From:

(local government)

 

To:

(appropriate Ecology office)

 

 

 

 

 

 

 

 

 

Date of Transmittal:

 

 

Date of Receipt:

(provided by Ecology)

Type of Permit: (Indicate all that apply)

 

Substantial Development ; Conditional Use ; Variance ; Revision ; Other .

Local Government Decision: Approval ; Conditional Approval ; Denial :

Applicant's Representative: (if primary contact)

Name:

 

 

Name:

 

 

 

 

Address:

 

 

Address:

 

 

 

 

 

 

 

 

 

 

Phone(s):

 

 

Phone(s):

 

 

 

 

Is the applicant the property owner? yes no

Location of the Property: (Section Township and Range to the nearest 1/4, 1/4 Section or latitude and longitude, and a street address where available)

 

 

 

 

Shoreline of Statewide Significance: Yes No .

 

Description of the Project: (Summary of the intended use or project purpose)

 

 

 

 

 

By:

(Local Government Primary Contact on this Application)

Phone No: