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HomeMy WebLinkAboutMLA15-00020 (0002) i 6,61- I-s --ae szpi5-,o1 �,soN ��� DEPARTMENT OF COMMUNITY DEVELOPMENT ,, k ,� 621 Sheridan Street,Port Townsend.WA 98368 ..e; Tel:3t)0.379.4450 Fax:36 379.4471 ��� ��� �� Web:wwrv.co jettenon.wa.us/communitvdev ownerA E-mail:dcdCri)co.jeffecson.wa.us IR o� APR 0 1 2C15 ,SNI NCs' PERMIT APPLICATION ,Li rtrs0 CON BCD Steps in the Permit Process: -Review application checklist to ensure all information is completed prior to submitting application. -Make sure septic has been applied for and water availability has been proven. -Make an appointment to meet with the Permit Technician by calling 360-379-4450. -This is not a standalone application;it must be accompanied by a project specific supplemental application. -Fees will be collected at intake. Additional fees may apply after review and payment is required before permit is issued. For Department Use Only Building Permit# Related Application#s: MLA# --] Site Information Assessor Tax Parcel Number: 953 7 or 3 S ,�J Site Address and/or Directions to Property: 3.25-3 i li3 /et- �` — d /a II el i r, / 9 Z.3.- Access(name of street(s)) from which access will be gained: I=`/a fit-i- le<I Present use of property: Si"L. to ( d- i i// I``e'5 E' �'G" `'c' I Description of Work(include proposed uses}: ..r./-5'�z /f l..t.. c%Y/ c-c'/- /N-f b0 Ci /1.,•// 5 Cc 114:i-iot 1 v itJrev, el 114 ‘-'t, 1-a .3 ' /A.., c,e7 ir e Ste o ec if /d k e I. [Wastewater-Sewage Disposal . This property is served by Port Townsend of Port Ludlow sewer system? YES NO If not served by sewer identified above, identify type of septic system below: Type of Sewage System Serving Property: Septic Septi Permit#: Community Septic Nam of System: ,�A Case#: Are other residences connected o e se is system? All Additions or repairs to sewage yste : Is it a complete or partial sys 'm inst ation: Complete Partial Has a reserve drainfield been designated? Yes No Date of Last Operations& Maintenance check: Attach last report to application Describe or attach any drainfield easements,covenants or notices on title,which may impact the property: %) 6-qUDC)" The authorized agent/representative is the primary contact for all project-related questions and correspondence. The County will mail/ e-mail requests and information about the application to the authorized agent/representative and will copy(cc)the owner noted below. The authorized agent/representative is responsible for communicating the information to all parties involved with the application. It is the responsibility of the authorized agent/representative and owner to ensure their mailbox accepts County email(ii.e.,County email is not blocked or sent to"junk mail"). Applicant/Property Owner Information Property Owner: Name: 6 e e 'fe Noe �r Address: j� , ©4- t.a. Lie e , .0 Phone#: Z O1 b 9 -- /9 E-mail Address: 9 ,,,ici-ctay i 'i 6 . «ni Please contact Authorized Agent/Represen ative with project info. (select only one). Property Owner Signature: ° - 12 Date: 2/2 3 Note: For projects with multiple owners,attach a' eparate sheet with each owner information and signatures. Applicant: Authorized Agent/Representative Of other than owner) Name: Address: Phone#: E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant Name: Address: Phone#: E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant Name: Address: Phone#: E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant Name: Address: Phone#: E-mail Address: 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 making any issued permit null and void. I further agree to that all activities I intend to undertake or complete associated with this permit will be performed in compliance with all applicable federal,state and county laws and regulations and I 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. Applicant may request notice of he County's" t nt to ent- upon the property for visits related to this application and subsequent permit issuance. Signature: 'r, / i Print Name: -fL>l'c'�� �C'� by Date: Z/Z.JV/,� J AGENCY USE ONLY ;24,-, 1 ( AM Date received: US Army Corps WASHINGTON STATE ofEngiinene�rs• Joint Aquatic Resources Permit Agency reference#: Application (JARPA) Form 1,2 Tax Parcel#(s): USE BLACK OR BLUE INK TO ENTER ANSWERS IN THE WHITE°SPACES BELOW. IR v C 11 TE 1 AC`"-r F In L APR 0 1 2015 Part 1-Project Identification JEFFEOSON COONT' OCO 1. Project Name (A name for your project that you create. Examples: Smith's Dock or Seabrook Lane Development) (help a 0e d 6y /f !' ar2i''lN5 1?c t1 y Part 2-Applicant The person and/or organization responsible for the project. [help 2a. Name (Last, First,Middle) /L r-cf 4' Geof e RD 2b. Organization (If applicable) 2c. Mailing Address (Street or PO Box) 5.5"o 1 /-- ke vie yv U r Ala t . 2d. City, State, Zip 2e. Phone(1) 2f. Phone(2) 2g. Fax 2h. E-mail (2.06 )96j - 600 ( ) ( ) g,lri ord by 4 erne. eeni 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/Regulatory/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 http://www.epermittinq.wa.gov/site/alias resourcecenter/jarpa jarpa form/9984/jarpa form.aspx. For other help,contact the Governor's Office for Regulatory Innovation and Assistance at(800)917-0043 or help ora.wa.gov. JARPA Revision 2012.2 pans 1 of 1 A R EcETr VTF DrD- Part 3-Authorized Agent or Contact Person authorized to represent the applicant about the project. (Note: Authorized agent(s) must hirrR1QbIf this application.) (help] J J ECCC�c�� ��€I�� (,C) 3a. Name (Last, First, Middle) JEFFERSON L U U Se(pri e /4/2p b-e a e 3b. Organization (If applicable) 3c. Mailing Address (Street or PO Box) 3d. City, State, Zip 3e. Phone(1) 3f. Phone(2) 3g. Fax 3h. E-mail ( ) ( ) ( ) Part 4-Property Owner(s) Contact information for people or organizations owning the property(ies) where the project will occur. Consider both upland and aquatic ownership because the upland owners may not own the adjacent aquatic land. Ihelpi ❑ Same as applicant. (Skip to Part 5.) ❑ Repair or maintenance activities on existing rights-of-way or easements. (Skip to Part 5.) n There are multiple upland property owners. Complete the section below and fill out JARPA Attachment A for each additional property owner. Your project is on Department of Natural Resources (DNR)-managed aquatic lands. If you don't know, contact the DNR at (360) 902-1100 to determine aquatic land ownership. If yes, complete JARPA Attachment E to apply for the Aquatic Use Authorization. 4a. Name (Last, First, Middle) 4b. Organization (If applicable) 4c. Mailing Address (Street or PO Box) 4d. City, State, Zip 4e. Phone(1) 4f. Phone(2) 4g. Fax 4h. E-mail ( ) ( ) ( ) JARPA Revision 2012.2 Page 2 of 14 Part 5—Project Location(s) R ECE!VEf Identifying information about the property or properties where the project will occur. [help] APR 0 l 2010 n There are multiple project locations (e.g. linear projects). Complete the section below a wir t ,;,,';r,: MTV DCD Attachment B for each additional project location. Jtf Il 5a. Indicate the type of ownership of the property. (Check all that apply.) [help] n Private Li Federal n Publicly owned (state,county, city, special districts like schools,ports, etc.) I I Tribal Al 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] 033 /= i- /e,- R 5c. City, State, Zip(If the project is not in a city or town, provide the name of the nearest city or town.) [help] 4'I2KJ /it z c U/4- 01233 5d. County [help fe 5e. Provide the section, township, and range for the project location. [help] 1/4 Section Section Township Range. 29 3 6 AI /_ 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) 8, D 6'11 2- C* -/Z Z. . 7 U4.5f..› ? c 6 0 447) 5g. List the tax parcel number(s) for the project location. [help] • The local county assessor's office can provide this information. ' s37 'o43e 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) CAL ley 4 Ern: -!� NLordlt11 Lv� 98 33-0 3 `�U r' ° � r-vl- ,-� p0 -8ex/ 175 f vre - 1 /01-d /a 4 Xg3. 8 95 3 7°42 4'3 PD 8oX 2 / �� / j-6-3 7'O y %4. e .�crd4 �s 3 9 vse f 1`4 S 3 Z 5 953 70(9 44 / JARPA Revision 2012.2 P.nc R nF in IVF>f 5i. List all wetlands on or adjacent to the project location. [help, R nn r ® `1 / 5 Ns 4 ^I , 5j. List all waterbodies (other than wetlands) on or adjacent to the project location. [help1JEFFHSDN EDMY DCD ,/isut fie Or 5k. Is any part of the project area within a 100-year floodplain? [help IX Yes ❑ No ❑ Don't know 51. Briefly describe the vegetation and habitat conditions on the property. [help U O Lv ill be lid Kr /t Se.t t s1"d N el-, S`f t' ie 74a/ivy/ /it h© one is' "t' Sci 6j: ec f /4 4 ,/it ti ve 44t 6 44 S e / vYt.e ter ra 15 eg' o.v 5m. Describe how the property is currently used [fiei0 , t,-'g le 1i > /y Ye 5 e ( A‘9n-t e 43' d A/ `ec f /)e4/--e--e-e(. 5n. Describe how the adjacent properties are currently used [helpl ef-A p e 5.3- P /01 ) jj Barnes. 5o. Describe the structures(above and below ground) on the property, including their purpose(s) and current condition. [heipi �«t9'/'c 4i4-r) h vek►. day 11d 6 dse0 en f 5p. Provide driving directions from the closest highway to the project location, and attach a map. [helpl 54,. 6 J-t c t e e� / l r, zd t c (1 /-ec j-1 y a if „i4 e2- s Pi(ej/ei- t-A,3 /3 !L/Q to.fit ?p.t'e /0$ J y 49.e7 �t �QC 1-- f- 44 j /ti f-r ,f e y rJ t d ! I � iC�I`s'� G--.�"" • ♦ ! �c /( JARPA Revision 2012.2 Page 4 of 14 • • - .- - -. . - 01x:S.Wfrarize the everok1-p54044yottfcgkaroffde more detail . . rA; 5 1a I I tt. /e ix a,4/444:2,-- evi-1 1 meeti-‘,A.1 o ay 5 ir IL) at- NaVh ° 10 lile051) " ye e-14--e- 5'a Zeet- Pet I. 6b. Describe the purpose of the project and why you want or need to perform it [help] aris 9f raj"ec-i Ii i0 V1- 6' r- 5)-e" i/e/ k4 --) ,/ 544 /r ee t - e e"5:5 ei,fr"let Al 444 'g 4 iv x to e. // he a V* e CI if 1-he 5 a. 6 j•e ineWee"/: v-e 5-5 ez. L t- ( / I-at-ii d;& 7 RP) 1-& e 144 fr-e ,4 is 1 7 flt-e 6 (.9c4. t-fi 13t lo c et e V& 5-5 e> ( , et. /44 AA. P/ 71 el et, t K ti-1'hv t.t, i le, -i-he I el I r j es> .s/ 1--ei-k-% I I be 1.445 f---a j. et_. e-cor Aa-Afe-e._ 0 Al kegy/-11;:e. 6c Indicate the project categpry. (Check all that apply) [help] El Commercial cor Residential 0 Institutional 0 Transportation 'Recreational 0 Maintenance 0 Environmental Enhancement 6d. indicate the major elements of your project (check all th44Ph)'IhelpY-if E Aquaculture 0 Culvert 0 Float 0 Retaining Wall 0 Bank Stabilization 0 Dam /Weir 0 Floating Home (upland) E Boat House Dike/ Levee/Jetty El Geotechnical Survey 0 Road O Boat Launch 0 Ditch D Land Clearing El Scientific Measurement Device E Boat Lift 0 Dock/ Pier 0 Marina /Moorage Stairs E Bridge 0 Dredging 0 Mining Stormwater facility El Bulkhead 0 Fence 0 Outfall Structure 0 Swimming Pool [2f*Buoy 0 Ferry Terminal 0 Piling/Dolphin 0 Utility Line O Channel Modification 0 Fishway 0 Raft El Other: RECERTED APR 0 1 2915 JEFFERSON COLINIIIED 6e. Describe how you plan to construct each project element checked in 6d. Include specific construction methods and equipment to be used. [help] • Identify where each element will occur in relation to the nearest waterbody. • Indicate which activities arehu; e 1fO-year floodplain. A.e[ix jv Wx // he i,/s at% y ,4/ c M Sri to tNf is f/ r dv.f , cie be r t 1/ he Ali itrz oz- iy 5'00 f�"�^ b a f� ®� b a b Gt , /n//t...//`syt artvi de, e--A ,o( ier r/`, i4. - vesse e X t if l w ,--t e cv c lie 7a I) /s'f` t-C9 o ed4egs 7° eitC s 1,vj 6 a-7 i2P e-e w''Cl b e r /--e i-ve t o iV/��S th// eGY et,-t-it? x✓� ( 1114 GEr<4,1 90e l�1°i l�'t !iI i 6f. What are the anticipated start and end dates for project construction?(Month/Year) tsefipi, '4 t° • If the project will be constructed in phases or stages use JARPA Attachment D to list the start and end dates of each phase or stage Start date: 3/3 /:///5' End date: '` 131 /rs ❑ See JARPA Attachment D 6g. Fair market value of the project, incktdtng materials, labor, machine rentals, etc. pifipj j26'e 6h. Will any portion of the project receive federal funding? nei • If yes, list each agency providing funds. ❑ Yes O No ❑ Don't know Part 7-Wetlands: impacts and Mitigation ._ Check here if there are wetlands or wetland buffers on or adjacent to the project area. (If there are none, skip to Part 8.)[help] 7a. Describe how the projecthas been designed to avoid andmiriirnize a&J rse`impacts to wetlands. [help] 1g Not applicable 7b. Will the project impact wetlands'? [tier ❑Yes JNo ❑ Don't know 1r1 'T'nE7V7Efl 7c. Will the project impact wetland buffers? [help] AR Yes Fa No ❑ Don't know 1 75 7d. Has a wetland delineation report been prepared? [help] JEffili t COl1 IY OCR • If Yes,submit the report, including data sheets,with the JARPA package. Yes S, No 7e. Have the wetlands been rated using the Western Washington or Eastern Washington Wetland Rating System? [help] • If Yes,submit the wetland rating forms and figures with the JARPA package. FT Yes xK No n Don't know 7f. Have you prepared a mitigation plan to compensate for any adverse impacts to wetlands? [help] • If Yes, submit the plan with the JARPA package and answer 7g. • If No,or Not applicable, explain below why a mitigation plan should not be required. ❑ Yes ❑ No ,�j Not applicable 7g. Summarize what the mitigation plan is meant to accomplish, and describe how a watershed approach was used to design the plan. [help] A 7h. Use the table below to list the type and rating of each wetland impacted, the extent and duration of the impact, and the type and amount of mitigation proposed. Or if you are submitting a mitigation plan with a similar table, you can state (below) where we can find this information in the plan. [help] Activity (fill, Wetland Wetland Impact Duration Proposed Wetland drain, excavate, Name type and area (sq. of impact3 mitigation mitigation area flood, etc.) rating ft. or type4 (sq. ft. or category2 Acres) acres) 4/1 'If no official name for the wetland exists,create a unique name(such as'Wetland 1"). The name should be consistent with other project documents,such as a wetland delineation report. 2 Ecology wetland category based on current Western Washington or Eastern Washington Wetland Rating System. Provide the wetland rating forms with the JARPA package. 3 Indicate the days,months or years the wetland will be measurably impacted by the activity.Enter"permanent"if applicable. 4 Creation(C),Re-establishment/Rehabilitation(R),Enhancement(E), Preservation(P),Mitigation Bank/In-lieu fee(B) Page number(s) for similar information in the mitigation plan, if available: JARPA Revision 2012.2 _ , , . 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] R IF ENA:"l(�� ID N A APR 012015 JEFFERSON LUUN I uuU 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 !v 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 Ur 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. [helpl ❑ Not applicable IJSe o/ gt /fie/rk a 4,6' / 't :�• 1<%,,ve lacer 144i ' '11 yr. e /A,14"de f5- h e ft-c9 8b. Will your project impact a waterbody or the area around a waterbody? [help] ❑ Yes kNo IA ODA 0n4') Dona R of 14 8c. Have you prepared a mitigation plan to compensate for the project's adverse impas tb~Gir , waterbodies? [helot • If Yes, submit the plan with the JARPA package and answer 8d. APR 0 1 2015 • If No, or Not applicable,explain below why a mitigation plan should not be required. [1 Yes U No Not applicable J F SIA COUNTY bui e Jr- /l t/ten 0( it A lr j( A ..c l G a 5,'erz r-ta �ly • 0 iJtre P3 e I nva etc-t`s k/t tr b6I y ( Art k su � )e 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 / l 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 A/ 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. 2 Indicate whether the impact will occur in or adjacent to the waterbody. If adjacent,provide the distance between the impact and the waterbody and indicate whether the impact will occur within the 100-year flood plain. 3 Indicate the days,months or years the waterbody will be measurably impacted by the work. Enter"permanent"if applicable. 8f. For all activities identified in 8e, describe the source and nature of the fill material, amount (in cubic yards) you will use, and how and where it will be placed into the waterbody. [help] JARPA Revision 2012.2 Pane Q of 1d 8g. For all excavating or dredging activities identified in 8e, describe the method for excavating or dredging, type and amount of material you will remove, and where the material will be disposed. [help] APR 7 1 2015 A/A dtti-ERSON LUUNIY DEC Part 9—Additional Information Any additional information you can provide helps the reviewer(s) understand your project. Complete as much of this section as you can. It is ok if you cannot answer a question. 9a. If you have already worked with any government agencies on this project, list them below. [help! Agency Name Contact Name Phone Most Recent Date of Contact we +zd f �Ski a i O Q r7 /1 fie___ (36c) 4f57- 2316 f eve, ,,J er- Z7'l.e (Cris 94, 41x5. Dave In!c -y- i (iDa) 264- 6f24L' Hdvern6t 2 9i4 e.F e'v- OeptD,_,...0 oh id u C=vi),f-Adi/n (360) 373 - 44-84 i/n tit/7 2,6.9/5- ' 9b. Are any of the wetlands or waterbodies identified in Part 7 or Part 8 of this JARPA on the Washington Department of Ecology's 303(d) List? (helps • If Yes,list the parameter(s)below. • If you don't know, use Washington Department of Ecology's Water Quality Assessment tools at: http://www.ecy.wa.gov/programs/wa/303d/. ❑ Yes 154 No pi. q 13ieliftfifi (36 �y 4 Gals- z /..� l�,ru¢uy'�� t C)� 732-C ,3 f% 9c.What U.S. Geological Survey Hydrological Unit Code (HUC) is the project in? [help] • Go to http://cfpub.epa.gov/surf/locate/index.cfm to help identify the HUC. %7// ®Z-)j 9 9d. What Water Resource Inventory Area Number (WRIA#) is the project in? [help] • Go to http://www.ecy.wa.qov/services/gis/maps/wria/wria.htm to find the WRIA#. / 7 JARPA Revision 2012.2 Page 10 of 14 9e. Will the in-water construction work comply with the State of Washington wat qualit turbidity'? [helps Z y r • Go to http://www.ecy.wa.gov/programs/wq/swgs/criteria.html for the standards. 0 Yes n No n Not applicable 9f. If the project is within the jurisdiction of the Shoreline Management Act, what idwiztaiii amt► ECC environment designation'? [help • If you don't know, contact the local planning department. • For more information, go to: http://www.ecv.wa.dov/procirams/sea/sma/la%.vs rules/173-26/211 designations.html. I Rural ❑ Urban ❑ Natural , Aquatic n Conservancy Other 9g. What is the Washington Department of Natural Resources Water Type? [help] • Go to http://www.dnr.wa.qov/BusinessPermits/Topics/ForestPracticesApplications/Pages/fp watertypinq.aspx for the Forest Practices Water Typing System. )g[f 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 ► No 9j. If you know what the property was used for in the past, describe below. [help] A,„ 9k. Has a cultural resource (archaeological) survey been performed on the project area? [help] • If Yes, attach it to your JARPA package. n Yes No JARPA Revision 2012.2 91. Name each species listed under the federal Endangered Species Act that occurs in the vicinity of the project area or might be affected by the proposed work. [help] n ,- t� A/ 4 IL 235 ariSUN COUNTY HD 9m. Name each species or habitat on the Washington Department of Fish and Wildlife's Priority Habitats and Species List that might be affected by the proposed work. [help] Ai A Part 10—SEPA Compliance and Permits Use the resources and checklist below to identify the permits you are applying for. • Online Project Questionnaire at http://apps.ecy.wa.gov/opas/. • Governor's Office for Regulatory Innovation and Assistance at (800) 917-0043 or help(c ora.wa.cov. • For a list of addresses to send your JARPA to, click on agency addresses for completed JARPA. 10a. Compliance with the State Environmental Policy Act (SEPA). (Check all that apply.) [help] • For more information about SEPA, go to www.ecy.wa.gov/programs/sea/sepa/e-review.html. fI A copy of the SEPA determination or letter of exemption is included with this application. A SEPA determination is pending with (lead agency). The expected decision date is C I am applying for a Fish Habitat Enhancement Exemption. (Check the box below in lob.) [help] This project is exempt (choose type of exemption below). X Categorical Exemption. Under what section of the SEPA administrative code (WAC) is it exempt? .) Other: C SEPA is pre-empted by federal law. IAPDA P ,iicinn 7n17 9 Page 12 of 14 IR FiT,C Elf V P ED 1 Ob. Indicate the permits you are applying for. (Check all that apply.) [help] LOCAL GOVERNMENT �;` Local Government Shoreline permits: (J 1LCCLO� � �oU�N D�D Substantial Development n Conditional Use 1:1 Variance ryj Shoreline Exemption Type (explain): ke c pea "-ion / eoi--/A ej 80 u y ,rt° el-3 c�,v C-� <<�d� Acr A Cam'dam,f ion Other City/County permits: ❑ Floodplain Development Permit ❑ Critical Areas Ordinance STATE GOVERNMENT Washington Department of Fish and Wildlife: Al Hydraulic Project Approval (HPA) E 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: yi$150 check enclosed. Check# Attach check made payable to Washington Department of Fish and Wildlife. ❑Charge to billing account under agreement with WDFW. Agreement# n 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: IX 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 On 404 (discharges into waters of the U.S.) n Section 10 (work in navigable waters) United States Coast Guard permits: ❑ Private Aids to Navigation (for non-bridge projects) JARPA Revision 2012.2 -SCE)J VED Part 11—Authorizing Signatures �q �tt ��gg��qq�� Signatures are required before submitting the JARPA package. The JARPA package includd etIAfZI'�t'I�brm, project plans, photos, etc. (helpl JEFFERSON f'^I �l JEFFERSON COUNTY DCB 11 a. Applicant Signature (required) [help] I certify that to the best of my knowledge and belief, the information provided in this application is true, complete, and accurate. I also certify that I have the authority to carry out the proposed activities, and I agree to start work only after I have received all necessary permits. I hereby authorize the agent named in Part 3 of this application to act on my behalf in matters related to this application. (initial) By initialing here, I state that I have the authority to grant access to the property. I also give my consent to the permitting agencies enterjgg he property where the project is located to inspect the project site or any work related to the project. (initial) eirP / DatA ..3/45-- Applicant Pnn�d Name App scant Sr nature 11 b. Authorized Agent Signature [help] I certify that to the best of my knowledge and belief, the information provided in this application is true, complete, and accurate. I also certify that I have the authority to carry out the proposed activities and I agree to start work only after all necessary permits have been issued. Authorized Agent Printed Name Authorized Agent Signature Date 11 C. Property Owner Signature (if not applicant) [help] Not required if project is on existing rights-of-way or easements. I consent to the permitting agencies entering the property where the project is located to inspect the project site or any work. These inspections shall occur at reasonable times and, if practical, with prior notice to the landowner. Property Owner Printed Name Property Owner Signature Date 18 U.S.0§1001 provides that:Whoever,in any manner within the jurisdiction of any department or agency of the United States knowingly falsifies,conceals, or covers up by any trick,scheme, or device a material fact or makes any false,fictitious, or fraudulent statements or representations or makes or uses any false writing or document knowing same to contain any false,fictitious, or fraudulent statement or entry,shall be fined not more than$10,000 or imprisoned not more than 5 years or both. If you require this document in another format, contact the Governor's Office for Regulatory Innovation and Assistance(ORIA)at(800) 917-0043. People with hearing loss can call 711 for Washington Relay Service. People with a speech disability can call (877)833-6341. ORIA publication number: ENV-019-09 rev. 08/2013 IA DDA Dcvicinn 9(117 9 Page 14 of 14 lot k egnaw& I1 j1 ;❑Town WASHINGTON STATE tgApocalkta Fay - ❑Fee NM Joint Aquatic Resources Permit = ;StielvAppritatemn oRieneffiaAppsadion Application (JARPA) lid :▪ T >c c ap ; uginitiab • RE Asada Irmance II Aftach ent E: ; T f Aquatic Use Authorization on • AQR x Department of Natural Resources ( Tar Pandit* : DNR)-managed aquatic lands ihqm 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) 902-1100 or going to http:/lwww.dnr.wa.00v/Publications/aqr land manager map.pdf. lheipi • 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.lheipi 1. Applicant None( .Fm.Wide) III Q ''d by eo i-f e "Cod/ 2. Phone Ntunb and Eirtz 0 , — 9e3-- 3-6/9 3. Which of the feffaiking apprtes te Applicant?Check one and,t apiAceble,atach the tats aithorty—by taws,power of aftontey.etc..f3 O Corporation ❑ Incividual ❑ limited Painersh0 Maitt Community(Idenbly spouse): 41D1111_ fVDi ❑ General Partnership ❑ Government Agency o Limited qty Company ❑ Other(Reese Explain): Home State of Registration: 1[;r-E-TAVEi) JARPA Attachment E Revision 2012.2 APR 0 1 2015 Paae 1 of 2 JEFFERSON COUNTY DCO 4. Washington U®1(U Ted Busirmss Identifier) , if appficable. gmbj Mq 5. Are you aware of any existing or,previously citified Aquatic Use Authorizations atthe project location? Yes F No ®Don't know If Yes,Authorization number(s): 6. Do you intend to sublease the property to somecne else? Yes ! No If Yes, contact your Land Manager to discuss sitileastig.. 7. If fill material was used wavitmsly on DNR-managed aquafic lands,describe below the type of fill material andthe-purpose for using it l NA 1 To be completed by DNR and-a copyJreturned'to the applicant' Signature for projects on DNR-managed aquatic lands: Applicant must obtain the signature of DNR Aquatics District Manager OR Assistant Division Manager if the project is located on DNR-managed aquatic lands. I, a designated representative of the Dept. of Natural Resources, am aware that the project is being proposed on Dept. of Natural Resources-managed aquatic lands and agree that the applicant or his/her representative may pursue the necessary regulatory permits. My signature does not authorize the use of DNR-managed aquatic lands for this project. ml.;44ft' r(/4- -t 3/247//4- Printed Name Signature Dept.of Natural Resources Dept of Natural Resources Date District Manager or Assistant Division Manager District Manager or Assistant Division Manager If you require this dominant in another format,coded the Govemnots OlSce for Regulatory lenovation and Assistance(ORIA)at (800)917-0041 People with treating loss can call 711 forinfashirtgton Relay Service.People with a speech chsabity can can (877)833.6341_ ORIA Publication ENV-049-12 rev.081 )13 ECEJV'ED APRr1a JEFFEUSUN CUUNTY DCD C R FPM " s ee ,see4rvii-ele J c 0 A.) isu 6 e 4,1 s 4t- 6 $. c_J n A9 4 „,, ,r-7;r1„ re 5 v I 74—e- e rfri e.A-1 tg'$4 eJ <e .c. /47 pt .` \,e9 sr heei 4 rt.z.. L. Er\TED APR 0 1 2015 bruiStiN COONIY DCD R ECEJvEn APR 0 1 2015 JEFF 'f ; no F(4.1 te.. ke5 Map/Directions Marrowstone Island Fort Hogier State Pork Marrowstone Island can be easily reached from the Quimper Peninsula on ''\, 1 Flag ler Rd. south of Port Townsend and `�. "'�_`°�" t°"e 9 '1 to:nti Port Hadlock. `°`'1 Wf'"nd I� From Olympia and southwest Take Interstate 5 north to Poi Olympia.Take Highway 101/12 MY'`" "Bay , toward Aberdeen/Shelton and Indian i «� �', N -ti.c.-Lt ,, then north on Highway 101 U5 Naval toward Shelton. Follow 101 a"°`"` ire north to Quilcene and take the `, Mcwlc Center Valley Rd.to the right. Part Wa tlt Follow to Chimacum.At the 4- - ; .f- "�.,, }— way intersection with Beaver } \K'"='°`Rd o Valley Rd./SR 19,go straight. ode n At the 4-way intersection in Port Bay eoa6.4„Pt. Hadlock,take a right on Hagler \\Rd. and follow signs to Fort Ch um Flagler. '.0\ Oak Bayl J From Seattle For more maps and directions visit: PTguide-City Guide to Port Townsend From Colman Dock (Pier 52), take the Seattle-Bainbridge ferry to Bainbridge Island.Take State Route (SR) 305 north/west At Ness' Corner Rd. take a right. about 13 miles (past Poulsbo) to At the 4-way intersection with State Route (SR) 3 north and Irondale Rd. go straight and follow the signs 7 miles to the follow Flagler Rd. Follow signs Hood Canal Bridge.Take a left to Fort Flagler. and cross the bridge.Take a -------- - right immediately off the bridge (Oak Bay Rd.) and follow north to a right on Flagler Rd. and follow signs to Fort Flagler. No r 4 go cti y From Sequim and Port Angeles O,r/ IA, 0/Y —� � o wie Take Highway 101 east,then a 1,1 in a /,rig ,v f-te,-yl e 2'5. left onto State Route (SR) 20 east. Follow SR 20 to Anderson IR F CI EIATEn Lake Rd. and take a right.At Rhody Drive/SR 19 take a left. APR 0 1 2015 JEFFERSON COONIY ULU . ... 1 At... . A, A 1 1 ,.., 0 , .. , ptute ■Zi 1 — . _.. . , - - d , ..... „,., . „....„, , \ 14- ...___. Parcel .,\v% . .. ..,. , .. . 4 ., marro., al 'land a \ O b . ...„ It • „10,,,,,,,,r,'44.1 n ••• otOW **4'* ' ; .4 Marrowstone b , . $ , Go„. s 1 e earth feet1 km1 1 14000 ilk 13 EcETATET) APR 0 1 2015 N ;5 . 1,?; r c, L, ),/ ' / ryi a 1...,_ r, If 5 ,1 $1, - Eft.•■ / \\ :,"*."4°..*.":^1.— ' ;*1 ' _____, _. `' ;1 « ar 3 953 '- Sw A, Ct rG /e - ®— [ lD ',esr exist- { N. m„. .7 �''xist' bogy i, Goggle earth,” 2015 Googie Google earth feet 400 )44 meters 100 IR ECET f APR 3 1 2015 JEFFERSON COUNTY BCD /Vt9KciJy 8®tL/ .'1 e p la_ ki JOB EARTH TECH ,/jj 10800 NE 8th Street Seventh Floor SHEET NO. [' OF -- Bellevue, Washington 98004 CALCULATED BY (425) 455-9494 L? i f ( -A EMS'F 1 FAX (425) 453-9470 CHECKED BY l DATE SCALE ,-I'R 0 1 2015 Afor d 8 au / JEFFERSON COUNTY DO d.A f, A ! n12 KY) VV Sye I.-- . 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