PURPOSES ONLY- efferson County does not attest to the accuracy of the data contained herein and makes no warranty with respect to its correctness or validity. Data contained in this map is limited by the method and accuracy of its collection.Wed Dec 18 10:57:23 2013 http://gisserver/servlet/com.esri.esrimap.Esrimap?ServiceName=ovmap&ClientV ersion=... 12/18/2013 Map Output Page 1 of 1 ArcIMS HTML Viewer Map • ,µ, I 1 r hitilt r 9762(x 304 976200202 r (1 , ■r ~ 476200301 Legend � Selected Features 1C_Roads /I/ I 91610C?20` 976200302 Parcels-H Shoreline Designation-Arc Conscrvan.-y,'Sutruruart Beveridge Ln "°° w.`. -tip° / Consarvant�Na�ura U Olen 916s20040`. q, Suburean i X 11 ISk7ntl ly �y Natural L ,v Conserwncy �� ,eav Nat urai'Suburban - y M 976200501 C ,/ 01 her f I Shoreline Designaticn- ---L-1 Poly il 976200402 1 ■ Natural ■ Conservancy '.1 Kr.--rasckata ..ti`cr.:.:riwurrcw,.c-a :x+-rece_a... 0Mill1.1611.11.140f1 Other FOR INFORMATIONAL PURPOSES ONLY- Jefferson County does not attest to the accuracy of the data contained herein and makes no warranty with respect to its correctness or validity. Data contained in this map is limited by the method and accuracy of its collection. Sun May 25 12:56:45 2014 I http://gisserver/servlet/com.esri.esrimap.Esrimap?ServiceName=ovmap&ClientVersion=4.... 5/25/2014 Parcel Details Page 1 of 2 *_ :._� Jefferson County Weather Station Database Tools Maps . Webcam -OT e County Info Deportme th. Seo'ci Parcel Number: 976200401 1 SEARCH Parcel Number: 976200401 Printer Friendly Owner Mailing Address: THOMAS ROSE SUSAN M ROSE PO BOX 233 NORDLAND WA983580233 Site Address: 42 BEVERIDGE LN NORDLAND 98358 Section: 33 School District: Chimacum (49) Qtr Section: NW1/4 Fire Dist: Chimacum (1) Township: 30N Tax Status: Taxable Range: 1E Tax Code: 211 Planning area: Marrowstone (3) Sub Division: NORDLAND Assessor's Land Use Code: 1100 - HOUSES (single units, non-farm) Property Description: NORDLAND I BLK 4 TAX 1,56,65(ENLGD BY I N20' OF TX 7) SUBJ/REST I COVT 562115/5637491 Click on photo for larger image. I -�:' _sue._►-' Permit Data Assessor Bldg Data Map Parcel Plats &Survev Septic Monitoring Info Tax, A/V Sales Info Jefferson County HOME I COUNTY INFO I DEPARTMENTS I SEARCH }l Best viewed with Microsoft Internet Explorer 6.0 or later http://www.co j efferson.wa.us/assessors/parcel/parceldetail.asp?Parcel_NO=976200401 12/18/2013 Parcel Details Page 2 of 2 Via,:. Windows - Mac http://www.co.j efferson.wa.us/assessors/parcel/parceldetail.asp?Parcel_NO=976200401 12/18/2013 Map Output Page 1 of 1 ArcIMS HTML Viewer Ma• 9,76200304 9/UV-VW 9tb2.x)306 Oki r -'1a Legend Selected Features � r :..Beveddge JC_Roads Parcels-H DMR Water Bodies 9/624X22401 ■ c ■ N • s II No Oas+gnatwn 976200406 0: 976200403 07620(moi 976200:0:1 i1+r.�xv�ckixi✓r:e4rvriCoso corm�arv0eiC43 0 ON00111111111111111111111144'3311 FOR INFORMATIONAL PURPOSES ONLY- efferson County does not attest to the accuracy of the data contained herein and makes no warranty with respect to its correctness or validity. Data contained in this map is limited by the method and accuracy of its collection.Wed Dec 18 10:42:54 2013 III http://gisserver/servlet/com.esri.esrimap.Esrimap?ServiceName=ovmap&ClientVersion=... 12/18/2013 Map Output Page 1 of 1 ArcIMS HTML Viewer Map 1' r "/, 976204361 '416i CAU :'I /{ 976200301 / • }! 111620020" �7i.1 'k 1, l' ,f Lege nd Selected feature i / i / JC_Roads ._.. Beveridge Ln. =' , C ParCals.l 1 1 / � n Sails*, (+ 97&2(X)101, r ! i' �r r.i CaS Iii t IO t j 976200601 976200405 \ ----11--- j t . 476200402 thiC r S7620060 41xa.7ar(kdt7jG 1o'iCo.RyColvdSeromsGIS ) 0 "5'311 FOR INFORMATIONAL PURPOSES ONLY- Jefferson County does not attest to the accuracy of the data contained herein and makes no warranty with respect to its correctness or validity. Data contained in this map is limited by the method and accuracy of its collection.Wed Dec 18 10:46:21 2013 http://gisserver/servlet/com.esri.esrimap.Esrimap?ServiceName=ovmap&ClientVersion=... 12/1 8/20 13 Map Output Page 1 of 1 ArcIMS HTML Viewer Map 9 e6.20::.3.9,1 9+t,.i..::{:■if.:.i 7/4.__ _ / 976200301 SI t ---------- , , , ! i if 9762tt3Xr2 Legend 1 ' -, Selected Features L JC_Roads 7r— - - -Beveridge Ln IParcels-H Heritage Points ( 4 - 9. 4‘,. V ,,.., ,.: .:' ^• 1 Ce °I 9 MAX:40', Ataib vvV- 9/62005Q3 114a,:ro,and tro...o.rx..rt Ctli(tie Cow:"'''..a. wt.GG Orsimmomonnemm ism FOR INFORMATIONAL PURPOSES ONLY- Jefferson County does not attest to the accuracy of the data contained herein and makes no warranty with respect to its correctness or validity. Data contained in this map is limited by the method and accuracy of its collection.Wed Dec 18 10:46:50 2013 1 http://gisserver/servlet/com.esri.esrimap.Esrimap?ServiceName=ovmap&ClientVersion=... 12/18/2013 Map Output Page 1 of 1 ArcIMS HTML Viewer Map yr tra3C•1 9?t2..cx:,2Y Legend Selected Features J C_Rca d s Beveridge Ln .. Parcels-H Priority Habitats and Species 9762(1a01 476209445 7 rf+ UlF<Y l.mo2 ( t ckxl':re,(4cr:m Casey CO.f.:r ua•1'ca,G,3 r;1111= 53t1 FOR INFORMATIONAL PURPOSES ONLY- Jefferson County does not attest to the accuracy of the data contained herein and makes no warranty with respect to its correctness or validity. Data contained in this map is limited by the method and accuracy of its collection.Wed Dec 18 10:47:16 2013 http://gisserver/servlet/com.esri.esrimap.Esrimap?ServiceName=ovmap&ClientVersion=... 12/18/2013 Map Output Page 1 of 1 ArcIMS HTML Viewer Ma• 7 , /1 LIMMIlli • 't 976200302 a Legend Pr,' selected Features n JC Roads j Beveridge In Parcels-H ■ Wetlands I 976200•01 ■ J 1 ta _ I 976200601 cn d_t (k7+x_ E 1 UfFtY1_„,,,1 NYas•rm.<d T.ecr•:ri Co.x'h•Ccrrra c,vcx..Gtr, 0 islowimm='9A11 FOR INFORMATIONAL PURPOSES ONLY- Jefferson County does not attest to the accuracy of the data contained herein and makes no warranty with respect to its correctness or validity. Data contained in this map is limited by the method and accuracy of its collection.Wed Dec 18 10:47:32 2013 http://gisserver/servlet/com.esri.esrimap.Esrimap?ServiceName=ovmap&ClientVersion=... 12/18/2013 Map Output Page 1 of 1 ArcIMS HTML Viewer Map 97P24304 4+e2etkIb_e ? , 1 4 97K524Q30r 0 b{ei4f,102i Y 916200.102 Legend �' Selected Features e JC_Roads Beveridge Ln „ Parcels-H r Seismic Hazard . inr.M i tV c phi_,..∎'' K N _,;F2rr..105 414.",raa l:_;.,1.01 Coro.Cord°rs-rt c,Is Q isi=====`.6311 FOR INFORMATIONAL PURPOSES ONLY- Jefferson County does not attest to the accuracy of the data contained herein and makes no warranty with respect to its correctness or validity. Data contained in this map is limited by the method and accuracy of its collection.Wed Dec 18 10:47:52 2013 http://gisserver/servlet/com.esri.esrimap.Esrimap?ServiceName=ovmap&ClientV ersion=... 12/18/2013 Map Output Page 1 of 1 ArcIMS HTML Viewer Ma• / 978200304 9{62Yts sr /_______ ±. _ ihmoi. / 976200301 d A � +lrs�ltiRl+ t 976200201 976200302 Legend n Selected Features ,*,! JC_Roads TBevef9eLn Parcels H i FEMA FIRMS al y{61{ pf ■ A mil ■ Other I( tO 976200601 ( tt 97620 MC4 I w 976200406 1 Me=randod uy 1eMr ri Casty Gears SerVOM GIS n INEMIONIMEMEt'Sail FOR INFORMATIONAL PURPOSES ONLY- efferson County does not attest to the accuracy of the data contained herein and makes no warranty with respect to its correctness or validity. Data contained in this map is limited by the method and accuracy of its collection.Wed Dec 18 10:48:14 2013 0 (c') http://gisserver/servlet/com.esri.esrimap.Esrimap?ServiceName=ovmap&ClientVersion=... 12/18/2013 Map Output Page 1 of 1 ArcIMS HTML Viewer Ma• s 9l624tb??42 '- Legend Selected Features ir JC_Roads Parcels-H Critical Aquifer Recharge 9?6a'ONO' :� Areas I I SARPA•SJ ,: El SUSC . III SARPA (#( I I SARPA+UNK {ti I I 4111233! , Mx!,:ravdd�:_e�"c-su.1Curry C.•e-a SCrvcx, GIS (.. FOR INFORMATIONAL PURPOSES ONLY- efferson County does not attest to the accuracy of the data contained herein and makes no warranty with respect to its correctness or validity. Data contained in this map is limited by the method and accuracy of its collection.Wed Dec 18 10:48:37 2013 http://gisserver/servlet/com.esri.esrimap.Esrimap?ServiceName=ovmap&ClientVersion=... 12/18/2013 Map Output Page 1 of 1 ArcIMS HTML Viewer Map 9/6,100:9:91 9 P6200202 _ r 976200301 1 976200201 Legend Selected Features ' JC_Roads 6e,;eridge Ln I Parcels-H Wells-Chloride . 106 or'ass .... * ao'.wean 100 and 200 * 200w higher 47�rZ 1.261Q4 476Xyy:39Y a i t}r432.:YA.y u,_z_ 1-2 Max:aurdad lr-chcrsui Curry Curry G'0 r0 ?.:■+it FOR INFORMATIONAL PURPOSES ONLY- Jefferson County does not attest to the accuracy of the data contained herein and makes no warranty with respect to its correctness or validity. Data contained in this map is limited by the method and accuracy of its collection.Wed Dec 18 10:48:57 2013 http://gisserver/servlet/com.esri.esrimap.Esrimap?ServiceName=ovmap&ClientV ersion=... 12/18/2013 Map Output Page 1 of 1 ArcIMS HTML Viewer Map• _ ,Z. yam. I' Legend Selected Features JC_Roads Beveridge Ln Parcels-H Shoreline Slope Stability Stag c .:.:. I I Intc-mc�■alc Unslanr_' U n slat‹RMen!Lande de U rt stark Oia Lantls.d• IMoadrJ 47 Msr:aen•-dcd 7r' c+Cr c rt Ca"Grr,a,Da, tits 4 t ,";a3d't FOR INFORMATIONAL PURPOSES ONLY- Jefferson County does not attest to the accuracy of the data contained herein and makes no warranty with respect to its correctness or validity. Data contained in this map is limited by the method and accuracy of its collection.Wed Dec 18 10:49:20 2013 http://gisserver/servlet/com.esri.esrimap.Esrimap?ServiceName=ovmap&ClientV ersion=... 12/18/2013 Map Output Page 1 of 1 5a ArcIMS HTML Viewer Ma• 6200304 WEE r 9r } 9162UC204::: CMS f Legend ''; Selected Features a JG_Roads Parcels-H SIPZ 9:6100,10/ Ai Ms*SIM ■ 91tph R+sR SMZ nCoastal SNPZ 91621. (16 MEMO C/3 9r82r.X.4406 916200402' MOM �l.uv.s s l:n'.cr4rs+si tier; Curmx u,-,ViVr.G15 FOR INFORMATIONAL PURPOSES ONLY- efferson County does not attest to the accuracy of the data contained herein and makes no warranty with respect to its correctness or validity. Data contained in this map is limited by the method and accuracy of its collection.Wed Dec 18 10:49:50 2013 http://gisserver/servlet/com.esri.esrimap.Esrimap?ServiceName=ovmap&ClientVersion=... 12/18/2013 Map Output Page 1 of 1 ArcIMS HTML Viewer Map r i Legend Selected Features J C_Roads Parcels-H County Zoning MPR SF Tracts Rural Resgento]1:5 Rural Reselentol 1:19 Rural Residential 1:20 97620030' MPR Single Family __... ._... ■ M PR MuM!family M PR-Resort Complex u?g2ry;2,�r Parks and Rocroatwn t?/62_+_5.)2 MPR.Oxon Spaces ■ R rat Forest ■ Commarciai Forest Beveridge In In hoot mg Forest Heavy Industril ONSAXMOT Airport CPF ■ M PR Village Center ▪ AP 1:20 ■ Rural Vntaga Canter ■ Reseu roe Based Intl. Lign1 Indust nal MPR-Rocreatan •��ry�a��.�;� Wash Mgml iPF LOA rn +62,:t 42,5 Lit 111\ 1111 Crossroads-CC Crossroads,NC 9/62CC•1O2 AL 1:20 UGA-Urtian Commercial UGA-Urban Light Industrial Nmrsiraednd try.ic?kari Corny Cotta firrcxfr.GtS 0 Nweemeineenesee t53H UGA.MOR UGA•II OR UGA-Pu blic UGA LOR UGA-Va:tlor Oriented Commercial MPR-ORN Bannon CF,00'M RLO Commercial Forest Mineral Resou roe Overlay FOR INFORMATIONAL PURPOSES ONLY- Jefferson County does not attest to the accuracy of the data contained herein and makes no warranty with respect to its correctness or validity. 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A a' .:-..Ga°� _ 5 ` F 8$8 a ,, — o C_ o ' 3 am• w .. .. xxx w2 € , a r a� ° 8° °y oio ° 2 2 0 m 6'86 j a o 5 � q a<u ° 5 < QA a ' s F§ g3 °g 2o V 8 Wa2 N — Ilrlfilli ° IS i a y*G** j91fit. g I ,,,b1,..,. .-e,§ %X U T X m a �G Q °�K rc S N 84. ''; O .. b V F O p g— '' .. . f 0: w .:.: 1.q1-4!w — <- ~ - w.2 O _ o_8 i<$Vii¢ u J S 1. CASES, FINDING, CONDITIONS, PERMISSIONS FOR Parcel 976200401 Printed: December 13, 2013 Gait's Name Review Type Status Planner BLD07-00241 ROSE F Application Received: 5/18/2007 Permit Issued/Case closed: 5/18/2007 Case Finaled: 4/21/2008 A/G 120 GAL PROP TANK,WALL HEATER&GAS PIPE No findings, conditions, or permissions found. BLD94-00856 MALONEY F Application Received: 12/21/1994 Permit Issued/Case closed: 12/21/1994 Case Finaled: 12/23/1994 Fuel Tank Remove(2) No findings, conditions, or permissions found. BLD96-00679 ROSE F Application Received: 10/31/1996 Permit Issued/Case closed: 11/1/1996 Case Finaled: 11/3/1997 propane tank installation No findings, conditions, or permissions found. SEP72-00099 MALONEY C Application Received: 7/21/1972 Permit Issued/Case closed: 7/21/1972 Case Finaled: Now filed w/SEP11-1 9 No findings, conditions, or permissions found. XMP95-00062 JOHNSON A Application Received: 11/8/1995 Permit Issued/Case closed: 11/9/1995 Case Finaled: repair existing bulkhead 1.) The proposal is consistent with Exemptons Section 3.402(1), (6)of the Jefferson-Port Townsend Shoreline Management Master Program.The proposal is not a substantial development. 2.) This approval pertains to Jefferson-Port Townsend Shoreline Management Master Program requirements only. The approval of any other agency with jurisdiction or any other required permits shall be obtained prior to undertaking the project. 3.) Work within the jurisdiction of the Shoreline Program other than described above shall receive separate review and approval from this office. 4.) No fill or other material may be placed in the waters or intertidal areas of Jefferson County. 5.) The proponent shall notify the Jefferson County Permit Center, Development Review Division 48 hours in advance prior to commencing construction in order to allow monitoring and ensure conformance with project conditions. FEP12-00141 NORDLAND GENERAL STORE ACT Mina Kwansa Application Received: 10/8/2012 Permit Issued/Case closed: 3/13/2013 Case Finaled: 1.) Potable water supply to be monitored in accordance with drinking water regulations per WAC 246-290. 2.) Potable water supply must be from an approved source. 3.) Operations and Monitoring inspection of the onsite sewage system is required annually and report submitted to Jefferson County Health. 4.) Waste water system must be maintained in accordance with WAC 246-272A and Jefferson County Ordinance 8.05. 5.) Approved for Grocery. PRJ11-00045 MLA11-00046 ROSE P Application Received: 3/8/2011 Permit Issued/Case closed: Case Finaled: No findings, conditions, or permissions found. SDP11-00010 MLA11-00046 ROSE I A Application Received: 3/8/2011 Permit Issued/Case closed: 4/18/2011 Case Finaled: SHORELINE EXEMP I ION 1-01i SEPTIC APPLICATION 1.) The proposal is to repair and upgrade an existing septic system to serve existing development. A new septic tank and a portion of the transport line serving the Nordland Store are located within shoreline jurisdiction. The drainfield and reserve area are located outside of shoreline jurisdiction. On April 15,2011 Jefferson County Environmental Health staff notified Jefferson County DCD staff that the existing system at this location is failing and there is surfacing sewage. 2.) The Development Review Division finds that this proposal is consistent with Shoreline Master Program JCC 18.25.090 (6)and is consequently exempt from the substantial development permit(SDP)requirements. Exemptions from the substantial development permit requirements do not exempt a proposed development from compliance with the applicable policies and standards of the Shoreline Master Program or other applicable Federal, State, or local permit or license requirements. \\tidemark\data\forms\R_MLT_Parcel_Cond.rpt 12/13/2013 Page 1 of 8 Cases Name Review Type Status Planner 3.) The septic tank and a portion of the septic transport line is within the Fish and Wildlife Habitat Conservation Area (FWHCA)buffer. This application is consistent with JCC18.22.250(2)(b)which states, "Construction of sewer lines or • on-site sewage systems are not permitted in FWHCAs or their buffers, except that they may be permitted in a buffer area when the applicant demonstrates it is necessary to meet state and/or local health code requirements; there are no other practicable alternatives available; and construction meets the requirements of this article.Joint use of the sewer utility corridor by other utilities may be allowed." 4.) The application was reviewed by the Jefferson County Department of Community Development staff on April 18, 2011 for the potential presence of Environmentally Sensitive Areas(ESAs)under the provisions of the Unified Development Code(UDC). After an initial Geographic Information Systems mapping review, the following ESAs were confirmed to be present on the subject property: Shoreline Designation: Conservancy, Bald Eagle Habitat Area, Special Aquifer Recharge Protection Area(SARPA), Seawater Intrusion Protection Zone(SIPZ): High Risk. 5.) Aquifer Recharge Areas in Jefferson County are characterized by porous geological formations that allow percolation of the surface water into the soils and the underlying zone of saturation. Aquifers are geologic formations that contain sufficient saturated permeable material to yield significant quantities of water to wells and springs. Aquifers serve as the source of drinking water within most of the rural portions of Jefferson County. 6.) Critical Aquifer Recharge Areas are defined as Seawater Intrusion Areas, and Special Aquifer Recharge Protection Areas and the following land uses located within Susceptible Aquifer Recharge Areas (1)All Industrial Land Uses(2) All Commercial Uses(3)All Rural Residential Land Uses requiring a Discretionary Use or Conditional Use Permit(4) All Rural Residential Land Uses with nonconforming uses that would otherwise require a Discretionary Use or Conditional Use Permit(5) Unsewered Planned Rural Residential Developments (6) Unsewered residential development with gross densities greater than one unit per acre. All of the above listed uses shall be subject to the applicable requirements and standards of the Jefferson County Unified Development Code. 7.) Marine shorelines and islands are susceptible to a condition that is known as seawater intrusion. Seawater intrusion is a condition in which the saltwater/freshwater interface in an aquifer moves inland so that wells drilled on upland areas cannot obtain freshwater suitable for public consumption without significant additional treatment and cost. Maintaining a stable balance in the saltwater/freshwater interface is primarily a function of the rate of aquifer recharge (primarily through rainfall)and the rate of groundwater withdrawals(primarily through wells).The Washington Department of Ecology is the agency with statutory authority to regulate groundwater withdrawal for individual wells in Jefferson County. New development, redevelopment, and land use activities on islands and in close proximity to marine shorelines in particular should be developed in such a manner to maximize aquifer recharge and maintain the saltwater/freshwater balance to the maximum extent possible by infiltrating stormwater runoff so that it recharges the aquifer. 8.) The parcel is located within a High Risk SIPZ(seawater intrusion protection zone)according to the County GIS map. There are mandatory measures identified in the Jefferson County Seawater Intrusion Policy(Resolution 44-22, effective September 23, 2002)that apply to well drilling proposals and building permit applications on existing lots of record. A High Risk SIPZ is defined as:areas within 1,000 feet of a groundwater source with a history of chloride analyses above 200 milligrams per liter(mg/L). 9.) To help prevent seawater from intruding landward into underground aquifers, all new development activity on Marrowstone Island, Indian Island and within 1/4 mile of any marine shoreline shall be required to infiltrate all stormwater runoff onsite. 10.) MANDATORY MEASURES OF HIGH RISK SIPZ: Water conservation measures: 1. Roof and other intercepted precipitation shall be routed to on-site detention ponds and/or other approved means and allowed to be released to the soil slowly. 2. Water collected from Storm water and roof catchments may be used for watering lawns and gardens. Unless catchment water has been treated to meet drinking water standards, there shall be no cross connections allowed between the potable supply and impounded water. 3. Water withdrawn from wells on each property shall not be used for watering of lawns and/or gardens. 4. Ground water withdrawn from each property shall be restricted to a rate of three(3)gallons per minute. 5. Installation of water conserving fixtures such as low flow toilets,faucets and shower restrictors and other water saving plumbing fixtures. 6. Landscaping plan(xeriscaping, native vegetation with minimal amounts of irrigation). Please NOTE that the above listed measures are not intended to be exhaustive, but rather is intended to be illustrative of the types of water conservation measures. \\tidemark\data\forms\R_MLT_Parcel_Cond.rpt 12/13/2013 Page 2 of 8 Cases Name Review Type Status Planner 11.) MANDATORY MEASURES FOR HIGH RISK SIPZ: 1. For proof of potable water on a building permit application, applicant must utilize DOH-approved public water system if available. 2. If public water is unavailable,a qualifying alternative system may be used as proof of potable water or an individual well may be used as proof of potable water subject to the following requirements: a. Variance from Chapter 173 WAC standards granted by Ecology per WAC 173-160-106 for a new groundwater well within 100 feet of a sea-salt water intrusion area per WAC 173-160-171 (i.e.,within 100 feet of a groundwater source showing chloride concentrations above 200mg/L or within 100 feet of the marine shoreline); or for an existing or proposed groundwater well not subject to an Ecology variance, applicant must provide evidence through a hydrogeologic assessment(relevant components of an Aquifer Recharge Area Report per UDC 3.6.10.e)of a reasonable probability that the subject aquifer will not be degraded by the proposed use of well. b. Installation of a flow meter. c. On-going well monitoring for chloride concentration. d. Submittal of flow and chloride data to the County per monitoring program. 3. If public water is unavailable, a qualifying alternative system may be used as proof of potable water. 12.) The project shall adhere to the Best Management Practices(BMPs)to control stormwater, erosion and sediment during construction. BMPs shall address permanent measures to stabilize soil exposed during construction, and in the design and operation of stormwater and drainage control systems. 13.) Jefferson County determined that this proposal is categorically exempt from review under the State Environmental Policy Act(SEPA)pursuant to WAC 197-11-800(3). 14.) The site plan as submitted with the septic permit application on March 8, 2011 has been reviewed for consistency under the UDC, and has been approved by Jefferson County Department of Community Development. Any modifications, changes, and/or additions to the stamped, approved site plan dated April 18, 2011 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 15.) This approval is for a repair and upgrade to an existing septic system only. Any future permits on this site are subject to review for consistency with applicable codes and ordinances and does not preclude review and conditions which may be placed on future permits. 16.) The parcel has been designated as Convenience Crossroads under the Jefferson County Comprehensive Land Use Map effective August 28, 1998. 17.) NOTICE: This permit does not excuse the proponent from complying with other local, state, and federal ordinances, regulations, or statutes applicable to the proposed development, but consistent with RCW 90.58. Development pursuant to this permit shall be undertaken subject to the applicable policies and performance standards of the Jefferson County Shoreline Management Master Program and the Jefferson County Unified Development Code. If during excavation or development of the site an area of potential archaeological significance is uncovered, all activity in the immediate area shall be halted, and the Administrator shall be notified at once. The Federal Endangered Species Act rules to protect threatened Chinook and Summer-run Chum salmon became effective on January 8, 2001. Bull trout have been listed as threatened since early 2000. Under the ESA, any person may bring lawsuit against any individual or agency that"takes"listed species(defined as causing harm, harassing, or damaging habitat for the listed species). In addition,the National Marine Fisheries Service can levy penalties. All areas in Jefferson County are included as"critical habitat"for a listed species. Development of property along any marine shoreline,freshwater shoreline, or floodplains could harm habitat if protective measures are not taken. To minimize the potential to damage habitat, all property owners developing adjacent to marine shoreline,freshwater shoreline, or floodplains are advised to do the following: -All development activities should avoid unstable slopes,wetlands, and forested areas near surface waters - Remove minimal vegetation for site development, especially large trees -Allow trees that have fallen into surface waters to remain there - Infiltrate stormwater from buildings and driveways onsite through drywells rather than discharging directly into surface waters or roadside ditches Any individual, group, or agency can bring suit for a listed species"taking",even if you are in compliance with Jefferson County development codes. The risk of a lawsuit against you can be reduced by consulting with a professional fisheries habitat biologist, and following the recommendations for site development provided by the biologist. For more information, contact the National Marine Fisheries Service in Seattle, or the U.S. Fish and Wildlife Service. 18.) The septic tank and a portion of the septic transport line is within the Fish and Wildlife Habitat Conservation Area (FWHCA)buffer. This application is consistent with JCC18.22.250(2)(b)which states, "Construction of sewer lines or on-site sewage systems are not permitted in FWHCAs or their buffers,except that they may be permitted in a buffer area when the applicant demonstrates it is necessary to meet state and/or local health code requirements; there are no other practicable alternatives available; and construction meets the requirements of this article.Joint use of the sewer utility corridor by other utilities may be allowed." \\tidemark\data\forms\R_MLT_Parcel_Cond.rpt 12/13/2013 Page 3 of 8 Cases Name Review Type Status Planner 19.) NOTICE: This permit does not excuse the proponent from complying with other local, state, and federal ordinances, regulations, or statutes applicable to the proposed development, but consistent with RCW 90.58. • Development pursuant to this permit shall be undertaken subject to the applicable policies and performance standards of the Jefferson County Shoreline Management Master Program and the Jefferson County Unified Development Code. If during excavation or development of the site an area of potential archaeological significance is uncovered,all activity in the immediate area shall be halted, and the Administrator shall be notified at once. The Federal Endangered Species Act rules to protect threatened Chinook and Summer-run Chum salmon became effective on January 8, 2001. Bull trout have been listed as threatened since early 2000. Under the ESA, any person may bring lawsuit against any individual or agency that"takes"listed species(defined as causing harm, harassing, or damaging habitat for the listed species). In addition,the National Marine Fisheries Service can levy penalties. All areas in Jefferson County are included as"critical habitat"for a listed species. Development of property along any marine shoreline,freshwater shoreline, or floodplains could harm habitat if protective measures are not taken. To minimize the potential to damage habitat, all property owners developing adjacent to marine shoreline,freshwater shoreline, or floodplains are advised to do the following: -All development activities should avoid unstable slopes,wetlands, and forested areas near surface waters -Remove minimal vegetation for site development, especially large trees -Allow trees that have fallen into surface waters to remain there - Infiltrate stormwater from buildings and driveways onsite through drywells rather than discharging directly into surface waters or roadside ditches The Federal Bald and Golden Eagle Protection Act requires landowners within 660 feet(1/8th of a mile)of an eagle nest to consult with the US Fish and Wildlife Service. This Eagle Act prohibits anyone from "taking"bald eagles. This federal law defines the term "take"and describes the possible legal consequences when a"take"occurs. Among other actions, "take" includes a disturbance of bald eagles or their habitat. Under federal law a permit may still be required for activities that impact bald eagles or their habitat. Contact the US Fish and Wildlife Service (http://www.fws.gov/pacific/eagle/)to learn more about how this law affects your project. Any individual,group, or agency can bring suit for a listed species"taking", even if you are in compliance with Jefferson County development codes. The risk of a lawsuit against you can be reduced by consulting with a professional fisheries habitat biologist, and following the recommendations for site development provided by the biologist. For more information, contact the National Marine Fisheries Service in Seattle, or the U.S. Fish and Wildlife Service. SEP11-00019 MLA11-00046 ROSE I F Application Received: 3/8/2011 Permit Issued/Case closed: 4/29/2011 Case Finaled: 11/29/2011 System serves the Store-7180 Hagler Rd, Home-42 Beveridge Ln. and AUU-62 Beveridge Ln. SEP72-99&SEP82-162 no longer valid and filed here 1.) This permit was issued to correct a violation of WAC 246-272A.The permit must be completed within 90 days of the date of issuance. 2.) Store use and capacity of this septic permit is intended for an employee only restroom and mop sink. Prior to any other uses, a licensed septic system designer will be required to justify and prove capacity in the system. 3.) H-The existing open ditch must be culverted as designed. 4.) H-Well to be decommissioned as per WAC 173-160-381 by licensed well driller. Contact Jefferson County Public Health for information on required applications and inspections.Verification of decommissioning to be provided to Public Health Department. 5.) H-This permit is granted based on the recorded RESTRICTIVE COVENANT combining lots to meet the minimum land area required under WAC 246-272A Onsite Sewage Code. COVENANT recorded under AFN 563749 6.) Septic tank and pump chamber to be water tight. Extra protection(i.e. Bentonite)to be used around inlet,outlet, and risers due to high water table. 7.) H -The existing water line that serves the ADU/SHOP must be re-routed 10 or more feet away from any septic component. Designer to verrify on record drawing 8.) H-Existing tank shall be properly abandoned. It shall be pumped and filled with clean fill. Documentation to be provided to Health Dept. prior to final. 9.) H-An asbuilt drawing and certification of completion by the designer is required prior to final approval. 10.) Setback to the decommissioned well is 10' minimum \\tidemark\data\forms\R_MLT_Parcel_Cond.rpt 12/13/2013 Page 4 of 8 Cases Name Review Type Status Planner 11.) H- AS PER WAC 246-272AAND JEFFERSON COUNTY CODE 8.15 ALL ONSITE SEWAGE SYSTEMS REQUIRE THAT A RESTRICTIVE COVENANT REGARDING THE MONITORING OF THE ONSITE SEPTIC SYSTEM BE • RECORDED TO THE PROPERTY TITLE. THE PROPERTY OWNER SHALL ASSURE THAT MONITORING IS PROVIDED BY AN APPROVED ENTITY AT THE FREQUENCY DEFINED PER STATE WAC 246-272AAND JEFFERSON COUNTY CODE 8.15 AS ADOPTED OR AMENDED. A COPY OF THE RECORDED OPERATIONS AND MONITORING AGREEMENT IS REQUIRED PRIOR TO FINAL APPROVAL OF THE SEWAGE DISPOSAL PERMIT 12.) Health Dept. required to observe pressure test with system designer when system fully installed/complete, 48 hours notice to be provided for scheduling. 13.) Designer must be contacted prior to start of construction and for inspections during installation. DESIGNER IS REQUIRED TO DO A PRECOVER INSPECTION ON ALL TYPES OF SYSTEMS. 14.) Notification of the start of construction shall be faxed or emailed to Jefferson County Public Health ONE WORKING DAY prior to start. 15.) Approval/issuance of a sewage disposal permit does not guarantee the approval of other development or a building permit on this site. Compliance with other Jefferson County and Washington State Codes is required. 16.) Divert all sources of drainage, including roof drains away from septic tank and drainfield area. 17.) Approval of this permit does not assure the septic system has capacity for all uses allowed by current code. 18.) All construction and development activities must comply with all permit conditions,Washington State and Jefferson County Codes and Recommended Standards and Guidance documents in effect when the permit is issued. 19.) Before final approval is given,the designer shall provide an operations and maintenance manual to the property owner and the Health Department.The manual must instruct the owner of the on site sewage system on the ways to properly operate and maintain all components of the system. 20.) Dry season installation required. 21.) Contact designer prior to installation for staking of drainfield area. 22.) Approval of this sewage disposal permit does not preclude the permit holder from complying with the Unified Development Code for other/future development on the site. 23.) This onsite sewage system is designed for domestic strength wastewater only. Disposal of any other waste strength is considered a violation of this permit. 24.) This approval is valid only with a connection to an approved public water supply. 25.) The project shall adhere to the Best Management Practices (BMPs)to control stormwater, erosion and sediment during construction. BMPs shall address permanent measures to stabilize soil exposed during construction, and in the design and operation of stormwater and drainage control systems. 26.) Installation shall comply with the Bald Eagle Site Management Plan signed by the property owner on March 30, 2011. BLD11-00065 MLA11-00055 ROSE I F Application Received: 3/22/2011 Permit Issued/Case closed: 5/16/2011 Case Finaled: 3/20/2012 CONVERT EXISTING PEKMI I I ED GARAGE TO ADU(UNPERMI I FED) 1.) The application was reviewed by the Jefferson County Department of Community Development staff on May 12, 2011 for the potential presence of Environmentally Sensitive Areas(ESAs)under the provisions of the Unified Development Code(UDC). After an initial Geographic Information Systems mapping review,the following ESAs were confirmed to be present on the subject property: Eagle Habitat; Seismic Hazard; SARPA; High Risk SIPZ. 2.) Geologically Hazardous Areas in Jefferson County are characterized by slope, soil type,geologic material, and groundwater that may combine to create problems with slope stability, erosion, and water quality during and after construction or during natural events such as earthquakes or severe rainstorms. 3.) The parcel is located within a High Risk SIPZ(seawater intrusion protection zone)according to the County GIS map. There are mandatory measures identified in the Jefferson County Seawater Intrusion Policy(Resolution 44-22, effective September 23, 2002)that apply to well drilling proposals and building permit applications on existing lots of record. A High Risk SIPZ is defined as: areas within 1,000 feet of a groundwater source with a history of chloride analyses above 200 milligrams per liter(mg/L). \\tidemark\data\forms\R_MLT_Parcel_Cond.rpt 12/13/2013 Page 5 of 8 Cases Name Review Type Status Planner 4.) MANDATORY MEASURES OF HIGH RISK SIPZ: Water conservation measures: 1. Roof and other intercepted precipitation shall be routed to on-site detention ponds and/or other approved means and allowed to be released to the soil slowly. 2. Water collected from Storm water and roof catchments may be used for watering lawns and gardens. Unless catchment water has been treated to meet drinking water standards,there shall be no cross connections allowed between the potable supply and impounded water. 3. Water withdrawn from wells on each property shall not be used for watering of lawns and/or gardens. 4. Ground water withdrawn from each property shall be restricted to a rate of three(3)gallons per minute. 5. Installation of water conserving fixtures such as low flow toilets,faucets and shower restrictors and other water saving plumbing fixtures. 6. Landscaping plan(xeriscaping, native vegetation with minimal amounts of irrigation). Please NOTE that the above listed measures are not intended to be exhaustive, but rather is intended to be illustrative of the types of water conservation measures. 5.) Aquifer Recharge Areas in Jefferson County are characterized by porous geological formations that allow percolation of the surface water into the soils and the underlying zone of saturation. Aquifers are geologic formations that contain sufficient saturated permeable material to yield significant quantities of water to wells and springs. Aquifers serve as the source of drinking water within most of the rural portions of Jefferson County. 6.) Critical Aquifer Recharge Areas are defined as Seawater Intrusion Areas, and Special Aquifer Recharge Protection Areas and the following land uses located within Susceptible Aquifer Recharge Areas(1)All Industrial Land Uses(2) All Commercial Uses(3)All Rural Residential Land Uses requiring a Discretionary Use or Conditional Use Permit(4) All Rural Residential Land Uses with nonconforming uses that would otherwise require a Discretionary Use or Conditional Use Permit(5) Unsewered Planned Rural Residential Developments(6) Unsewered residential development with gross densities greater than one unit per acre. All of the above listed uses shall be subject to the applicable requirements and standards of the Jefferson County Unified Development Code. 7.) The project shall adhere to the Best Management Practices(BMPs)to control stormwater,erosion and sediment during construction. BMPs shall address permanent measures to stabilize soil exposed during construction, and in the design and operation of stormwater and drainage control systems. 8.) The applicant is proposing to create or add zero square feet of impervious surface and zero square feet of land disturbing activities. JCC 18.30.060 and 18.30.070 require your proposal comply with Minimum Requirement#2 (Construction Stormwater Pollution Prevention)of the Department of Ecology Stormwater Management Manual for Western Washington to control stormwater, erosion and sediment during construction. BMPs shall address permanent measures to stabilize soil exposed during construction, and in the design and operation of stormwater and drainage control systems. 9.) Jefferson County determined that this proposal is categorically exempt from review under the State Environmental Policy Act(SEPA)pursuant to WAC 197-11-800(1)(b)(i). 10.) The site plan as submitted with the Building Permit application on March 22, 2011 has been reviewed for consistency under the UDC, and has been approved by Jefferson County Department of Community Development. Any modifications, changes, and/or additions to the stamped,approved site plan dated May 12, 2011 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 11.) This approval is for a Change of Use to Convert a Permitted Existing Garage to an Accessory Dwelling Unit(ADU) only. Any future permits on this site are subject to review for consistency with applicable codes and ordinances and does not preclude review and conditions which may be placed on future permits. 12.) The parcel has been designated as Convenience Crossroads under the Jefferson County Comprehensive Land Use Map effective August 28, 1998. \\tidemark\data\forms\R_MLT_Parcel_Cond.rpt 12/13/2013 Page 6 of 8 Cases Name Review Tvpe Status Planner 13.) NOTICE: This permit does not excuse the proponent from complying with other local, state, and federal ordinances, regulations, or statutes applicable to the proposed development, but consistent with RCW 90.58. Development pursuant to this permit shall be undertaken subject to the applicable policies and performance n Shoreline Management Master Program and the Jefferson County Unified standards of the Jefferson County g 9 ty Development Code. If during excavation or development of the site an area of potential archaeological significance is uncovered, all activity in the immediate area shall be halted, and the Administrator shall be notified at once. The Federal Endangered Species Act rules to protect threatened Chinook and Summer-run Chum salmon became effective on January 8,2001. Bull trout have been listed as threatened since early 2000. Under the ESA, any person may bring lawsuit against any individual or agency that"takes"listed species(defined as causing harm, harassing,or damaging habitat for the listed species). In addition,the National Marine Fisheries Service can levy penalties. All areas in Jefferson County are included as"critical habitat"for a listed species. Development of property along any marine shoreline,freshwater shoreline, or floodplains could harm habitat if protective measures are not taken. To minimize the potential to damage habitat, all property owners developing adjacent to marine shoreline,freshwater shoreline, or floodplains are advised to do the following: -All development activities should avoid unstable slopes,wetlands, and forested areas near surface waters -Remove minimal vegetation for site development, especially large trees -Allow trees that have fallen into surface waters to remain there -Infiltrate stormwater from buildings and driveways onsite through drywells rather than discharging directly into surface waters or roadside ditches Any individual, group, or agency can bring suit for a listed species"taking , even if you are in compliance with Jefferson County development codes. The risk of a lawsuit against you can be reduced by consulting with a professional fisheries habitat biologist, and following the recommendations for site development provided by the biologist. For more information, contact the National Marine Fisheries Service in Seattle, or the U.S. Fish and Wildlife Service. 14.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 15.) Not more than 2 unlicensed vehicles shall be stored on any lot unless totally screened from view of neighboring dwellings and rights-of-way. Such screening shall meet all applicable performance and development standards specific to the district in which the storage is kept, and shall be in keeping with the character of the area. Screening shall meet the requirements of Chapter 18.30 JCC. Outdoor storage of 3 or more junk motor vehicles is prohibited except in those districts where specified as an automobile wrecking yard or junk(or salvage)yard and allowed as a permitted use in Table 3-1 or Chapter 18.18 JCC, and such storage shall meet the requirements of JCC 18.20.100, Automobile wrecking yards and junk(or salvage)yards. In no case, shall any such junk motor vehicles be stored in a critical area. 16.) Maximum lot coverage is not to exceed 60%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 17.) The building height is not to exceed 35 feet. 18.) Building Setback from Beveridge Lane is no less than 20 feet. Side and rear setbacks are no less than 5 feet. 19.) The applicant shall fully adhere to all conditions and requirements of the eagle habitat management plan. PRJ11-00051 MLA11-00055 ROSE P Application Received: 3/22/2011 Permit Issued/Case closed: Case Finaled: CONVERT EXISTING PEKMI I I ED GARAGE TO ADU(UNPERMITTED) No findings,conditions, or permissions found. RAP11-00015 MLA11-00055 ROSE i F Application Received: 3/22/2011 Permit Issued/Case closed: 5/16/2011 Case Finaled: 11/1/2011 RAP&911 -Beveridge Ln 1.) The Applicant may install a private road approach to#42 Beveridge Ln. at mile post 0.04 right. 2.) The access must accommodate a 10 to 16 foot wide driveway with 10-25 foot approach radius. An approach culvert is not necessary at this location at this time; however, if drainage becomes a problem here in the future the county reserves the right to require one. 3.) The grade of the approach shall follow the crown of the road for 20 feet from the edge of the road and be no greater than 2%and, be such that no surface water is directed onto the county road. 4.) The applicant must place a minimum of 2 inches of crushed surfacing to the right-of-way line. 5.) The applicant shall be responsible for maintaining all vegetation on their property to maintain the minimum sight distance requirement for this location. 6.) The Applicant must contact the Public Works Department at 360-385-9160 for a final inspection. \\tidemark\data\forms\R_MLT_Parcel_Cond.rpt 12/13/2013 Page 7 of 8 Cases Name Review Type Status Planner SDP13-00046 MLA13-00150 ROSE P Application Received: 11/19/2013 Permit Issued/Case closed: Case Finaled: MOORING BUOY IN MYSTERY-BAY, SDP No findings, conditions, or permissions found. OTH11-00007 ROSE CLS Application Received: 3/8/2011 Permit Issued/Case closed: Case Finaled: 1/24/2012 WET SEAS EVAL No findings, conditions, or permissions found. RAP11-00019 ROSE F Application Received: 4/11/2011 Permit Issued/Case closed: 5/16/2011 Case Finaled: 11/1/2011 RAP&911 FOR ADU-Beveridge Ln 1.) The Applicant may install a private road approach to#62 Beveridge Ln. at mile post .065 right. 2.) The access must accommodate a 10 to 16 foot wide driveway with 10-25 foot approach radius. An approach culvert is not necessary at this location at this time; however, if drainage becomes a problem here in the future the county reserves the right to require one. 3.) The grade of the approach shall follow the crown of the road for 20 feet from the edge of the road and be no greater than 2%and, be such that no surface water is directed onto the county road. 4.) The applicant must place a minimum of 2 inches of crushed surfacing to the right-of-way line. 5.) The applicant shall be responsible for maintaining all vegetation on their property to maintain the minimum sight distance requirement for this location. 6.) The Applicant must contact the Public Works Department at 360-385-9160 for a final inspection. SOM72-00099 ROSE RCR Application Received: Permit Issued/Case closed: 2/7/2013 Case Finaled: serves Nordland Store-7180 Flagler Rd, main res.-#42 Beveridge Ln,ADU-#62 Bev. Ln No findings, conditions, or permissions found. SEP82-00162 MALONEY C Application Received: 3/3/1982 Permit Issued/Case closed: 3/18/1982 Case Finaled: 3/18/1982 Now filed w/SEP11-19 Incinerating toilet no longer in the building No findings, conditions, or permissions found. USR11-00044 ROSE F Application Received: 9/27/2011 Permit Issued/Case closed: 10/5/2011 Case Finaled: DECOMMISSION WEILADDRESS WAS LISTED AS 7180 FLAGLER RD-NORLAND No findings, conditions, or permissions found. \\tidemark\data\forms\R_MLT_Parcel_Cond.rpt 12/13/2013 Page 8 of 8 } C: 0) H 0) = 0) Cr U... Z LL ` 0 H O N- I—I -) L17 O a) — —. Cr) - w 0 -v - CO J O O L CD -0 X C= 'O +, CO Z C U C = I-I LU 0 O CA ++ V H CO CO I .. O L C L CD ti CC .0 C.) 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CO •— -- co a) F- I- X 4- I- co a) 4- XE )E F- co_ 1■,(3 'S — t-lk JEFFERSON COUNTY k ef.4�� DEPARTMENT OF COMMUNITY DEVELOPMENT `' '4 621 Sheridan Street ' Port Townsend • Washington 98368 360/379-4450 • 360/379-4451 Fax p� vwvw.co.jefferson.wa.us/commdevelopment Master Permit Application MLA: Ir- '—• 1 3 'Project Description (include separate sheets as necessary): Ro5e moo RING. --ivc,11 1 IAA`t5"-e,-1 di)t4-1 Tax Parcel Number: q 1 h 2.00 0 '1 0 1 Property Size: I A t R e (acres/square feet) Site Address and/or Directions to Property: 1 t iso 1 L.It GrL.ta '1�-D. N o Ft-oL. 14 i.$a � W W . 9 t 3 Sg Property Owner(s)of Record: "Nt o vin A s 1 $V SA 10 12 0 SE. Telephone: 340 — 31 et-S'-1 n I Fax: email: Yo Se P 0150% 'ds.rof Mailing Address: E' 0 . 'Es e x 2.33 N o 1a-DL.rk 0 W Or - ct e 3 ST Applicant/Agent(if different from owner): Telephone: Fax: -u. _ Mailing Address: ; .. r" ("-` r- I �r s What kind of Permit? (Check each box that applies ❑ Lot or Road Segregat-•rf __. ['Building ❑ Critical Areas Stewart h,i. Flan , El Demolition Permit ❑Variance (Minor, Maj.rl,'r,".as e c o cnUse) 'i ❑ Single Family ❑ Garage Attached/Detached ❑ Conditional Use[C(a), (d),l or *� 11' ` I ❑ Manufactured Home ❑ Modular 0 Discretionary"D"or and Use Classification ' ❑ Commercial* ❑ Special Use(Essenti:l Public Fa DA.COUNTY ❑ Change of Use ❑ Boundary Line AdjustmentpFpT OF COMMUNITY DEVF n�rc;�T ❑ Address ❑ Road Approach El Short Plat`* L._, --- ❑ Home Business ❑ Cottage Industry ❑ Binding Site Plan** ❑ Propane ❑ Long Plat** • ❑ ::,ign .. -0 Planned kurai Residential Development(PRRD)/Amendments** ❑Allowed"Yes"Use Consistency Analysis ❑ Plat Vacation/Alteration** ❑ Stormwater Management C Shoreline Master Program Exemption/Permit Revisions** ❑ Site Plan Approval Advance Determination(SPAAD)* ❑ Shoreline Management Substantial Development** ❑ Temporary Use ❑ Shoreline Management Variance ❑Wireless Telecommunication* ❑ Comprehensive Plan/UDC/Land Use District Map Amendment it Forest Practices Act/Release of Six-Year Moratorium ❑ Jefferson County Shoreline Master Program Amendment *May require a Pre—Application Conference ❑ Tree Vegetation Request **Re•uires a Pre-A..lication Conference Please identify any other local, state or federal permits required for this proposal, if known: WpNR. � Wtfv4C V. S. ARIin9 Co RR of EN4tN6ERS 1 W h0 14 DESIGNATION OF AGENT I hereby designate to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE Date: By signing this application form,the owner/agent attests that the information provided herein,and in any attachments, is true and correct to the best of his, her or its knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respect to this application packet may result in this permit being null and void. I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs, reasonable attorney's fees and expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit. I further agree to provide access and right of entry to Jefferson County and its employees, representatives or agents for the sole purpose of application review and any required later inspections. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the time of the application that he or she w is prior notice. Signature: _ Date: I S— 'I — I3 The action or actions Applicant will undertake as a result of the issuance of this permit may negatively impact upon one or more threatened or endangered species and could lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the "Endangered Species Act"or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this permit has been issued will not violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your action(s)even if you are in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-transferable respoil�it�Cyjpr`he ri_g to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature: 11 Date: IL-1 —1 3 BUILDER STATEMENT The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that they will be assuming the responsibility of the General Contractor for the proposed project. Signature: Date: GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PI-ZONE: FAX: ( ) ( ) MAILING ADDRESS: EMAIL: CONTRACTORS LICENSE WAINS NUMBER: NUMBER ARCHITECT/ENGINEER: PHONE'( ' ) FAX:( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: New D Wood Existing: . ` Sewer C Addition S Steel Proposed: Bank C Community System C Alteration/Remodel C Concrete Total: Height: C Individual System C Repair 2 Masonry SEP Permit# C Demolition = Other: Bedrooms: Water Supply: Existing: Setback: ` Private well Two Party Type of Heat: Proposed: C Public Total: Name of System: • If this is a Commercial Project you must answer the following: Number of Parking Spaces: Current: Proposed: Number of ADA Parking Spaces: Number of occupants (includes owners,tenants, employees, etc) Current Proposed • BC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply: I Underground Tank Above ground Tank Size of Propane Tank: i Heat Stove I Cook Stove I Woodstove I Fireplace Insert I Hot Water Tank I Pellet Stove I Other Is this appliance being installed in a Manufactured/Mobile Home? Yes / No When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property lines, tank location and size, distances from the propane tank to all property lines, buildings and septic system components, including the reserve area. Square Footage Current Proposed For Office Use Only Amount Revision Main Floor Heated EH Bld App Review: 2" Floor Heated Consistency Review: Other Heated fee: G s* C n GV• _ u � Mezzanine Additional Section: Heated Basement Plan Check fee: Unheated Basement State Surcharge fee: Other Unheated Pot Water Review fee: Garage/Carport SUBTOTAL Decks 911/Rd Approach fee: Other TOTAL: $ Receipt Number: 1 L_( $-6 2 Cash/Check Number: ' ESTIMATED COST(REQUIRED) Date: •Fair market value of all labor and materials foundation to finish IV lq ` 3 Initials: , e)›et-t0ANI1 DA.M9-6c1 . 1• _ lir 0' . ... , . - a s s'- s a ..... . . . . 0 . . . .. 1.• 7180 Flagler Rd,'Marrowstone, WA 98358, U „.,,..,,,,..,.. , . • „ II - - . . = . 0 . I ' ( 2013 Google t..1 Google earth feet 800 meters 200 A 0 LAAp_At ?R0?°S51) L.0 C V\-.\- 0 t•I f-DR gose T2ookA LAT : 4 . 0597.. Lot.“7: - 1-2.1.. . 62112- tgo APPROVED -- . .. SITE PLAN I C L __,............................................ MAY 2 5 2014 tl i NOV 1 9 2013 LA 11 ) i 1 J ------------ JEFFERSON COUNTY DEPT.OF JEFFERSON CO 1NTY r -- '-'-,.7 UNITY DEVELOPMENT , COMM IN DEVELOPMENT • p- / -0 17 RoSE t. D : '' ; • :- . . . . . • • - t75L T• - . 11. (o - - - N*4%1-:5wu4' 14t1gs-. 95'(i _ PST - 1.0.2 LENT�26.2= �' ( CHMM) SWPitn• W P0Pi I.INE --- 3e1,*r iLto, 1G•Vll fog . q f7 VE. 25 s - abs�w . . . I . HPU% 44C144F .. - - . . . . - . • . V1; I . -1.1.)11•1-6-. 01f-/.1,v : 1101 - - - . . . . i \HMAX ANC1-folz:. I W 122.6 61 14 - . . . . -. J rE.:. G. ,LE-.--__;: . .- --:!; ; '. - • r : N ly j 9 �,I I l) 1 I - JEFFERSON COUNTY. - i . . 1 . . . . . . DEPT.OF COMMUNITY DEUEL.OPMcNT. _.__1 1 1 M6 Rec ie—oencyt, Ntss+t cj 13a j •4 L AGENCY USE ONLY Date received: 1 I-S-1 a US Army Corps WASHINGTON STATE Engineers 's, Joint Aquatic Resources Permit Agency reference#: Application (JARPA) Form1'2 Tax Parcel#(S): USE BLACK OR BLUE INK TO ENTER ANSWERS IN THE WHITE SPACES BELOW. i NOV 07 �k P31 iI+�Y I?:("7^7^ Part 1—Project Identification 1. Project Name (A name for your project that you create.Examples:Smith's Dock or Seabrook Lane Development) [help] Rose Family Mooring Buoy, Mystery Bay Part 2—Applicant The person and/or organization responsible for the project. [help] 2a. Name (Last,First,Middle) Thomas Rose 2b. Organization of applicable) 2c. Mailing Address (Street or Po Box) P.O. Box 233 2d. City, State, Zip Nordland, Wa. 98358 2e. Phone(1) 2f. Phone(2) 2g. Fax 2h. E-mail ( 360 )3795471 ( 360 )7741266 ( ) rose @olympus.net 360 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.armv.m il/Missions/CivilWorks/Regul atory/PermitGuidebook/EndangeredSpecies.aspx. • Not all cities and counties accept the JARPA for their local Shoreline permits.If you need a Shoreline permit,contact the appropriate city or county government to make sure they accept the JARPA. 2To access an online JARPA form with[help]screens,go to httlx//www.epermitting.wa.aov/site/alias resourcecenterfjarpa lama fom7/9984/jarra form.aspx. For other help,contact the Governor's Office of Regulatory Assistance at 1-800-917-0043 or help©ora.wa.gov. JARPA Revision 2012.1 Page 1 of 16 a 91.40 Z abed 1:Z1.0Z uo!s[ne b'd2idf ' r ( ) ( ) ( ) Hew-9 'qv xej '6p (z)auoud 'It, (i)auoyd 'ep d!Z 'a}e}S 'APO 'pp (xog Od JO}eaa}S) ssaappy 6ufe[N '3p (algeolldde 31) uo!}ez!ue6JO `qp (9IPPIW `}said `}se-1)auleN •uo!}ez!aou}ny esn ogenby ay}ao4 Aidde o} 3 }uewgoe}}y yd2.1yf` o;eidwoo 'sei(}! .d!usJeumo puei ogenbe eu!waa}ap o} 001.1.-Z06 (09£) }e 2jNd 0q4}oe}uoo 'mom' pop noA •spuel ogenbe pe6euew-( Na) saoanosa2j Iean}eN}o}uewpedea uo s! perwd ano t3N 'JOUMO A}aadoad leuo!}!ppe pee ao}y}uewuoe}}y yd2lyr;n0114 pus mow{ uogoas au} eieldwoa •saauMo Apedoad pueldn aid!}lnw aae eaeq j LI (•g }aed o} dig) •s}Uawasee JO AeM jo-s}u6!a 6u!}s!x9 uo sal}!n!}oe eoueuelu!ew JO a!edeJ (.9 }aed o} OS) '}ueo!idde se awes xx ldlauJ 'puel o!}enbe }ueoefpe eu} uMO}ou Aew SJSUMO pueidn au}esneoeq d!usieuMo ogenbe pus pueldn u}oq Jeplsuoa •an000 Il m}oafoad ay}eieum (se!)Apedoad eu} 6u!umo suogez!ue6ao JO eidoed Jo}. uo!}ewao}u!}oe}uoa (s)JeuMO /caadoad—ti fed ( ) ( ) ( ) 1!ew-3 •y£ xed 'Be (3)auoud '4£ (G)auoud •a£ d!Z `a}e}S 'A4la `p£ (xos Od ao lowly) sseappy Burnet/4 '3£ (aigeo!Idde j1) uogez!ue6a0 •q£ (91PP1}N }said°}Se1)OWBN 'e£ [tliagJ (iuo!}eo!idde s!u}}o q 61. u6!s}snw (s)}ue6e pez!aou}ny :a}oN) ioefoad au}}nose}ueo!ldde eta}ueseadeJ o}pezuou}ne uosaad 10ewo3 JO 4ua6d peZiaoypny—£ ped w - 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.) [help] ❑ Private ❑ Federal ❑ Publicly owned (state,county,city, special districts like schools, ports,etc.) ❑ Tribal x❑ Department of Natural Resources (DNR)— managed aquatic lands (Complete JARPA Attachment E) 5b. Street Address (Cannot be a PO Box. If there is no address, provide other location information in 5p.) [help] 5c. City, State, Zip(If the project is not in a city or town,provide the name of the nearest city or town.) [help] Nordland 5d. County [help] Jefferson 5e. Provide the section, township, and range for the project location. [help] '/4 Section Section Township Range Nt/y 3 30N E 5f. Provide the latitude and longitude of the project location. [help] • Example:47.03922 N lat./-122.89142 W long.(Use decimal degrees-NAD 83) i.8,05 laa.6ca6 ya 5g. Listfthe tax parcel number(s) for the project location. [here] • The`Iocal county assessor's office can provide this information. State owned aquatic lands ,, a7b SOD Q I 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) Oov`it Abec`Ccore ,e i'30 QGvecidcse_ — ---- -- cc-7 ROb3®a (�1°R OLA i t D i8358 RicY cd V,ickt d Pa C3t3X 135 -- - ci-7bROOL-ioa. t�xxr�to c WA 9` 358 W It.c,A4i ? cRKeR 1 I !o 6.1A►cr1.Ecz. R0-__— q�,�, 1-° ° L®!, NoMP fry, ip WV( 0 $'3 JARPA Revision 2012.1 Page 3 of 16 9.do q aged 6'ZI.OZ uoislna2!Vd dV 141.1i0d 144!}}!10}o pua 3N a4l uaw} spuelxe 1e41 lids eql}o q nos pue qs j eqS puels1 euo}snnoiiei uaw}sswoe s! alis pesodwd 044 pue `ljeI 0144 uo aq !!inn Aee L}sod el1W Po( "u 91. uo -p e a)fel VolpeH pod uawd [dt9111 'dew e goe44e pue `uoi4eool l0afwd 3144 of Aenng6i4 4505013 9144 wag suol4oaa[p 6uinup apinoad "dg auou [clad -uoq!puoo luaaano pue (s)asodand 4eg4 6u[pn[oui `Apadoad eq4 uo (punw6 mo[aq pue enoqe) sampn4s 344 aquosaa •09 •s��op pue sAonq Buuoow lei}uapisad [algid •pasn AI4ueuno we se!pedoad 4ueoefpe a44 M04 aquosaa •ug puei 3genbe peuMo a;e}g talayj •pesn A14uaamo si Apadoad 3144 nno14 aquosaa 'tug wonoq pnw/pues `ties £aaisAgy ped (y}nos) episui eq ui Bale Aeq Moilegg Maid •Apedoid 9144 uo suai4ipuo3 le4igeq pue uoi4e4a6an 344 equosap Agaug .fig moue[4,uoa [] oN Ox saA [aia41 Lu[e[dpoo[}aeaA-00[, e uiy41nn ewe l0afwd 344}0 ped Aue si 'fig l k� co wz t vi,.5 vvi [alagj •uoi4eoo[4oaIwd 344 04 lueoefpe Jo uo (spue14ann ue44 Jeg4o) saIpogaa3enn He ls[-i 19 Ldla�#1 'uoi4eooI pafwd aql 04 4uaoefpe ao uo spue[l9M He;sr! •ig Part 6—Project Description 6a. Briefly summarize the overall project You can provide more detail in 6b. [help) Install a residential use mooring buoy, 18-in diameter, secured by 1 in braided line, with a subsurface float, anchored with an embedment style (helix) anchor at a depth of 14 ft.(0 tide) 6b. Describe the purpose of the project and why you want or need to perform it. Iheipl To provide a safe moorage for our 23 foot sailboat, convenient to our waterfront home. 4 C C 6--S $ S C, `� 5^- W 1 SE't c -c l o N (A-5 NBC frS CcA-P-4 6c. Indicate the project category. (Check all that apply) [help] ❑ Commercial xE.Residential ❑ Institutional ❑ Transportation ►.4 Recreational ❑ Maintenance ❑ Environmental Enhancement 6d Indicate the major elements of your project. (Check all that apply) [help] ❑Aquaculture ❑ Culvert ❑ Float ❑ Retaining Wall Bank Stabilization Dam/Weir ❑ Floating Home (upland) Ba ❑ 9 111 Boat House ❑ Dike/Levee/Jetty 11) Geotechnical Survey ❑ Road ❑ Boat Launch ❑ Ditch CI Land Clearing ❑ Scientific Measurement Device ❑ Boat Lift ❑ Dock/ Pier ❑ Marina /Moorage El Stairs ❑ Bridge ❑ Dredging ❑ Mining ❑ Stormwater facility ❑ Bulkhead ❑ Fence ❑ Outfall Structure ❑ Swimming Pool x❑ Buoy ❑ Ferry Terminal ❑ Piling/Dolphin ❑ Utility Line ❑ Channel Modification ❑ Fishway ❑ Raft ❑ Other: JARPA Revision 2012.1 • Page 5 of 16 91.;o L abed LZIOZ uo)sinab Vdbb'f • [dla41 Zspue!em)oedw! 4oefoJd eq4![JVi 'q1 e geo!!dde 4oN �x [j] -spue[4ann o}spedw! esienpe ez!w!u!w pue pone 04 peu6!sep ueeq seq }oafoad ay}JAN equose j "et ldla4l ('g ped 'euou ale aJay4 j!) .eeie 40afoid 6144 04 4ueoefpe Jo uo sJa}.nq puegenn Jo spuegenn ale away}I! eieq )10940 D uoge6i;iw pue s oedwi :spuegem—L Ped mow! 4,uoa ❑ oN ox saA❑ .spun]6uipinoJd Aouebe yoea leo'sari;! 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Aonq 9144 o4 einssawd eleJepow 6u!A!dde Aq Jogoue 914 4594 pue 'wog 04 sump.'Jana -Jana! ed!d ypnn 6u!wn4 Aq x!!ay 9143 pe4su! pue Ja4enn 314 Jewe Hon aan!p ay} uay4 'wol}og ay} 03 meg 344 Jenno1 .uo!}eool i[e4su!;e leoq JogOUs `)no 6u,Joow MO1 ua144 'wog 844 u! °Joys uo s!oo) pue s)uauodwoo !!e a gwessy -eoepns 3144 uo wog pews e wo4 poddns y)!nn Janlp 816u!s e /(q euop eq !!!nn uo!4epe4su! -uieidpoog JeeA-006 948 u!Lbinn aJe seginI}pe 143111nn eleolpui . ApogJo4enn 4seieeu 641 o}uomer ui Jndoo pIM weLuele time eiegm irouepa . [�47 -pesn eq o4 4uewd!nbe pue spog3ew uo!ona3suoO o poeds epnpu! -pg u! pavego 3ueweje 4OafoJd !pee 3ona4suoo o; ue!d not Moy equosea •09 • 7i. Forr 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. [helm 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. [help] - 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. Thetal ❑ Not applicable The helix anchor will be fully embedded in the sea bed, leaving only the eye at the top of the screw exposed.A mid-water float will keep the mooring line off the bottom to eliminate the possibility of disturbance of plant and animal life. The installation of the helix will be by a single diver, using manually operated tools. There is no need for removal of vegetation in the proposed location, and the potential for blocking light penetration into the water does not exist. 8b. Will your project impact a waterbody or the area around a waterbody? [help) x0 Yes ❑ No JARPA Revision 2012.1 Page 9 of 16 91.;o g abed L'Z6OZ uo!sinaa yddyr :e ge!!ene}i `ueld uo!}e6l;lw ay} u! uo!}ewao}u! ae!!w!S ao} (s)aegwma abed (a)ee;nag-unuee uoge6i;UJ'(d)uogemesaad`(3);ueweouequ3'(a)uoge)meyaaquawysijge;se-eN`(o)uoi;ee , 'aneoudde A!•;ueuewied•Je u3'App qoe ay;Aq pe oedw!Anwnseew eq'Dm pueRem ay;amity)sy;uow'sAep ay;a;eoipw 'a6ejoed Vdd`cfr ay;y;im swan;6twea pue;am ay;ap!noad wa;sAS 6ugeN pueROM uo;6uiyseM wa;se9 Jo uo;6wyseAA wa;sem luaamo uo peseq AJo6eleo pue em A6ojoo3 z -pods,uoi;eeuHep pue;am a se Lions`s;uewnoop oafoad Jewo wim;ua;sisuoo eq pinogs aweu eqi -(•i.pueRem”se Lions)aweu enb!un a wean's;sixa pue;am ay;Jo;aweu leioy;o ou;1 L (sei3e (saao■ 1Aao6a;eo ao `;j •bs) edit; .io •}; 6u!;ea (•o;a 'poop ease uoge6l;lw uo!;e6!;!w oedw!;o •bs) eaae pue edig 1eweN `a;eneoxe `u!eap puepem pesodoad uogeano ;oedwi puepem pUeReM `II!3) 4)413V laiay! 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(onH) woo pun leo!6oloJPAH Ae/uns leo!6oloe9 *s.n leLM '06 oN Dx saA 7P£0£/bM/sweino.id/nob.eM'noa*MMM//:duy :;e sloe;;uewssessy Alien°as;eM s,A6oloo3 o;uawpedea uolfiulyseM esn` ■OUE tuop noA II • •Molaq(s)leieweJed ay;Is!!`se ;I • tdlayl z;s!1 (0£0£0601oo3 Jo;uewpedea uo;6uIgseM ay; uo ydwyf s!q3 40 9 Ped JO L}red u1 pa!}!}uep! se■pogie eM ao spuel4eM eq 4o Aue aay •q6 ( ) ( ) ( ) ;0e;uo3;o a;ea ;uaoalf;sowN euoyd aweN pe;uoo ewe A0ue6y Ldlayl 'Molaq weql leg Vapid s!y;uo sa!oue6e;uawweAo6 Aue y;!M pe)pom Apeaale aneq noA j •e6 •uo!;Sanb e JaMSUe ;ouueo noA j! Flo s!;i ueo nog(se uopes s!1 }o gonw se a eidwoa •;oeioad anon( pue;siepun (s)JeMe!naa ay} sdieq ep!noad ueo nog( uo!;eu,uo4u! leuol;!ppe Auy uo feuuojui ieuomppy-6 Led V/N MN] •pesodslp eq p!M lelaa;ew ay;eae1M pue `anowea hI!M noA lelaa;ew;o;unowe pue edA4 `6u16p03p JO 6w;eneoxe a04 poq ew eq; eq!aosep `eg u! pe 4!;uep! Se!;moe 6u!6paap JO 6w;eneoxe Ile 10d -6g • 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 x❑ Not applicable The plan and design of the project will not have any adverse impact to Mystery Bay. There is no need for the removal of vegetation, and existing shellfish beds will not be affected. No heavy equipment will be used ( only manually operated tools), reducing potential for oil or gas spills. 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. [helpl N/A 8e. Summarize impact(s)to each waterbody in the table below. [help] 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 n/a n/a n/a n/a n/a n/a 'If no official name for the waterbody exists,create a unique name(such as"Stream 1")The name should be consistent with other documents provided. 2Indicate whether the impact will occur in or adjacent to the waterbody. If adjacent,provide the distance between the impact and the waterbody and indicate whether the impact will occur within the 100-year flood plain. 3lndicate 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 On cubic yards) you will use, and how and where it will be placed into the waterbody. [help] N/A • IA DOA co„is inn wnil i Paae 10 of 16 • Go to http://www.ecv.wa.gov/programs/wg/swgs/criteria.html for the standards. x❑ Yes ❑ No ❑ Not applicable 9f. If the project is within the jurisdiction of the Shoreline Management Act, what is the local shoreline environment designation? [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. x❑ Rural ❑ Urban ❑ Natural ;14 Aquatic ❑ Conservancy ❑ Other 9g. What is the Washington Department of Natural Resources Water Type? [help] • Go to http://www.dnr.wa.gov/BusinessPermits/Topics/ForestPracticesApplications/Pages/fp watertypinq.aspx 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? [help] • 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? [help] • If Yes,please describe below. ❑ Yes x❑ No 9j. If you know what the property was used for in the past, describe below. [helpl State owned Aquatic Lands 9k. Has a cultural resource (archaeological) survey been performed on the project area? [help] • If Yes,attach it to your JARPA package. ❑Yes x❑ No ,,,,,,,,, o....;n in.et qn,o 4 Page 12 of 16 91}o£6 96ed 1'Z10Z uotsinad tld2tb'f Mel leaepej Aq pe4dwe-aid si yd3S A uno0 uosjej4er Aq peulwie ep eq pine yd3S :a9410 ®, 41dwexe s1 (own) epoo emealslulwpe yd3S eq; uolpes;eiM iepun 'uoRdwex3 leolao6e e0 ❑ -(Motaq uogdwexe Jo adA}esoogo) 4dwexe s1 pe1oad s141 ❑ lataul ('qol. ut Motaq xoq aye Noeq ) 'uoi4dwex3 luaweouequ3 3emeH gsi3 e aoj 6u1Aidde we I ❑ Si amp uoisioep pepedxe eqj '(Aoue6e peel) tam 6uipued s! uo1}eulwa9}ep`dd3S y❑ 'uoi4eoydde S!q4 tam pepnloul Si uo4dwexe to Jane'JO uol4eu!Wielep yd3S eq; /(doo y❑ ]w1q Mat naa-a/eaas/eas/sweiboaa/no6.eM'Aoa-MMM 01 o6'yd3S}noge uot}euuoJut wow and . Wield (*Midde teu}ne No0UO) '(yd3S) 10y Ao!lod iewewuoainu3 a elS 941 q4!M eoue!Idw00 '001, 'v&ivf pe ldwoo ao1 sassaappe Aouebe uo Nollo '01 y&Ayr ano/t puss o; sesseippe ;sil e and . 'nob'eM•wogd$eq JO Et"00-L16 (008) )e eouelslssy A.toleinBej lo eot}}0 s,aoua9no0 • /sego/nobyeM'noe'sdde//:d4q 4e aneuuogsen0 43a(oad euguo . 'aoJ 6uuuldde we nog(s4lwied eq Aji;uepi o}Moleq ;swap pue seoanosaa eq;esn s;!wied pue eoueiidwoo Vd3S-0I. ped .(ssp{Aw sngouAyaoou0) Sda punoS 4e6nd peegiee s `(egoslAeMegs} sngouMgioouo) n33 punoS le6nd uowoies Noouig0 lataul •)laoM pesodoid aye Aq pepejle eq 3461w;eq;lsll saloadS pue s3e4lgeH A31aolad s,e !Ip11M pue gs13 juewpedea uo;6uigseM eq; uo 4e4lgey JO seioeds !pee aweN •W6 [ ta-a4l ")laoM pesodoad eq Aq pe oej a eq}y61w to ewe 4oeIoad ay} Apuloln eq; san000 35144 4oy saloadS peie6uepu3 'awe).941 aepun pals!! seioeds yoea aweN 16 • 1013. Indicate the permits you are applying for. (Check all that apply.) [help] LOCAL GOVERNMENT Local Government Shoreline permits: ❑ Substantial Development x❑ Conditional Use ❑Variance ►a Shoreline Exemption Type (explain): fC._ 1 — S500 C3) Other city/county permits: ❑ Floodplain Development Permit ❑ Critical Areas Ordinance STATE GOVERNMENT Washington Department of Fish and Wildlife: x❑ Hydraulic Project Approval (HPA) ❑ Fish Habitat Enhancement Exemption—Attach Exemption Form Effective July 10, 2012, you must submit a check for$150 to Washington Department of Fish and Wildlife, unless your project qualifies for an exemption or alternative payment method below. Do not send cash. Check the appropriate boxes: ■ $150 check enclosed. (Check# Attach check made payable to Washington Department of Fish and Wildlife. Cl Charge to billing account under agreement with WDFW. (Agreement# ) ❑My project is exempt from the application fee. (Check appropriate exemption) ❑ HPA processing is conducted by applicant-funded WDFW staff. (Agreement # ) ❑ Mineral prospecting and mining. ❑ Project occurs on farm and agricultural land. (Attach a copy of current land use classification recorded with the county auditor,or other proof of current land use.) ❑ Project is a modification of an existing HPA originally applied for, prior to July 10, 2012. (HPA# ) Washington Department of Natural Resources: x❑Aquatic Use Authorization Complete JARPA Attachment E and submit a check for$25 payable to the Washington Department of Natural Resources. Do not send cash. Washington Department of Ecology: ❑ Section 401 Water Quality Certification FEDERAL jGOVERNMENT United States Department of the Army permits (U.S. Army Corps of Engineers): ❑ Section 404 (discharges into waters of the U.S.) x❑ Section 10 (work in navigable waters) United States Coast Guard permits: ❑ General Bridge Act Permit ❑ Private Aids to Navigation (for non-bridge projects) JARPA Revision 2012.1 Page 14 of 16 91.Jo 91.e6ed L'ZLOZ uolslnad dd2idf ZL-90 ',AI 60-6I.0-AN :Jagwnu uogeolignd y110 '1/17£9-£C9(LL8)Ileo ueo ALIP.geslp yoeeds a y}Inn a doed 'eowas Aeiej uo}6ulyseAA Jo; L LL'leo ueo ssol 6ulieeq y}lnn eldoed '£V00-L L6(008)}e(y2:1O)aoue}slssy AJO}eln6aa;o eol}}O s,JOUJanoO eq joe}uoo';ewio;Jay;oue w wewnoop sly;aJlnbai noA;' -y}oq Jo sieeA g ueqi wow iou peuosudw!JO 000`0 L$uey}wow Lou peug eq pet's 'Aqua JO 4Uawa;e;s;uainpnei;JO 'snot 1101.4'esle;Aue ulei.uoo o}awes 6ulnnowl;uawnoop JO 6uqunn awl Aue sasn JO saNew JO suoge;ueseidej Jo s;uawa;eis;ualnpneJ;Jo `snot gog'asp;Aue saNew Jo pe;leua;ew e aol■ap Jo'ewayos glow Aue Aq do SJOAOJ Jo`sieaouoo'mime; Ai6wnnouii sa}e}s pa;lug ay;}o Aoua6e ao;uewpedep Aue;o uol;olpsun(ay}uly}lnn.ieuuew Aue w `Jane°LM:Ieya sepinoid LOO L§O'S'n 8L a}eO ainleu6!S Jaunt°AlJedoJd aweN pa;uud Jam()Apadoid 'Jeunnopuel aye o}eoi}ou wood y}inn 'Ieonoead 3i 'pue sewn a geuoseaa in000 pegs suonoadsul esegj ')Iwonn Aue JO 9415]oafowd eq3 pedsui pe4eooi Si pafowd ay}awagm Apedowd ay4 6upalue sepue6e 6upuped eq4 of luesuoo I 's}uewesee Jo Aenn}o-s4y6u 6unsixe uo si ;oefoad it paw-lbaw 40N May] •(lueolldde 4ou ji) eJn4eu6ls Jeumo Apedowd •��, a;eO eJn;eu6uS lue6y pazIJOy}ny aweN pa;uud;ua6y pezuoy}ny •panssi ueaq aney s4iwJed Aaesseoeu Iie wale Aluo )Iaonn pe}s 04 ee 6e [ pue seninnoe pesodoad eq4}no Awaeo o}Aluoy3ne eq4 aney limn Alpeo osle I .a3wnooe pue 's a dwoo sl uoneolidde sit'} ul pepinoad uonewao].w ay} 'mpg pue 96peinnowl Aw}o }seq Ieyn Appeo I Pau] awn4eu6ls way pez wotl;ny •q I.I. 918O aJn}eu6ls iueogddy aweN pa;uud Lueoliddy 'pe oad aye o pampa )Iaonn Aue ao alp 4oatoad 9q4 padsul o} pe eool sl pefowd ay4 aaaynn Apedowd 0q3 6uiie ua seioue6e 6ulThwJed eq 04}USSUOO Aw ani6 osle I •Apedoad ay}o}sseooe]uea6 0}A4laoy}ne 9144 aney limn awls ! `away 6ullenlu! Ag (Ien!u!) 'uoneoildde siyn 03 pe elei sa94ew ul}legeq Aw uo pa o} uoneolidde sly}Jo £ }wed ul peweu 4ua6e aye ezuoq ne Ageieq I •s4iwJed Awesseoeu Ile pei ieoaa aney 1 ie a Aiuo NliOnn}ae4S 01.a w6e [ pue 'senlnnoe pesodowd aye}no Awweo 04 A4poy]ne 9144 aney I ;mil Al peo owl 'e4ewnooe pue `elaldWOO 'artn si uoneoi dde sly4 w pepinoad uonewwooul 9144 'mayeq pue e6pe MouN Aw Jo lseq 0144 o3}8143 Aj peo I [d'au] (paalnbei) aan]eu6is lueollddy •eR Maul •040 `so]oyd `sueld pefowd `wao�yd2Iy(' ay}sepnpul a6eved yduv ayl -e6e)ped vdNvr ay} 6ul}}Iwgns eioa.aq pawinbei Jae saan}eu6lg scan;eu6iS 6uiziaoyDnV-1,4 lied I , ► I AGENCY USE ONLY US y nrE e s Date received: II -I a ; ❑Town WASHINGTON STATE Seattle District ❑Application Fee Received; Igi Fee N/A Joint Aquatic Resources Permit New Application; ❑Renewal Application Application (JARPA) [help] Type/Prefix#: a3 ;NaturE Use Code:74cil LM Initials&BP#: 106131-19 l Z- RE Assets Finance BP#: New Application Number: Attachment E. Trusts): ;County: Aquatic Use Authorization on AQRPIate#(s): DeDepartment of Natural Resources Gov Lot#(s): p Tax Parcel#(s): (DNR)-managed aquatic lands [help] Complete this attachment and submit it with the completed JARPA form only if you are applying for an Aquatic Use Authorization with DNR. Call (360) 902-1100 or visit www. bit.ly/dnr aquatic lease for more information. • DNR recommends you discuss your proposal with a DNR land manager before applying for regulatory permits. Contact your regional land manager for more information on potential permit and survey requirements. You can find your regional land manager by calling (360) 902-110.0 or going to http://www.dnr.wa.gov/Publications/aqr land manager map.pdf. [help] • The applicant may not begin work on DNR managed aquatic lands until DNR grants an Aquatic Use Authorization. • Include a $25 non-refundable application processing fee, payable to the "Washington Department of Natural Resources." (Contact your Land Manager to determine if and when you are required to pay this fee.) [help] DNR may reject the application at any time prior to issuing the applicant an Aquatic Use Authorization. [help] 1. Applicant Name (Last,First,Middle) Rose, Thomas C. 2. Organization Name(If applicable) 3. Which of the following applies to Applicant? Check one and if applicable,attach the written authority-bylaws,power of attorney,:etc. [help] ❑ Corporation x❑ Individual ❑ Limited Partnership ❑ Marital Community (Identify spouse): ❑ General Partnership ❑ Government Agency ❑ Limited Liability Company ❑ Other (Please Explain): Home State of Registration: JARPA Attachment E Revision 2012.1 Page 1 of 2 Z;o Z abed VZ60Z uolsinad 31U W(1^epy ddbdr 4 a Z6-6i70-AN3 uol;eoNnd V80 •14£9-££8(LLS)ueo eo Allllgeslp Weeds e y;lM aldoad -eouues Aejej uo;6ulyseM ao4 4 II neo ueo ssol 6uueeq U;lnn aldoad '£i700-L 66(008)le(Veld eoue;slssy Aao;eln6ejo eo j o s,aouienoO ay;pe;uoo `;euajoj Jagl;oue ul;uewnoop sly;annbea noA ae6euen uolslnlo;ue;slssy JO Je6euelnl;ou;sla ie6euelN uolslnla;ue;sissy JO Je6eueW 101a4s!a a;ea seoanosej lean;eN;o •}dea seamosej lean;eN;o idea aan;eu61-, eweN pe;ui�d ;oafoad s!q;Jo;spue! of;enbe pa6euew-2JNa ;o asn eq;ezuoy;ne ;ou seop aan;eu6is AW •s;iwaad Aao;ein6aa Aaesseoeu ay;ensand Aew ange;ueseJdeJ aawsiy Jo ;ueoudde ay;;ey;ea.168 pue spue! ogenbe pa6euew-seoanosaj dean;eN;o .;dad uo pesodoad 6uieq s! oafoad ay;;eg; aaenne we `seoanosaa dean;eN;o idea ay;;o ani;e;uesaadaa pa;eu6isep e `1 .spue! ogenbe pa6euew- No uo pa;eool s! ;oafoad ay;I! ie6euew uo!sin!a ;ue;sissy tic)aa6euew ;oia;sia soi;enby 2i■a do aan;eu6is ay; uie;go;snw ;ueoiiddy :spue! ogenbe pa6euew-aNa uo s;oafoad ao;aan;eu6ig •;ueondde etp o; peuin;ai Adop e pue jjNa Aq pe;eidwoo eq ol;. [slay) ;i 6uisn aoj esodand ay;pue leua;ew imp edA;ay;nnoleq agiaosep `spue!ogenbe pa6euew-}JNa uo Alsnoinaad pesn Senn ieua;ew .6uisealgns ssnosip o;ae6euej puei anoA;oe;uoo `se,k;j oN Ox sad ,es�e auoawos o;Apedoad ay;esee ins o; pua;ui noA oa -g :(s)aagwnu uogezuoy;ny `saA;I nnou)j ;,uoa El ON Ex seA 0 4uogeool;oafoad ay;le suogezuoy;ny asn oi4enby pem!dxe Alsno!Aaad J0 6ugsixe Aue;o aaenne noA aay •g [81� :ameovide;i `megwnu (magi;uepi sseuisna pe iun) Ian uo;6uiyseM -p . r Tag# MOORING BUOY AFFIDAVIT State of Washington SS:Mystery Bay mooring County of Jefferson 'TAD Vvkv 5 1Z ,residing at t,c2=o i. 144-1`D t `� \ t 0 eL-Vsc Cst L�Yt- RvD, being first duly sworn on oath deposes and says:that I own a mooring buoy in Mystery Bay with the following description: Location: Latitude I-18.06-37 Longitude°%3ia bcia.b ,NAD 83 DNR Authorization No.: Description of boat usually S �� c - moored there: f 7-17 to 14 D Q ET Type of toilet facilities on boat(check one): ❑ I have no toilet facilities on the boat 1 I have a portable toilet ❑ I have a holding tank with a dye tablet ❑ _ I have another type of toilet I certify under penalty of perjury that any boat moored to this buoy will • Not have overnight occupants • Not discharge any toilet waste into Mystery Bay • Not allow gray water(from showers,laundry or kitchen)or other substances to drain into Mystery Bay • Dispose of all toilet waste and gray water properly in upland sewage systems or at a boat pump-out station Date q 30 f 3 Name: I certify that I know or have satisfactory evidence that T homo5 g©5e_. is the person who appeared before me,and is the owner of the mooring buoy described above. I further certify that said person acknowledged the foregoing statement to be the free and voluntary act of said person. SWORN AND SUBSCRIBED before me this 3O day of APC►k a`O13by = l �� - NOTARY z�� ikdopt Notary Public Name: �i� PUIIJC `+,-!A 2-1-17 In and for the State of Washington 11,1‘‘i \ \""``':c My Commission expires:reb' �St Ul0) Appendix E January 27, 2010 Page 1 of 1