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
Also 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
scribed 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) Date
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