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HomeMy WebLinkAboutSHX2007-00081 JARPA - SHX Application - 1/11/2007 DAJe Recelved:_ JOINT AQUATIC RESOURCES PERMIT APPLICATION FORM (DARPA) (for use in Washington State) PLEASE TYPE no pRiNT IN BLAg-K INK I am applying for a Fish Habitat Enhancement Project Per requirements Of RCW 75,20.350. You must sum of this Completed JARPA application form, and the(Fish Habitat Enhancement DARPA Addition) to your local a copy Govemment Planning Department and Washington Department of Fish& Wildlife Area Habitat Biologist on the same day. NOTE: LOCAL GOVERNMENTS-You mint submit any comments on these projects to WDFW within 15 working c Based on the instructions provided, I am sending copies of this application to the following:0 Local Government for shoreline:❑Substantial Development {check all that apply) Management ❑Conditional Use ❑Variance *Exemption ❑ Revision Washington Department of Fish andpWilildlife for HPA(Submit 3❑ pies to WDFW R ical Areas finance ❑ Washington Department of Scot `� ��) ❑ Washington Department of Natural Resources for AquaticResources Use Certification tAuthoriza on Notificationwide Permits(to ion office-Federal Permit Unit) 0 Corps of Engineers for: ❑Section 404 ❑Section 10 permit ❑ Coast Guard for Section 9 Bridge Permit ❑ US Fish$Wildlife Service or National Marine Fisheries Service for Endangered Species Act(ESA)Consultation SECTION A-Use for all permits covered by this application. Be sure to ALSO complete Section C(Signature Block)for all permit applications. I.APPLICANT ( i I ( _ PP ns. MAILING ADDRE�:SS� SJA `C. -r 14. Ct�d`� �S WORK PHONE E-MAIL ADDRESS HOME PHONE FAX# h'an agent is acting for the applicant during the permit process,complete#2. 2.AUTHORIZED AGENT MAILING,ADDRE U -r'►"'/�l WORK PHONE. l' "`i"{ Ck �s aQ6 a 1� MAIL ADDRESS HOME PHONE V FAX# 3.RELATIONSHIP OF APPLICANT TO PROPERTY: V OWNER O PURCHASER ❑LESSEE ❑OTHER; 4+NAME.ADDRESS,AND PHONE NUMBER OF PROPERTY OWNER(S),IF OTHER THAN APPLICANT: e LOCATION(STREET ADDRESS.INCLUDING CRY,COU AND ZIP C W 11 �� y<,�PROPOSED A r1Y EXISTS OR WILL OCCUR) LLr LOCAL GOVERNMENT WITH JURISDICTION(CITY OR COUNTY) ATERBODY 71 (�Q✓ L p t e RISMARY J 1 Ru# 'I.SECTION SECTION TOWNSHIP RANGE /kli�o r0A GOVERNMENT LOT SSHORELINE DESIGNATION � �3n 1UJ LATITUDE&LONGITUDE F KNOWN: ONING DESIGNATION AX PARCEL�Q J / ) 3 o 5 + 0 C�^� DNR STREAM TYPE IF KNOWN �3 4.J 6. DESCRIBE THE CURRENT USE OF THE PROPERTY,AND STRUCTURES EXISTING ON THE PROPERTY. IF ANY PORTION OF THE PROPOSED ACTIVITY IS ALREADY COMPLETED ON HIS PROPERTY,INDICATE MONTH AND YEAR OF COM ION. IS THE PROPERTY AGRICULTURAL LAND? 0 YES ill NO ARE YOU A USDA PROGRAM PARTICIPANT? 0 YES %NO Ta. DESCRIBE THE PROPOSED CONSTRUCTION AND/OR FILL WORK FOR THE PROJECT THAT YOU WANT TO BUILD THAT NEEDS AQUATIC PERMITS: COMPLETE PLANS AND SPECIFICATIONS SHOULD BE PROVIDED FOR ALL WORK WATERWARD OF THE ORDINARY HIGH WATER MARK OR LINE,INCLUDING,TYPES OF EQUIPMENT TO BE USED. �APPLYING FOR A SHORELINE PERMIT,DESCRIBE 6,WORK WITHIN AND BEYOND 200 FEET OF THE ORDINARY HIGH WATER MARK. ATTACH A SEPARATE SHEET IF ADDITIONAL SPACE IS NEEDED. z4 p u,)( ci.)A cju-kbTn Ooo,4 Occ b. DESCRIBE THE PURPOSE OF THE PROPOSED WORK AND WHY YOU WANT OR NEED TO PERFORM IT AT THE SITE. PLEASE EXPLAIN ANY SPECIFIC NEEDS THAT HAVE INFLUENCED THE DESIGN. I Le. bad (A 0( iC `moo vn ��sh o )odc c. DESCRIBE THE POTENTIAL IMPACTS TO CHARACTERISTIC USES OF THE WATER BODY. THESE USES MAY INCLUDE FISH AND AQUATIC LIFE,WATER QUALITY,WATER SUPPLY, RECREATION,and AESTHETICS. IDENTIFY PROPOSED ACTIONS TO AVOID,MINIMIZE,AND MITIGATE DETRIMENTAL IMPACTS,AND PROVIDE PROPER PROTECTION OF FISH AND AQUATIC LIFE. ATTACH A SEPARATE SHEET IF ADDITIONAL SPACE IS NEEDED. a PREPARATION OF DRAWINGS: SEE SAMPLE DRAWINGS AND GUIDANCE FOR COMPLETING THE DRAWINGS. ONE SET OF ORIGINAL OR GOOD QUALITY REPRODUC713LE DRAWNGS M W ATTACHED, NOTE: APPLICANTS ARE ENCOURAGED TO SUBMIT PHOTOGRAPHS OF THE PROJECT SITE,BUT THESE DO NOT SUBSTITUTE FOR DRAWINGS. THE CORPS ENGNNFERS AND COAST GUARD REQUIRE DRAWN W ON 8-112 X if'NCH SHEETS. LARGER DRAWN"MAY l8E REQUIRED 8Y OTTER AGENCIES OF WILL THE PROJECT BE CONSTRUCTED IN STAGES? J PROPOSED STARTING DATE: / •- L,q ❑YES D NO ESTIMATED DURATION OF ACTIVITY: 41 wee J s CHECK IF ANY STRUCTURES WILL BE PLACED: Jrt WATERWARD OF THE ORDINARY HIGH WATER MARK OR LINE FOR FRESH OR TIDAL WATERS:AND/OR OWATERWARD OF MEAN HIGH WATER LINE IN TIDAL WATERS 10.WILL FILL MATERIAL.(ROCK,FILL.BULKHEAD,OR OTHER MATERIAL)BE PLACED: rvo CI WATERWARD OF THE ORDINARY HIGH WATER MARK OR LINE FOR FRESH WATERS? IF YES,VOLUME(CUBIC YARDS)_ /AREA (ACRES) 0 WATERWARD OF THE MEAN HIGHER HIGH WATER FOR TIDAL WATERS? IF YES,VOLUME(CUBIC YARDS) AREA (ACRES) 11.WILL MATERIAL BE PLACED IN WETLANDS? IF YES:' A. IMPACTED AREA IN ACRES: D YES *NO B. HAS A DELINEATIOq BEEN COMPLETED? IF YES.PLEASE SUBMIT WITH APPLICATION. C. HAS A WETLAND REPORT BEEN PREPARED? IF YES,PLEASE SUBMIT WITH APPLICATION. 0 YES 0 NO D. TYPE AND COMPOSITION OF FILL MATERIAL(E.G..SAND,ETC.): rto ❑YES IWNO E. MATERIAL SOURCE: F. LIST ALL SOIL SERIES(TYPE OF SOIL)LOCATED AT THE PROJECT SITE,&INDICATE IF THEY ARE ON THE COUNTyS UST OF HYDRIC SplLS.SOUS INFORMATION CAN BE FROM THE NATURAL RESOURCES CONSERVATION SERVICE(MRCS): OBTAINED 12.WILL PROPOSED ACTIVITY CAUSE FLOODING OR DRAINING OF WETLANDS? IF YES,IMPACTED AREA IS_ACRES, 13.WILL EXCAVATION OR DREDGING BE REOUiRED IN WATER OR WETLANDS? 0 YES V NO IF YES: A. VOLUME: ❑YES ONO (CUBIC YARDS)/AREA (ACRES) B. COMPOSITION OF MATERIAL TO BE REMOVED: C. DISPOSAL SITE FOR EXCAVATED MATERIAL: tp D. METHOD OF DREDGING: 14.HAS THE STATE ENVIRONMENTAL POLK:Y ACT(SEPA}BEEN COMPLETED? SEPA LEAD AGENCY: $EPA DECISION: SUBMIT A COPY OF YOUR Sep DECISION:ECISIO : LETTER MONS.EIS.ADOPTION,EXEMPTION 1S.LIST OTHER APPLICATIONS, ETTER O WDFW A3 REQUIRED FOR A COMPLETE DECISION DATE(END OF PERIOD): ®YE3 17 NO OTHER APPROVALS,OR CERTIFICA APPLICATION REGULATORY COMMISSION DESCRIBED IN THE APPLICATION(I.E„PRELIMINARY ETHER FEDERAL,STATE OR LOCAL AGENCIES FOR ANY DRAWINGS, MMiS$K?N LICENSE(FERC},FOREST PRACTPM APPROVAL,HEALTH DISTRICT APPROVAL,BUILD)NG$ ORE&CQNSTRUCTION,DISCHARGES.OR APPLICATION ETC.)ALSO INDICATE WHETHER WORK HAS BEEN rpm,SEPA REVIEW,FEDERAL ENERGY MPLETED AND INDICATE ALL EXISTING WORK ON TYPE OF APPROVAL I$$tIING AGENCY IDENTIFICATION DATE OF APPLICATION DATE APPROVED COMPLETED? NO. 3-HAS ANY AGENCY DENIED APPROVAL FOR THE ACTIVITY DESC HEREIN? ©YES LWIVO IF YES,EXPLAIN: RIBED HEREIN OR FOR ANY ACTIVITY DIRECTLY RELATED TO THE ACTIVIT Y DESCRIBED CT10N B.Use for Shoreline and Corps of Engineers peM�SW- TDTAL COST OF PROJECT THIS MEANS THE FAIR MARKET VALUE OF THE PROJECT INCLUDING MATERIALS,LABOR,MACHINE RENTALS,ETC, 000 l OCAL GOVERNMENT WITH JURISDICTION: �^ OR CORPS,COAST GUARD,AND DNR t EASE NOTE:SHORELINE PERMITS,PROVIDE NAMES,ADDRESSES,AND TELEPHONE NUMBERS OF ADJOINING MANAGEMENT GAkI�(IgNCEMAYf?Et f,/ AIJlJITIONAL —CONS(A.T YOUR LOCAL GovERAIMENT. NOTICE PROPERTY OWNERS,LESSEES,ETC., NAME ADDRESS PHONE NUMBER SEC77ON C-This section MUST be tom leted for any Permit covered b this applicefion APPLICATION IS HEREBY MADE FOR A PERMIT OR PERMITS TO AUTHORIZE THE ACTIVITIES DESCRIBED HEREIN, I CERTIFY THAT I AM FAMILIAR WITH THE NFORMATtON CONTAUNED IN THIS APPLICATION AND THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF,SUCH INFORMATION IS TRUE,COMPLETE,AND CURATE. t FURTHER CERTIFY THAT i POSSESS THE AUTHORITY TO UNDERTAKE THE PROPOSED ACTIVITIES. I HEREBY GRANT TO THE AGENCIES TO WHICH HIS APPLICATION IS MADE,THE RIGHT TO ENTER THE ABOVE-DESCRIBED LOCATION TO INSPECT THE PROPOSED,IN-PROGRESS OR COMPLETED WORK. i AGREE TO START WORK Q( Y AFTER ALL NECESSARY PERMITS HAVE BEEN RECEIVED SIGNATURE O OR A RQED AGENT =,/-//- 0-7TE I HER Y DESIG TE TO ACT ASMY AGENT MATTERS RF►ATEO TO THIS APPL I MUST SIGN THE PERMIT. FOR PERMIT(S). I UNDERSTAND THAT IF A FEDERAL PERMIT IS ISSUED, SIGNATURE OF APPLICANT DATE SIGNATURE OF LANDOWNER(EXCEPT PUBLIC ENTITY LANDOWNERS,E.G.DNR) TE THIS APPLICATION AM.T BE SIGNED BY THE APPLICANT AND THE AGENT,IF AN AUTHORIZED AGENT IS DESIGNATED. is U.S.0§1001 Provides that: Whoever,to any manner within the Jurisdiction o/ material fact or makes arty false,fictitious.or fraudulant statements a Y department or agency of the Ajong States meet kno falsifies,contests,or avers up by arty trldc, or a entry,shall be fined not mare than$10,000 Or t representations or mattes or uses any tails writing or document knrnNrrg same to contain any false,fictidOus.or fraudulent statement or rTrprisoned not more than g years or both. v R q ..7 3 sgs.;a ih Y ✓ These A9encles arts Equal Opportunity and Affirmative Action employers. For spec{a1 accommodation Reeds,Please contact the appropriate agency in the instructions. r d �J cd d ° C. l u J � ►. ea wa c W v � to �j a � vi b o q ci '.0 F-1 O U p d ea u co 0 cc Wo � OM,$ \ /, g � � ^ y o " 0-4 ba a�Z MK Q.e' LLp.. wa % awa +o 0 Z 1I.. ° m 72 0 a 0G wK-- Rim.ILAAVp lb. + f r 0 �o 'ON v �I UJI CY 0 w 'ya a /� f d / Z J� o GO t^. ry yam, X •— O p A� S eo W W - -- � Zr J �i� Z'ro:a � Z r _ .� y � X�N I> ,o an> Ita w� O W GQ CJ �df1J O L� 0010-4 m a ZQUIL xti0 REVIEW INFORMATION 100%UMPISM DESIGN INFORMATION SHEET ID CODE Lake Shore Construction } ��yr Q� ,1DDr Inenaeee velil0adan Bolo to lR0.bB PROJECT MENtmp'AvMNW onto"s i&0,,Exposure Chwvod:aE Flw NAMe. PEER ,reM New 110meme Typical Float Design OnCe»tS AO,oN SHEET Na. ngineering DRA-a CAR NCO, 1 Of 1 ISOR1etY1C Phone:360-264-5161 oNEclwo o me 'reninD Wn PLMIED DATES T'd dG2:Ze bOEZ-ST-J�t