Shorelines & Sensitive Areas Permit Application
APPLICATION No. __________________
SECTION I - Applicant and Property Information
1. Owner Name:________________________________
Mailing Address:__________________________________________________________________
Alternate/Cell phone: Fax #:
2. Applicant/Authorized Agent:______________________________
Mailing Address:________________________________________________________________
Alternate/Cell phone: Fax #:
3. Property/Activity Location:
ite Address: __________________________________________ Tax Parcel No.:_____________
Section:_______ Township:_________ Range:__________ Allotment No.:_____________
4. Applicant/
owner interest in property: ___Owner
___Purchaser ___Lessee ___other:
if Other ____________________________________
Section II – Project Information
5. Describe the current use of the property and any structures on the property.
Shoreline Class: ____ High Intensity ____ Shoreline Residential ____ Rural Conservancy
____ Natural Shoreline ____ Aquatic Lands
6. Describe the proposed activity and the activity’s purpose. Include a general description
of probable impacts on shorelines, wetlands, and fish and wildlife. Provide a site plan and
basic design for the project including slope contours (5 ft intervals as appropriate). For
any proposed work below the Mean Higher High Water Mark or top of a marine bluff,
provide a cross-sectional diagram with the location of the Ordinary High Water Mark
indicated, cubic yards and types of any materials to be placed, and types of equipment to
be used. Please attach additional sheets as necessary.
7. Proposed S
duration of activity_______________
Will the project be phased?
YES  NO
8. Are any of the proposed activities within 100 feet of a stream or within 50 feet of the top of a
ravine through which a stream
runs? 
YES NO
9. Are any proposed activities within 200 feet of any fish and wildlife area?  YES NO
If yes, submission of a Fish and Wild
life Sensitive Areas Report is required
(see Section 19-04.450)
10. Are any proposed activities within a wetland or its associated buffer?  YES NO
Will any fill be placed in any wetlands?  YES  NO
If yes to either question above:
1. Has delineation been completed?  YES NO (
if yes, attach to application
2. Type and composition of fill material (e.g. sand, gravel, etc.) _________________
3. Material source:________________________________
4. Impacted area:________________________________
11. Are any proposed activities within 200 feet of any wetland?  YES  NO
If yes, submission of a Wetlands Report is required (see Section 19-04.420)
12. Will proposed activity cause flooding or draining of a wetland?  YES  NO
If yes, impacted area: ____________________(acres)
13. Is excavation or dredging proposed in water or wetlands?  YES  NO
If yes, volume:___________(cubic yards).
14. Is the proposed project within a geologic hazard area? YES  NO
15. Is there any road work associated with this application?
If yes, complete all blocks that apply and
label each type separately on the map.
Type of Activity Total Length (ft.) Total length of work area
New road _______ _______
Existing Road Reconstruction _______ _______
Existing Road Maintenance _______ _______
16. Will any other impervious areas be constructed as part of this project?  YES  NO
If yes, describe type and extent (square feet):
Section III - Other permits and approvals.
17. List other applications, approvals, or certificat
ions required from this or other agencies for any
structures, construction, discharges, or other activities described in the application (i.e. preliminary plat
approval, health district approval, building permit, TEP
review, et
lso indicated whether work has
been completed and indicate all existing work on drawings.
Type of Approval
Issuing Agency I.D. No. Date of Application Date Approved
18. Has any agency denied approval for the activity described herein or for any activity directly
to the
activity de
d herein YES  NO
If yes, explain:
Application is hereby made for a permit to authorize activities described herein. I certify that I am familiar with
the information contained in this application, and that to the best of my knowledge and belief, such information
is true, complete, and accurate. I further certify that I possess the authority to undertake the proposed
activities. I hereby grant to the officials of the Swinomish Indian Tribal Community the right to enter the above-
described location to inspect the proposed or completed work.
______________________________________________________ __________________________
Signature of Applicant or Authorized Agent (REQUIRED)
click to sign
click to edit