Kitsap County Department of Community Development Phone: (360) 337-5777
614 Division Street, MS-36 Form Number: 4207A
Port Orchard, WA 98366-4682 Email: help@kitsap1.com
www.kitsapgov.com/dcd/ Page 3 of 3
Revision Date: 7/18/18
AFFIDAVIT OF BUFFER POSTING
CERTIFICATION:
I, _____________________________ of ______________________________
(Wetland Specialist) (Company)
hereby certify that no jurisdictional wetland is located within 250 feet of any proposed
regulated activity associated with this single-family development, as indicated on the
attached site plan and as submitted as part of the building permit or Kitsap County Health
District application for the above-referenced property.
OR
I, _____________________________of ______________________________
(Wetland Specialist) (Company)
hereby certify that a jurisdictional wetland is present within the 250 feet of a proposed
regulated activity associated with this single-family development, as indicated on the
attached site plan and as submitted as part of the building permit or Kitsap County Health
Department application for the above-referenced property. The wetland is a Category
___ wetland as determined using the Department of Ecology Rating Form (Pub.
14-06-029). I also certify that all proposed regulated activities will be outside of the
wetland, the required _____ foot buffer, and 15-foot building setback, as indicated on the
enclosed site plan.
ACCEPTANCE:
I, _______________________________ (Property Owner) understand that I am responsible
for the accuracy of this form. I understand that all regulated activities must occur outside of
any wetland and buffer areas shown on the attached site plan. I also understand that Kitsap
County reserves the right to enter the above-referenced property to confirm the accuracy of
this form and that I am responsible for correcting any identified inaccuracies, including but not
limited to, providing mitigation for impacts to wetland or buffer areas. I also understand that
my development must still meet all other applicable state and federal wetland regulations.
Signatures: ______________________________________________________
(Wetland Specialist) (Property Owner)
Date signed: _____________________________________________________
VALID FOR 5 YEAR FROM DATE OF SPECIALIST’S SIGNATURE
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