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HomeMy WebLinkAboutJARPA - SHX Application - 1/20/2002 AGENCY USE ONLY Agency Reference#: Date Received: Other. 1 JARPA FORM (for w*in waLwglon shb) � PLEASE TYPE OR PRINT IN BLUE OR BLACK INK Based on the preceding checklist. I am sending copies of this application to the following: (check all that apply) (�J Loca�Govemment for shoreline: (-J Substantial Development O Conditional Use ❑ Variance O Exemption; or, if applicable ❑ Floodplain Management ❑ Critical Areas Ordinance ❑ Washington Department of Fish and Wildlife for HPA ❑ Washington Department of Ecology for. O Approval to Allow Temporary Exceedance of Water Quality Standards; ❑ 401 Water Quality Certification Nationwide Permits O Washington Department of Natural Resources for. ❑ Aquatic Resources Use Authorization Notification ❑ Corps of Engineers for. ❑ Section 404 O Section 10 permit ❑ Coast Guard for. ❑ Section.9 Bridge Permit SECTION A- Use for all pwTWfs covered by this application. Be sure to also complete Section C(Signature Bkw4 for all permit applications. t.AP CANT F-6 0 MAILING ADDRESS D/U6 Tl� t .. 1.� t 12- C WORK PHONE HOME PHONE ( FAX B If an agent is acting for the applicant during the permit process, complete#2 V 2 AUTHORIZED AGENT MAILING ADDRESS WORK PHONE HOME PHONE FAX i 3.RELATIONSHIP OF APPLICANT TO PROPERTY: ❑OWNER O PURCHASER 0 LESSEE C3 OTHER 4.NAME,ADDRESS,AND PHONE NUMBER OF PROPERTY OWNER(S), IF OTHER THAN APPLICANT: A 5.LOCATION(STREET ADDRESS.INCLUDING CITY,COUNTY AND ZIP CODE,WHERE PROPOSED ACTIVITY EXISTS OR WILL OCCUR) dd 6• c �Q. Gt GQ "f' S SL-Fd f LOAw WATERBODY TRIBUTARY OF , 1l4 SECTION TOWNSHIP RANGE GOVERNMENT LOT SHORELINE DESIGNATION 2,305 Goo, L,0 f -#-L- (a05 C-ov. "i � � ZONING DESIGNATION AI TAX PARCEL NO:-M 13 B.� 6-ou'Lo it't Z M J, �b aL114 2 I DNR STREAM TYPE,IF KNOWN n,WK EM P4Q4,,e 4 l CURRENT USE OF THE PROPERTY,AND STRUCTURES EXISTING ON THE PROPERTY. IF ANY PORTION OF THE PROPOSED ACTIVITY IS ALREADY COMPLETED ON INDICATE MONTH AND YEAR OF COMPLETION. IS THE PROPERTY AGRICULTURAL LAND? 0 YES>(No ARE YOU A USDA PROGRAM PARTICIPANT7 •O YES *0 7a DESCRIBE THE PROPOSED WORK COMPLETE PLANS AND SPECIFICATIONS SHOULD BE PROVIDED FOR ALL WORK WATERWARD OF THE ORDINARY HIGH WATER MARK OR LINE INCLUDING TYPES OF EOUIPMENT TO BE USED.'IF APPLYING FOR A SHORELINE PERMIT,DESCRIBE ALL WORK WRHIN AND BEYOND 200 FEET OF THE ORDINARY HIGH WATER MARK ATTACH A SEPARATE SHEET IF ADORIONAL SPACE IS NEEDED. C:r9-N�s�-ti-uc p r, 4 1r �(a.0 `�C.R�i fioa llL bAk I IL h Qa cQ. +0 a 6t;<<k 7b. DESCRIBE THE PURPOSE OF THE PROPOSED WORK 7-�, ��14Q a e,,.o n o �. 1.6Lv,& kL ©�- rVW-fCII P- sir boc'A 4t ,.* d. 7c. DESCRIBE THE POTENTIAL IMPACTS TO CHARACTERISTIC USES OF THE WATER BODY. THESE USES MAY INCLUDE FISH AND AQUATIC LIFE.WATER QUALITY.WATER SUPPLY. / RECREATION,uW AESTHETICS. IDENTIFY PROPOSED ACTIONS TO AVOID.MINIMIM AND MITIGATE DETRIMENTAL IMPACTS,AND PROVIDE PROPER PROTECTION OF FISH AND AQUATIC LIFE. �nN�= PREPARATION OF DRAWINGS: SEE APPENDIX A•SAMPLE DRAWINGS AND CHECKLIST FOR COMPLETING THE DRAWINGS. ONE SET OP O MNAL OR GOOD QUALITY REPROOUGBLE DRAWINGS NR/ST BE ATTACHED. NOTE: APPLICANTS ARE ENCOURAGED TO SUBMIT PHOTOGRAPHS OF THE PROJECT SITE,BUT THESE DO NOT SUBSTITUTE FOR DRAWINGS. THE CORPS OF ENWNEERS AND COAST GUARD REOIBRE DRAWING!ON 644 X 11 INCH SHEETS. LARGER DRAWN=MAY BE REQUITED BY OTHER AGENCIES. CT BE CONSTRI&M IN STAGES? 0 YES No /3TARTING DATE: ArED DURATION OF ACTIVITY: a CHECK IF ANY STRUCTURES WILL BE PLACED: /vo 0 WATERWARD OF THE ORDINARY HIGH WATER MARK OR LINE FOR FRESH OR TIDAL WATERS:ANDIOR ❑WATERWARD OF MEAN HIGH WATER LINE IN TBLLL WATERS 10,WILL FILL MATERIAL(ROCK FILL BULKHEAD.PILINGS OR OTHER MATERIAL)BE PLACED: 0 WATERWARO OF THE oROINARY HK9H WATER MARK OR LIME FOR FRESH WATERS? F YES,VOLUME(CUBIC YARDS) !AREA (ACRES) ❑WATERWARD OF THE MEAN HIGHER HIGH WATER FOR TIDAL WATERS? IF YES,VOLUME(CUBIC YARDS) /AREA (ACRES) 11.WILL MATERIAL BE PLACED IN% ETLANOS? C YES KNO IF YES: A IMPACTED AREA IN ACRES: B. HAS A DELINEATION BEEN COMPLETED? IF YES,PLEASE SUBMIT WITH APPLICATION. O YES 0 NO C..HAS A WETLAND REPORT BEEN PREPARED? IF YES.PLEASE SUBMIT WITH AMICAWK O YES 0 NO 0. TYPE AND COMPOSITION OF FILL MATERIAL(E.G..SAND,EMC E. MATERIAL SOURCE: F. LIST ALL SOIL SERIES(TYPE OF SOIL)LOCATED AT THE PROJECT SITE M INDICATE F THEY ARE ON THE COUNTY'S LIST OF HYDRIC SOILS.SOTS INFORMATION CAN BE OBTAINED FROM THE NATURAL RESOURCES CONSERVATION SERVICE(HRM 12 WILL PROPOSED ACTIVITY CAUSE FLOODING OR DRAWING OF WETLANDS? C YES �NO IF YES,IMPACTED AREA 13 ACRES. 11 WILL EXCAVATION OR DREDGING BE REQUIRED IN WATER OR WETLANDS? 0 YES 51kNO F YES: A-VOLUME: (CUBIC YARDSI/AREA (ACRES) B. COMPOSITION OF MATERIAL TO BE REMOVED: C. DISPOSAL SITE FOR EXCAVATED MATERIAL: 0. METHOD OF DREDGING: 14.LIST OTHER APPLICATIONS.APPROVALS.OR CERTIFK:ATWNS FROM OTHER FEDERAL.STATE OR LOCAL AGEJVCIE3 FOR ANY STRUCTURES,CONSTRUCTM DISCHARGES.OR OTHER ACTIVITIES DESCRIBED IN THE APPLICATION II.E..PRELMAINARY PLAT APPROVAL HEALTH DISTRICT APPROVAL BUDDING PERMIT,SEPA REVIEW.FERC LICENSE.FOREST PRACTICES APPLICATION.ETC.) ALSO INDICATE WHETHER WORK HAS BEEN COMPLETED AND INDICATE ALL EXISTING WORK ON DRAWINGS. TYPE OF APPROVAL ISSUING AGENCY IDENTIFICATION NO. DATE OF APPLICATION DATE APPROVED COMPLETE07 EPA LEAD AGENCY EPA DECISK*t EPA DECISION DATE: 15.HAS ANY AGENCY DENIED APPROVAL FOR THE ACTNITY DESCRIBED HEREIN OR FOR ANY ACTIVITY DIRECTLY RELATED TO THE ACTMTY DESCRIBED HEREIN? 0 YES '�gtNO IF YES. EXPLAIN: Appbc~Yp6 31A 4 Jse for Shorvllne and Corps of Engineers permits oMv. �r OF PROJECT. TH13 MEANS THE FAIR MARKET VALUE OF THE PROJECT,INCLUDING MATERIALS,LABOR MACHINE RENTALS,ETC. ,GAL GOVERNMENT WITH JURISDICTION: 19.FOR CORPS.COAST GUARD,AND DNR PERMITS,PROVIDE NAMES.ADDRESSES,AND TELEPHONE NUMBERS OF ADJOINING PROPERTY OWNERS,LESSEES.ETC.. PLEASE NOTE: SHORELINE MANAGEMENT COMPLIANCE MAY REQUIRE ADDf710NAL NOTICE—CONSULT YOUR LOCAL GOVERNMENT. NAME ADDRESS PHONE NUMBER SECTION C- This section MUST be comphtsd for any permit covered by this aWicadom 19.APPLICATION IS HEREBY MADE FOR A PERMIT OR PERMITS TO AUTHORIZE THE 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,SIXTH INFORMATION IS TRl1E,COMPLETE AND ACCURATE. I FURTHER CERTIFY THAT I POSSESS THE AUTHORITY TO UNDERTAKE THE PROPOSED ACTIVITIES. I HEREBY GRANT TO THE AGENCIES TO WHICH THIS APPLICATION IS MADE,THE RIGHT-TO ENTER THE ABOVE-DESCRIBED LOCATION TO INSPECT THE PROPOSED,IN4ROGRESS OR COMPLETED WORK I AGREE TO START WORK ONLY AFTER ALL NECESSARY PERMfTS HAVE BEEN REZ`.EIVED. SIGNATURE OF APPLICANT OR A ORIZED AGENT TE vv d GC�Z.. I HEREBY DESIGNATE TO ACT AS MY AGENT IN MATTERS RELATED TO THIS APPLICATION FOR PERMIT(S). I UNDERSTAND THAT IF A FEDERAL PERMIT IS ISSUED, I MUST SIGN THE PERMIT. SIGNATURE OF APPLICANT DATE SIGRATURfE OF LANDOWNER(EXCEPT PUBLIC ENTITY LANDOWNERS,E.G.DNR) DATE �'!lRS►��.� c c.� /Q � THIS APPLICATION MUST BE SIGNED BY THE APPLICANT AND THE AGENT,IF AN AUTHORIZED AGENT IS DESIGNATED. 18 U.S.c 51001 provides tnat Whoever.in any manner wiIfhn the jurisdiction of any department or agency of the United Slates knowingly faisWAs,conceals.ar tour up by any trick,scheme,or device a material fact or makes any false,fictitious,or fraudulent statements or representations or makes or uses any false writing or document knowing same to coitse any false,fictitious,or fraudulent statement or entry,stall be fined not more than$10.000 or imprisoned not more than 5 yam or troth. COMPLETED BY LOCAL OFFICIAL:, A. Nature of the existing shoreline. (Describe type of:shoreline, such as marine, stream, lake, lagoon. marsh,.bog;.swamp, flood plain, floodway, delta; type of beach, such as accretion. erosion,.high bank, low bank; or:dfice,materW su6b.as:sand,gravel, mud, clay, rock. riprap; and extent and type of bulkheading;,if any:) B. In the event that any of the proposed buildings or structures wift exceed a height of thirty-five feet above theaverage grade level, indicate the approximate location of and number of residential units, existing and potential; that wig have an obstructed view: C. If the application involves a conditional use or variance, set forth in full that portion of the master program which provides that the proposed use may be a conditional use, or, in the case of a variance, from which the variance:is being sought: These Agencies are Equal Opportunity and Affirmative Action employers. For special accommodation needs,please contact the appropriate agency from Appendix B. Applicalwn Page 4 rA 4