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Home My WebLink AboutAPPLICATIONDEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street, Port Townsend, WA 98368 Tel: 360.379.4450 1 Fax: 360.379.4451 Web: vvunv. ms - myamy_Com al 11 ni ry acych)l2me E-mail: c] c3 �co.=c ffcr.o;►.►vs:u. PERMIT APPLICATION 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 Related Application #s: Site Information Assessor Tax Parcel Number: 601071002, 601071001 Site Address and/or Directions to Property: Pnint Mlhifna►■ R Access (name of street(s)) from which access will be gained: Present use of property: WDFW Access site Description of Work (include proposed uses): Buildin Wastewater - Sewal Building Permit # MLA # new public boat launch on top of existing launch. This property is served by Port Townsend or Port Ludlow sewer system? YES ^ _ NO If not served by sewer identified above, identify type of Tyoe of Sewage System Serving Property: ✓ Septic Septic Permit #: is system below: Community Septic Name of System: Pressure Distribution System Case #: SEP98-00126 Are other residences connected to the septic system? Additions or repairs to sewage system: Is it a complete or partial system installation: Has a reserve drainfield been designated? Complete _ Partial 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: 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 isthe responsibility of the authorized agent/representative and owner to ensure their mailbox accepts County email (i.e., Countv email is not blocked or sent to "funk mail"). Owner Information Pronertv Owner: Name: Washington Department of Fish and Wildlife- Chris Gourley Address: 600 Capitol Way North; Olympia, WA 98501 Phone #: 360-790-3118 E-mail Address: Chris.Gourley@dfw.wa.gov Please contact Authorized Agent/Representative with project info. (select only one). Christina L Gourley °s.E- ° Date: 12/31/2020 Property Owner Signature: 1 - 231rz°4. « "°°""m " """'"`�°""° Note: For projects with multiple owners, attach a separate sheet with each owner(s) information and signatures. Applicant: Authorized Agent/Representative (if 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: License # Address: Phone #: E-mail Address: _I Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant Name: License # Address: Phone #: E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant Name: License # 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 or her 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 the County's intent to enter upon the property for visits related to this application and subsequent permit issuance. ow. ape° p mn.en icw.y "W Christina L Gourley12/31/2020 Signature; ChristinaLGourley ,U.. Print Name:Date: MIA # DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street, Port Townsend, WA 98368 Tel: 360.379.4450 1 Fax: 360.379,4451 Web: >vw.as icFfernst.wa.u,Icnrnmutaitydcvclulsnxrtt Jan 01 2021 SUPPLEMENTAL APPLICATION SHORELINE DEVELOPMENT A completed application form is a requirement of submittal. Include "N/A" in Case # JEFFERSON COUNTY 11DCC that do not apply. Application Type (select one): I Statement of Exemption - See Examples on back side of application 1-1 Variance* Conditional Use (administrative)* Substantial Development* Conditional Use (discretionary)* 1) Does your proposal require in water work and/or works below ordinary high water mark? Yes [ ] No [ ] 2) Does your pronn-al require 1n,000 sq/ft or more of impervious siirfarp anri/nr nnn-single family structures of 5,000 sq/ft or more? Yes [ ] No [ ] * If either of the boxes for 1 or 2 above are checked yes or if the permit type above has an asterisk then a pre -application conference is re uired prior to submitting for a shoreline permit. Site Information Assessor Tax Parcel #: Property Owner Name(s): 601071002; 601071001 I Name of Body of Water: WA Department of Fish and Wildlife Project Description Describe the existing property use and condition: Existing property has a public restroom facility, public parking area, and water access. Buildings are ]eased by o other parties. I he bathroom aci i y and parking area were upgraded in grade of the beach. Beach sediment accumulates up to 12" which does not allow for public use of the ramp. Proposed distance from ordinary high water mark to use/development: 0 feet Describe the proposed work that requires a shoreline permit or permit exemption: Building a new boat launch on top of the existing boat launch to meet the grade of the beach sediment, reducing accumulation on the launch. I his will a low the aunc o be used y e 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 or her 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. Owner Signature: Christina Gourley Date: 12/30/2020 Christina L Gourley Print Name:•�.w....aw.o_wn�,�a�o.o,w�,Mo,Fe�.bw,�,. These activities require a formal statement of Exemption issued by Jefferson County. Check 'Statement of Exemption' box on the front of this form and submit with Permit Application to apply for your Exemption Approval. 18.25.570 Statement of Exemptions (1) The administrator is hereby authorized to grant or deny requests for statements of exemption from the shoreline substantial development permit requirement for uses and developments within shorelines that are specifically listed above. Such statements shall be applied for on forms provided by the administrator. The statement shall be in writing and shall indicate the specific exemption of this program that is being applied to the development, and shall provide a summary of the administrator's analysis of the consistency of the project with this program and the Act. As appropriate, such statements of exemptions shall contain conditions and/or mitigating measures of approval to achieve consistency and compliance with the provisions of this program and Act. A denial of an exemption shall be in writing and shall identify the reason(s) for the denial. The administrator's actions on the issuance of a statement of exemption or a denial are subject to appeal pursuant to the appeal provisions in Article X of this chapter. 18.25.560 Exemptions listed — This is a summary from JCC18.25.560, please review the code section for detailed information regarding these exemptions. (1) Fair Market Value. (2) Maintenance and Repair. (3) Residential Bulkhead. (4) Emergency Construction. (5) Agriculture. (6) Drainage. (7) Navigation Aids. (8) Single -Family Residences. (9) Residential Docks. (10) Irrigation. (11) State Property. (12) Energy Facilities. (13) Site Exploration. (14) Noxious Weeds. (15) Watershed Restoration. (16) "Watershed restoration project" (17) "Watershed restoration plan" (18) A public or private project, the primary purpose of which is to improve fish or wildlife habitat or fish passage. SuJ1J)1Cmcntal Shorcliuc . Applicuiton Page 2 of 2