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CASE # E/I)IJfC/-O@6
Th S E' I P I' S RC 3 J.,....,- .... . I ...-",., N99 &~~
e tate nVlronmenta 0 ICY Act (EPA), W4.L I v:- requires al governmental agencret to consllfer the
environmental impacts of a proposal before making decisions. An environmental impact statement (EIS) must be
prepared for all proposals with probable significant adverse impacts on the Quality of the environment, The purpose
of this checklist is to provide information to help you and the agency identify impacts from your proposal; reduce or
avoid impacts from the proposal, if it can be done; and help the agency decide whether an EIS is required.
PROPONENT:,,)~t.o\oSQ.~ ,-"",~ Q~1'.\Jlo\e.~Sh\~
ADDRESS:-.A2.5o S. t)'.~~o,,~~"1 e..,."" "~~\-\~t>>,",,5LI4~J W~. q~J~th
TELEPHONE: (home) 3(,,0 - ~ ~ S. Z. 7 ~ 0 (business) 7. 0 G,- ~ 1 ~ - <) 30 5
AUTHORIZED REPRESENT A TIVE/CONT ACT:-K ~~ U Ac:.J<) '\0 ~ e.....
ADDRESS: ~'L~O 'S. \:j\'S.~O"QA2...1 ~~. \ Y()-L\-\o""''''Stl~d, WA. ~<b3 Co~
TELEPHONE: (home) 3 (00 - 3 g,.5 - ?- 7 .5 ~ (business) '2. 0 (g - (p ~ ~ - <7 2 ~ $'
DIRECTIONS
This checklist asks you to describe some basic information about your proposal. The Questions apply to the entire
proposal, including those phased over a period of time or on separate parcels of land,
Answer each Question accurately and completely to avoid unnecessary delays in processing this checklist, If you
do not know an answer, write "unknown," or if a Question does not apply, write "not applicable."
Answers to some Questions may require special expertise or technical assistance from Qualified persons, The cost
of obtaining such information is the responsibility of the proponent.
Attach any additional information (reports, studies, maps, illustrations, leases, permits, etc.) that may further
describe the proposal or be required by Jefferson County.
Contact the Jefferson County Development Review Division for assistance in completing the checklist and for
information on the administrative procedures for its processing.
PLEASE PRINT IN INK OR TYPE EACH ANSWER, DO NOT WRITE I THE AREA DESIGNATED "EVALUATION."
PROPOSAL AND PROPERTY DESCRIPTION
PROPOSED PROJECT DESCRIPTION (include all factors that will give an accurate understanding of its scope and
purpose):
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LOG ITEM
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PROPERTY AND AREA DESCRIPTIO.
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Address: ~ \JlM~ ~~ ~~~ ~ ~ \I>.)\\.""- \o~^,\ c\~~i\~'",~ ~~A"'ul..t"W\~'S
Legal (from property tax statement): Lot:
Block:
Subdivision:
Tax Parcel:
Quarter Sections;
Section:
Township:
N
Range:
WM
Tax Number:
Land Area (dimensions):
Describe the location, physical characteristics, and extent of land area to be affected: include all factors that
will give an accurate understanding of the property and its environment:
SCHEDULE (beginning and ending dates of the proposal, including phases):
~. ,~
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r... ~ ~ Q...,\t~\
~o ~~, 0'" "-t \>Q..t'J" ~\ I
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OVERALL PLAN (describe future additions, expansions, or related activities or plans by others that may affect the
proposal) :
t-3 0 r-.~ ~ \\:, 17 to) .\
~ .,i\.},S ~iL.Q. ~\-A.w.,.:a..A ~ltA. '"~\s ~\UJ'A.
.
REQUIRED APPROVALS (all local, state, and federal approvals required for the completion's of this proposal and if
any approvals are pending that are related to the proposal):
~ ~ ~~l"'~ ~~..""" .:J1L\~\J(lS(1 ~ ~ lh'''''\y' ~o ~o~-:.\~\) ~ ~ Cl.\'\f ~\.~ ~o~S
~~ }.o \...~ ~A~a1 ~\.~\~ .k ~fYiS
ENVIRONMENTAL DATA (any existing or proposed environmental information such as studies or documents related
to the proposal):
No D"-Q.. ~ ....rhO ..1
2
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ENVIRONMENTAL COMMENTS
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EARTH EV ALUA TION
1 . Check the item that describes the site: '.
, ' flat u rolling n hilly [J steep slopes
'-'
,; mountainous X. other: ~lt-t ~\A\-. -:;.'11\2 ~'\\..;
u
2. What is the steepest slope on the site: Identify the approximate
percent of the slope: \ '2... a;~
3. What general types of soils are found on the site (sand, gravel, peat,
muck)? If you know the classification of agricultural soils, specify
them and note any prime farmland: tool '" ~ a....._ L Co ..d.
9",' ^-'.~v c:.....1~ A."'~ -...~"e>. ""'~""'.o <_\\
r .- ,
,
4. Are there surface indications or a history of unstable soils in the
immediate vicinity? If so, describe them: ~ONQ. v.... ..1" ..u ..J
5. Describe the purpose, type, and approximate quantities of any filli~~ or
grading proposed. Identify the source of the fill: H _"" ~\ ~...o.
1'I..l.\..., Co... ~oA.\^^-l ~_ tlt.A"~ 0 __ \ ... J LA .-~o'" "./
~ ~l,C!'\f.;,c,'AI\V (>\.3 ~ .
6. Could erosion occur as a result of c1ering, construction, or use? If so,
generally describe it: l:~ - sol":',,: ~Z\~"-.) .~
~LW\ <,,14l.'AW ~ " ~ \
7. About what percent of the site would be covered with impervious
surfaces after construction of the project (that is, asphalt or
buildings)?
2.(t.A..,o P~<:...e.~"
8. Describe proposed measures to reduce or control erosion or other
impacts to the earth, if any: ~iWJ~\\..Q.. {1..\)N ,,\A ~,,\\W\\."" .
~ ,,~\ t::l.... ~'1:l. ~~,~~~
AIR EVALUATION
9. What types of emiSSions to the air, if any, would result from the
proposal during construction and when the project is completed (dust,
car odors, industrial wood smoke)? Generally describe and give
approximate quantities, if known: A\.J~,,", V Q.,~,~~ AV-).\
~\~ M.Q.u~ ~'J..~,,~\-
10. Are there any off-site sources of emissions or odors that may affect
your proposal? If so, generally describe them: tJ" NQ \<..JJo ~ N
LOG ITEM
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AI.ntinuedl EVALUATION
11 . Describe proposed measures to reduce or control emissions or other
impacts to the air, if any: duST ~O~"~D\ (w~+Q.IL.) 6..S
.
o...Q.~,; \~
WATER EVALUATION
Surface Water
12. Is there any surface water body on or in the immediate vicinity of the
site, including year-round or seasonal streams, salt waters, lakes,
ponds, and wetlands? If yes, describe the type and provide names. If
appropriate, state what stream or river it flows into: NON~ ~ 0".,>....
13. Will the project require any work over, in, or adjacent to the described
waters (within 200 feet)? If yes, describe the work and attach
available plans: ~O
14. Estimate the amount of fill and dredge material that would be placed or
removed from the surface waters or wetlands and indicate the area of
the site that would be affected. Identify the source of the fill material:
~o '" l.
15. Will the proposal require surface water withdrawals or diversions?
Give a general description and identify the purpose and approximate
Quantities, if known: N()
16. Does the proposal lie within a 1 CO-year flood plain? If so, note the
location on the site plan: NO
17. Does the proposal involve any discharges of waste materials to surface
waters? If so, describe the type of waste and anticipated volume of
discharge: NO
Ground Water EVALUATION
18. Will ground water be withdrawn or will water be discharged to
groundwater? Give a general description and identify the purpose and
approximate Quantities, if known: NO
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Ground Water (continued)
1 9. Describe the waste material that would be discharged into the ground
from spetic tanks or other sources, if any (domestic sewage; industrial
wastes and chemicals contained; agricultural wastes). Describe the
general size of the system; the number of such systems; the number
of houses to be served, if applicable, or the number of animals or
humans the system(s) is expected to serve: No N ~
20.
21.
22. Describe proposed measures to reduce or control surface. ground, and
run-off water impacts, if any: 10 ~\
" ~ "
PLANTS
23. Check the types of vegetation found on the site;
Deciduous tree: iY'alder ~ maple Caspen
[j(' other: w', \\ow
Evergreen tree: if fir ~ cedar 0 pine
r5' other: \\t._\~c:..~
~ Shrubs 0 Grass 0 Pasture C Crop/Grain
Wet Soil Plants: C cattail 0 buttercup C bulrush 0 skunk cabbage
o other: NJ A
Water Plants: 0 water lily 0 eelgrass 0 milfoil
o other: r-4J..
Other:
24. What kind and amount of vegetation would be removed or altered?
5\c\{l"U~s.\o'A..I,)'!o'v\\ \.1,)lt4l.~Q.~ Ao"'~ ~o~\~uo.jS -"i'~<:,.
\~ "iU..-. ,.~ ~lao...~ 19~~~ ~~ '^~.~
25. list threatened or endangered species known to be on or near the site:
N /I) III Q \.( 10J III "'" to.>
26. Describe the proposed landscaping, use of nature plants, or other
measures to preserve or enhance vegetation on the site, if any:
~'(~~"'-s.".~ ~'\~IL<:' ~~ ~\~l\.Ilo.A.~ Q...\~\.\'.~-~A7'S
L' or; Il'Cf;V1
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EV ALUA TION
EVALUATION
EV ALUA TION
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ANIMALS EVALUATION
27. Check any birds and animals that have been observed on or near the
site or are known to be on or near ~ site:
Birds: ~ hawk 0 heron 0 eagle songbirds
0 other:
Mammals: ~ deer iifbear o elk 0 beaver
~ other: t. A<:.oC' 0.)
Fish: 0 bass 0 salmon 0 trout 0 herring ~ shellfish
u
0 other: r"'o~e..
28. List any threatened or endangered species to be on or near the site:
ND"'e. \A...,.a 17 ~...>
29. Is the site part of a migration route? If so, how? ..JO
30. Describe proposed measures to preserve or enhance wildlife, if any:
~...\O~ A.~ ""~ o~~vu i \ ~ \oN. ~1l...... .. ~~ U
t:lo.Cl.~~ .~ 'l-.\~'t.~.. ~ - -.JJ "'I~ I
ENERGY AND NATURAL RESOURCES EV ALUA TION
31. What kinds of energy lelectric, natural gas, oil, wood stove, solar)
would be used to meet the completed project's energy needs?
Describe whether it would be used for heating, manufacturing, etc.:
~~tol.~
32. Would the project affect the potential use of solar energy by adjacent
properties? If so, generally describe the affect: Nr:l
33. What kinds of energy conservation features are included in the plans
of this proposal? List other proposed measures to reduce or control
energy impacts, if any: NO""~
ENVIRONMENTAL HEALTH EVALUATION
34. Are there any environmental health hazards, including exposure to
toxic chemicals, risk of fire and explosion, spill, or hazardous waste,
that could occur as a result of this proposal? If so, describe the
hazards: \ Q......\k lIot.~t . ~ ~ \ \\"'1l ~ (l.O\M. '-~~ ~ 't t\.~ ~~ /t~
Q~~,~.t~h'l~
35. Describe special emergency services that might be required:
~\~ ~\.:l~ ~\~ v ~~\ ~\~~
36. Describe proposed measures to reduce or control environmental health
hazards, if any: Ne""t
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NOISE
37. What types of noise exist in the area that may affect your project
(traffic, equipment, operation)?' \ No ~ tllbA"~ "~,c..\~ \~.~\(;. \
O~Q,:"~\"'\J .~ I:.ll,:dtq,,,~\1'\) ~t1.\~u..Q.~\
38. What types and levels of noise would be created by or associated with
the project on a short-term or a long-term basis (construction, traffic,
operation)? Indicate what hours noise would come from this site:
~",,g.t -1-o..t"'^~~\i. 'IQ.\:'~~ ~\3~ M\3"!o\Q..\H..l\\!lU
Q..t'.\~M.~u~. "'o\,)~'. 0700 +1> \(000 ~f~ob(,
39. Describe proposed measures to reduce or control noise impacts, if
any: ~ ~Q.~~t.JL ,^-",,-,4.'\ ~~ ~~..."~,,,~\..-..)
Q..<t>,,\t~.LQu\ ~~Q.Q.~,.\.~
LAND AND SHORELINE USE
40. What is the current use of the site and adjacent properties?
\Io.~-A.~' \t\~~. t. ~~~~c..e.u~ U<;'\~Q.\.)U)~
41. Has the site been used for agriculture? If so, describe the use:
ND
42. Describe any structures on the site: No 14~
43. Will any structures be demolished? If so, what structures?
No~P
44. What is the current comprehensive plan or community development
plan designation of the site? Identify the plan: R..g. \ :-. ;
45. If applicable, what is the current Shoreline Master Program designation
of the site? N/ A
46. Has any part of the site been classified as an "environmentally
sensitive" area? If so, specify the part: NO rHo
47. Approximately how many people would reside or work in the
completed project? -e-
48. Approximately how many people would the completed project
displace? -&-
49. Describe proposed measures to avoid or reduce displacement impacts,
if any: ~J ^
LOG ITEM
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LAND AND SHORELINE USE (continued) EVALUATION
50. Describe proposed measures to ensure the proposal is compatible with
existing and projected land uses and plans, if any: NOH€.
HOUSING EVALUATION
51. Approximately how many units would be provided, if any? Indicate
whether the housing is high, middle, or low income: NON~
52. Approximately how many units, if any, would be eliminated? Indicate
whether the housing is high, middle, or low income: ~o He.
53. Describe proposed measures to reduce or control housing impacts, if
any: /'JorolQ..
AESTHETICS EV ALUA TION
54. What is the tallest height of any proposed structure(s), not including
antennas? What is the principal exterior building material(s) proposed?
"'"0 ~~O~,,~~ ~~~..,c1 u~
55. What views in the immediate vicinity would be altered or obstructed?
Nor-H)
56. Describe proposed measures to reduce or control aesthetic impacts, if
any: NoN.Q.
LIGHT AND GLARE EVALUATION
57. What type of light or glare would the proposal produce? What time of
the day would it mainly occur?"\(\)c:.~~~o~ t\tlo.~~'IIl..,^,\ \\'j"'--\
"'5;.LJ"", ~~ R.~ ,",,,...\ It'>...: ~It-.Jl '"' a.\)~... A.~ So '^t-~ ~~
58. Could light or glare from the finished project be a safety hazard or
interfere with views? NO
59. What eXisting off-site sources of light or glare may affect your
proposal? NoONe
60. Describe proposed measures to reduce or control light and glare
impacts, if any: N(!) 1'4(l
RECREA TION EV ALUA TION
61. What designate and informal recreational opportunities are in the
immediate vicinity? NO/'J~
8
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RECREATION (continued) EV ALUA TION
62. Would the proposed project displace any existing recreational uses? If
so, describe the displacement: No
63. Describe the proposed measures to reduce or control impacts on
recreation, including recreational opportunities to be provided by the
project or proponent, if any: NO Net
HISTORICAL AND CULTURAL PRESERVATION EVALUATION
64. Are there any places or objects listed on or proposed for national,
state, or local preservation registers known to be on or next to the
site? If so, generally describe them: NON.~ \l(,..4owtJ
65. Generally describe any landmarks or evidence of historic, cultural,
archaeological, or scientific importance known to be on or next to the
site: NO N~ \L...N~\.UtJ
66. Describe proposed measures to reduce or control impacts, if any:
NON~
TRANSPORT A TION EV ALUA TION
67. Identify public streets and highways serving the site and describe the
proposed access to the existing street system. Show on the site plat.
'\tJ A.<'a,,^-, ~'\.\.3 S't..~ \'-3 ::r Q.o ~-A\o. ~~1U.. ~a. i'\C.~ .
s,,~u~,,'L~ ~ 0" ~ ~ + 4.lL5Q.c:. ,,\....,
68. Is the site currently served by public transit? If no, what is the
approximate distance to the nearest transit stop? NO
69. How many parking spaces would the completed project have? How
many would the project eliminate? No !'Ie.
70. Will the proposal require any new roads, streets, or improvements to
existing roads or streets, not including driveways? If so, generally
describe them, indicating whether they are public or private:
\-~,,":\ <::.J~ \\~\: \-=0 ~,,~ "'~ ",<"}\.) S~'Q.\)~ \ ,,~ ,,~ ~QJJ.J
R ..~~s
71. Will the project use water, rail, or air transportation, or occur in the
immediate vicinity of these facilities? If so, generally describe the use:
NON.~
I rv" n-'~'p,n
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TRANSPORTATION (continued)
72. How many vehicular trips per day would be generated by the
completed project? If known, indicate when peak volumes would
occur: lJ ~ \(oll'1\.UN
EVALUATION
73, Describe proposed measures to reduce or control transportation
impacts, if any: ....0 ~e.
PUBLIC SERVICES
74. Would the project result in an increased need for public services (fire
protection, police protection, health care, schools)? If so, generally
describe the results: r-J 0
EVALUATION
75. Describe proposed measures to reduce or control direct impacts on
public services, if any: NO.... Q
UTILITIES
76. Check which utilities are currently available at the site:
o water u( electricity 0 natural gas 0 refuse service
r$ telephone 0 septic system 0 sanitary sewer
rY other: ~ A\a\4. v
77. Describe the utilities that are proposed for the project. the utility
providing the service, and the general construction activities on the
site or in the immediate vicinity that might be needed: N (7 "L
EVALUATION
ACKNOWLEDGMENT
I acknowledge that all information provided in this checklist and all attached material is true and correct to the best of my
knowledge. I understand the lead agency is relying on this information to make its decision. In addition, I understand that review
under SEPA does not constitute approval or a proposal; compliance with local, state, and federal regulations applicable to the
proposal shall constitute approval. (Check with appropriate agencies to determine what approvals are required.) SEPA approval is
based on t information I have provided. If found inaccurate, approval could be withdrawn.
~,,~ Q. ~ I \~~~
(date)
(authorized signaturel
FOR OFFICE USE ONt y
FEE
RECEIPT#
CHECK#
DATE
INITIALS
h:lhomelplncntrlinfoplnglsopa. doc
06/13/97
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