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Home My WebLink AboutJARPA - SHX Application f AGENCY C)SE`ONLY A enc Refer4n6 Dates,R�cetved :Other . JARPA FORM troy use in Wasrtrlstx+s5:e) PLEASE TYPS OR PRINT W BLUE OR BLACK INK Based on the preceding checklist,I am sending copies of this application to the following: (check all that apply) J"t Local Government for shoreline: ❑Substantial Development ❑ Conditional Use ❑Variance X Exemption: or,if applicable ❑ Floodplain Management ❑Critical Areas Ordinance Washington Department of Fish and Wildlife for HPA Washington Department of Ecology for. ❑Approval to Allow Temporary Exceedance of Water Quality Standards ❑401 Water Quality Certification Nationwide Permits ❑ Washington Department of Natural Resources for.❑Aquatic Resources Use Authorization Notification X Corps Engineers for. ❑Section 404 ❑Section 10 permit ❑ Coast Guard for. ❑Section 9 Bridge Permit SECTION A - Use for all permits covered by this application. Be sure to also complete Section C(Signature Block)forall permit applications. t APPLICANT Al r 0 N r J GrVb b ht.L'IING ADDRESS 2.-3 2S 634 �Cc) /✓,n wa fc� Gr�A `Z - 7205 H -PHONE FAX Y.Q R:<PHONE "tb) 3sa-563 7 If an agent is acting for the applicant during the permit process, complete--2 2.AUTHOR:=:O AGE>.� : / m TA h f 4 _S>4-p k•ef By lclt�R�✓.� L tie . ►tA.L,.NG ACORESS /-yo7 _S�m�„' oC✓� �! mow. 0� ��, ��. 9gsa Z Y.OR�aHONE HOME HONE FAX• 60) �� ,�0-3 `77 3bti� �� -d37 6o 56�-7`1b2 J RELATIONSHIP OF APPLICANT TO PROPERTY: y OWNER O PURCHASER O LESSEE O OTHER: 4.NAME.A:ORESS.AND PHONE NUMaER OF PROPERTY OWNER(S).IF OTHER THAN APPLICANT: 5.LOCATION(STREET ADDRESS.INCLUOING CITY.COUNTY ANO ZIP CODE.WHERE PROPOSED ACTMTY EXISTS OR VALL CCCUR) .1/Z0 vfAT:R30oY / TRI3UTARY OF vs SECTION TOb'N. SHIP RANGE GOv°RNMENT LOT SHORELINE DESI NATION S // 7//- V 1 C ZONING D=SIGNATION TAX PARCEL NO.: ONR STREAM TYPE.IF KNOV,N o.DESCRIBE THE CURRENT USE OF Trim PROPERTY.AND STRUCTURES EXISTING ON THE PROPERTY. IF ANY PORTION OF THE PROPOSED ACTTVrTY IS ALREADY COMPLETED ON THIS PROPERTY,I.NOICATE MO.' AND YEAR OF';OMPLETTON. SV m rn. -t r �P S�cr�'✓ e IS THE PROPERTY AGRICULTURAL LAND?p YES NO ARE YOU A USDA PROGRAM PARTICIPANT? 13 YES NO 7a. DESCRIBE THE PROPOSED WORK COMPLETE PLANS AND SPECIFICATIONS SHOULD BE PROVIDED FOR ALL WORK WATERWAAD OF THE OROWARY HIGH WATER MARK OR LINE INCLUDING TYPES OF EQUIPMENT TO BE USED. IF APPLYING FOR A SHORELINE PERMIT.DESCRIBE WORK«1THIN AND BEYOND:'-0 FEET OF THE ORDINARY HIGH VIATER LURK ATTACH A SEPARATE SHEET IF ADDITIONAL SPACE IS NEEDED. e vvi p✓e �gri ��it T/�i� 8 U�i�s�'I z� b� e��/F}o 6 Gc�� r d lec� Coll/C Pi! P b /F}-e S6 e IS19 olcdo NeCe- ss tg 7D.0ESCR!3E THE PURPOSE OF THE PROPOSED I.ORK Tie �xrs�,/� woa P�/� 8�/�rP,4 c✓ %s �i� .wee is 7c DESCRIBE THE POTENTIAL IMPACTS TO CHARACTERISTIC USES OF THE WATER BODY. THESE USES MAY INCLUDE FISH A::O AQUATIC OFE.WATER OUALTTY.WATER SUPPLY,RECREATION,and A=STHETtCS. IDENTIFY PROPOSED ACTIONS TO AVOID.MINIMLZE,AND MRIGAT_OETRIMENTAL IMPACTS.ANO PROVIDE PROPER PROTECTION OF FISH AND AQUATIC LIFE. ' PREPARATION'OF ORAWNGS: SEE APPENDIX A•SAMPLE DRAWINGS AND CHECKLIST FOR COMPLETING THE ORAVANGS, ONE SET OF ORIGINAL OR GOOD OLAALTTY REPROOUCf3L DRAWINGS MUST BE ATTACHED. NOTE: APPLICANTS ARE ENCOURAGED TO SUBmr-,PHOTOGRAPHS OF THE PRO;_:T SIT_.BUT THESE 00 NOT SUBSTITUTE FOR CPAWINGS. THE CORPS OF ENGINEERS AND COAST GUARD REQUIRE ORAW?NGS ON 8-1I2 X 11 INCH SHEETS. LARGER OPA WNGS MA Y BE REQUIRED BY OTHER - AGEIIC/ES a.MLL THE PROJECT BE CONSTRUCTED IN STAGES? p YES Av0 PROPOSED STARTING DATE: v ESTWIATEo ouRATIoN OF ACTNrr w e 2 ks' A-�7 r oS�gr 9.CHECK IF ANY STRUCTURES WILL BE PLACED: YWATERWARD OF THE ORDINARY HIGH WATER MARK OR LINE FOR FRESH OR MAIL WATERS:AVO/OR p WATERWARO OF THE MEAN HIGH WATER LINE IN TIDAL WATERS 10.WILL FILL MATERAL(ROCK FILL.BULKHEAD,PILINGS OR OTHER MATERIAL)SE PLACED: p WATERWARO OF THE ORDINARY HIGH WATER MARK OR LINE FOR FRESH WATERS? IF YES.VOLUME(CUBIC YARDS) IARFA (ACRES LVATERWARO OF THE MEAV HIGHER HIGH WATER FOR TIDAL WATERS? IF YES.VOLUME(CUBIC YARDS)20/AREA (ACRES) 11.AAF L MATERAL BE PLACED IN WETLANDS? (YES p NO IF YES: A IMPACTED AREA IN ACRES: S.HAS A DELINEATION BEEN COMPLETED? IF YES,PLEASE SUBMIT WITH APPLICATION. p YES 101,40 C.HAS A N.ETLANO REPORT BEEN PREPARED? IF YES,PLEASE SUB(MMI'T WITH APPLICnATION. p YES N0 0.TYPE AND COMPOSITION OF FILL MATERIAL(E.G.,SAND.ETC.): E.MAT'RIA sDURCE: e i — f&�k P l R►�� F.LIST ALL SOIL SERIES(TYPE OF SOIL)LOCATED AT THE PROJECT SITE,I INDICATE IF THEY ARE ON THE COUNTYS LIST OF HYORIC SOILS. SOILS INFORI ATION CAN BE CiITAINEO;RCM THE NATURAL RESOURCES CONSERVATION SERVICE(NRCS). ;?.A:ILL PROPOSED ACTIVITY CAUSE FLOODING OR ORAINING OF WETLANDS? p YES NO k YES.IMPACTED AREA IS ACRES 13.':aLL EXCAVATION OR OREOGING 3E REQUIRED IN WATER OR WETLINOST p YES p NO 1;YES. A VOLUME `' (CUBIC YARDSYAREA (ACRES) B.COMPOSITION OF MATERIAL TO BE REMOVED: S !E / C.DISPOSAL SITE FOR EXCAVATED MATERIAL: gt,h�k rn h u k I Le"q r 0 MET1400 OF DREDGING: S/q 1+ LIST OTHER APPLICATIONS.APPROVALS.OR CERTIFICATIONS FROM OTHER FEOERAL.STATE OR LOCAL AGENCIES FOR A14'f STRUCTURES.CONSTRUCTION,OISCHARGES. OR OTHER ACTIVITIES OESCRISEO IN THE APPLICATION(I.E..PRELIMINARY PLAT APPROVAL,HEALTH DISTRICT APPROVAL BV:LDING PERMIT,$EPA REVt_`N,FERC LICENSE. :ORE$T??A.: ICES APPLICATION.ETC.)ALSO INDICATE WHETHER WORK HAS BEEN COMPLETEO AND INOICATE ALL EXISTIN'e.'JRK ON DRAWINGS. TYPE OF APPROVAL ISSUING AGENCY IDENTIFICATION NO. DATE OF APPLICATION DATE APPROVED COMPLETED? 4c dor S Wiier S� 3!2A LEAD AaEsCY N gooe SEPA DECISION: SEPA DECISION OATE.' S HAS ANY AGENCY DENIED APPROVAL F04 THE ACTiV(TY DESCRIBED HEREIN OR FOR ANY ACTIVITY DIRECTLY RELATED TO THE ACTMTY 0_SCRIBE0 HEREIN?0 YES )(NO IF YES,EXPLAIN: Yt• w SECTION B-Use for Shoreline and Corps of Engineers permits only: 16. JOTALCOSTOF PROJECT.THIS MAANS THE FAIR MARIET VALUE OF THE PROJECT,INCLUDING/ TERIALS.LASOR,14:,CHINE RENTALS,ETC. "r �q too f.Lle fi oar �0C) q! - 17. LOCAL GOVERNMENT w1TH JURIS ICTION: mw .5O C viJJLv 13. FOR CORPS.COAST GUARD,AND ONR PERMITS. ROVIOE NA,NES.ADDRESSES.AND TELEPHONE NUMBERS OF ADJOINING PROPERTY DINERS.LESSEES.ET--C.PLEASE NOTE: SHORELINE MANAGEMENT COMPLIANCE MAY REQUIRE ADOmONAL NOTICE-CONSULT YOUR LOCAL GOV=RNM_h_.. NAME ADDRESS ` PHONE NUMBER r'r /✓I r. a PL4 11175 c tr3 D N G+ SECTION C -This section MUST be completed for any permit covered by this application. 19. APPLICATION IS HERESY MADE FOR A PERMIT OR PERMITS TO AUTHOR=-THE ACTMT1ES 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,SUCN INFORMATION IS TRUE.COMPLETE.AND ACCURA%;. I FURTHER CERTIF r THAT I POSSESS THE AUTHORITY TO UNDERTAKE THE PROPOSED ACT1Vrn_S. I HEREBY GRA`+T TO THE AGENCIES TO `PA CCH THIS APPLICATION IS MADE,THE RIGHT TO EN ER THE ABOVE-DESCRIBED LOCATION TO INSPECT HE PROPOSED,IV-PROGRESS OR COMPL__0 V.'ORK.I AGREE TO START N:ORK ONLY AFTER ALL NECESSARY PERMITS HAVE BEEN RECEIVED. SIG.•LA RE OF APPLIC •+ OR AUTHOR_E AGENT �T' Q Q • 1 ° SFYDES-G.W ) 01- ' "I/ TO ACT AS MY AGENT IN MATTERS RELATED TO THIS APPLICATION FOR PER.NR(S)_ I UNDERSTANO THAT IF A FEDERAL P_:WtT IS ISSUED.I MUST SIGN THE PERMrr. f DATE S:G.- OF APPLZ71IT SIG. TURF OF LAN00% .ER(EXCEPT PUBLIC ENTITY LANIO S.E.G. NR DATE 15 TH'S APPLI ION Mm T BE SIGNED BY THE PLI A. ANO THE Yi,IF AN ALMHORLZ.ED AGENT IS DESIGNATED. 13 Us C 1.CC I yTraes trot: Wnoe+er,;n ry manner..tm i t..e iunsdicon or any aco rr.•cra or agency of one Undod Sta:e s Of m.ers 6'0 oY'^r"%M se•ene,or �ceee a nawmi fac or makes any false.Gca wus.oe lraudu:ent statemems or eepraser~�:.orts or rnakas or Laos any false.nteq a'_assert k.%M q sane to COMA er•Y lab., or !7uGv<rl vattmert or eery.$ran toe rued rot More-.tan$10.0 0 or+npnsaned riot more:tin S years ce='N COMPLETED BY LOCAL OFFICIAL... .. A. Nature of the existingshoreline. (Describe type of shoietine,such`as marine,stream, lake,lagoon,marsh,bog,swamp,flood plain,floodway, detta;type of beach,such as accretion,erosion,high bank, low bank, or dike:material such as sand,•gravel," mud, da rock,ri ra and extent and a of bulkheadin if any-.) - y. P P: type g. . .... . .. _ . . B. In the event that any of the proposed buildings or structures will exceed a height of thirty-five feet above the average grade level, indicate the approximate location of and number of residential units,existing and potential,that will have an obstructed view I 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: I i iThese Agencies are Equal Opportunity and Affirmative Action employe•:,. Por special accommodation needs,please contact the appropriate agency fn.n