Wash. Admin. Code § 173-27-990 – Appendix A

Appendix A

Shoreline Management Act

Permit Data Sheet and Transmittal Letter

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 Information:	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)



Water Body Name:
Shoreline of Statewide Significance: Yes No .
Environment Designation:
Description of the Project: (Summary of the intended use or project purpose)



Notice of Application Date:		Final Decision Date:
By:	(Local Government Primary Contact on this Application)
Phone No:

[Statutory Authority: RCW 90.58.140(3) and [90.58].200. WSR 96-20-075 (Order 95-17), § 173-27-990, filed 9/30/96, effective 10/31/96.]