HomeMy WebLinkAboutSHX2008-00078 JARPA, HPA - SHX Permit / Conditions y N-STA MASON COU
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DEPARTMENT OF COMMUNITYDEVELOPMENT
o A v► Planning Division
>- o N z P O Box 279,Shelton,VVA 98584
T Z7 Ny (360)427-9670 ti
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1864
Exemption from Shoreline Management Act
Case No.: SHX2008-00078 Substantial Development Permit Requirement
The Proposal By: WAYNE OLSON
7103 NE 136TH ST
KIRKLAND,WA 98034
To undertake the following development:
Replace three (3) existing creosote piling with three new 10" galvanized piles.
Project is SEPA Exempt.
Within Hammersley Inlet and/or its associated wetlands is exempt from the requirement of su tantial development because
the development is categorized under WAC 173 27-040(2) as being category
B-normal maintenance
Please contact Grace Miller at ext 360 if you have any questions.
Issued: 9/16/2008 — -441 'U'4
Expires: 9/16/2010 Authorized Local Government Official -
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cc: APPLICANT WDFW- USACOE WDOE- TRIBAL CC UNCIL
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7777177
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JOINT AQUATIC RESOURCES PERMIT APPLICATION FORM (JARPA)
(tor use in Washirrgton state)
��•� PLEASE TYPE OR PRINT IN BLACK"C
TO FILL IN ELECTRONICALL
Y.USE F1 I TOMOVE THROUGH E FORM
❑ Application for a Fish Habitat Enhancement Project per requirements of RCW 77.55 You must submit a copy of this
completed JARPA application form and the(Fish Habitat Enhancement JARPA Add' 1 to your local Government
Planning Department and Washington Department of Fish&Wildlife Area Habitat Wok gist on the same day.
NOTE: LOCAL GOVERNMENTS—You must submit any comments on these projects to 1A DFW within 15 working days.
Based on the instructions provided.I am sending copies of this application to the following:.( aH that apply)
[Local Government for shoreline:dal Development ❑Conditional Use [JV zemption []Revision
E]Fbodpkdn-Management ❑Critical Areas Ordnance
9J'WaWngbon Department of Fish and Wildlife for HPA(Submit 3 copies to WDFW Region)
❑ Wa.4irington Department of Ecology for 401 Water Quality Certification(to Regional owwo-Feimw Pernut unit)
❑ Wastwigfon Department of Natural Resources for Aqufic Resources Use Authorization Noof cation
❑ Corps of Engineers for. ❑ Section 404 . ❑ Section 10 pemnit
❑ Coast guard fir. ❑ General Bridge Act Permit ❑ Pnvata Aids to Navigf lion(for non-bridge projects)
❑ For Department of Transportation projects only: This project will be designed to meet condilk es of the most current
Ecology/Depwtment of Transportation Wafer Quality Implamenting Agreement
SECTION A-Use for all permits covered by this application. Be sure to ALSO complete C(Sfgnature Block)for all
permit applicatbim
1.APPUCANT
�G 10N
MAILING ADDAESS
WORK PHONE E-MAIL ADDRESS HOME PHONE FAX#
[WA* �Gar��afe jtk _aGPI �4l.L 44pX1 Sz?P
If an agent is acffng for the app Ocant during the permit proms,conWiets#2 Be store t sipm Section C(Signature B/oclr)
fora//permita�
2.AUTHORIZED AGENT
MAILING ADDRESS
WORK PHONE E-MAIL ADDRESS HOME PHONE FAX#
3.Relati wJdp of applicant to property: ❑ OWNER ❑ PURCHASER ❑ LESSEE ❑
4.Name.address and phone number of property owner(s)if other than appkant
5.Location(street address,including city.county and zip code,where proposed activity exists or w6 occur)
Local govenwrient with won or
Why you are wwking In c,SKdOf(Gf/rf /�,Q Tmuhary of WRIA#
Is this waterbody on the 303(d)List" YES NO U
_
ff YES,what parameter(s)?
"For 303d List, Shorellne designadon
hitoJ/www ecv wa uov/ 3 Md—gx.Mmj ;
Wing designation uY
'/.Sedion I Section I Township Range Lot
R stream type 9 known /1� Iq
Latitude and Longitude: TaxParcelNumbw ,-LgA #�
- �
ECY 070-15(Rev. 11/04) JARPA Contact the state of Wasftington Hof Reailatory AssistanceRsaulatory Assistance for latest vel siGn or call 3601407-7037 or 800/917-0043
6. Describe the current use of the property,and structures existing on the property. Have you completed any portion of the proposed
activity on this property? ❑ YES [] NO
For any portion of the proposed activity already completed on this property,indicate month and year of completion.
Is the g2peq agdcukural Nand? 13 YES NO Are M a USDA YES NO
a. Describe the proposed work that needs aquatic pmyvts.: Complete plans and specifications shc uld be provided far.ij work waterward
of the ordinary high water mark or ire,including types of egtdpn xx t to be used. If applying for i shoreline permit,describe all work
within and beyond 200 feet of the ordinary high water mark. N you have provkted attached mab dais to describe your project,you still
must summarize the proposed work here. Attach a separate sheet If additional space is
PREPARATION OF DRAVAISM See awnple drawigs and gukbrm for canVN V tftg drawkV& ONE SET OF OR GOOD QUAIJTYR SMODUCABLE
DRAWAM MIKSEATTACNM NOTF- to Appkw are oncmwaged lo aulnnit pl imp apNs of the pa�jed arre.but DO NOT subSWtft for drawings. THE CORPS
OFENGNNE?SAN�D COAST GUARD REQINRE DRA*WJ8S QN 1-*2 X!f NWH SNEET3. 1.ARBE/t ORANWOS Y BE BY OTHER AGENCIES
. Describe the purpose of the proposed work and why you want or need 10 perform it at the site. I lease explain any specific needs that
have influenced the design.
?
c. Describe the potential irrrpads to characteristic uses of the water body. These uses may fish aid aquatic ifs,water quality.
water supply,recreation and aes111reiics. Identitry proposed 3C*M to avoid,mirlinliae,and nft Me detrtmental impacts and provide
proper prolection of fish and aquatic fife. IdeMgy which guidance docurnents you have used. A tach a separate sheet if additional I,
space is needed. it
/Id 15It if- J7v�`j/G10 f4C 7'
UG J G�
t
d. For in water construction work,will your project be in compliance with the State of Washington water quality standards for turbidity
WAC 173201A•1107 EIYES Q NO See USEFUL DEFIN AND INSTR S
B. Will the project be constructed In stages? YES ❑ NOEr
Proposed starting date: ��li�,: .p.9�,¢ 1-c�✓c
Estirrmated duration of acIlvW
9. Check if any temporary or permanent strictures wit be phiced:
❑ Walerward of the ordinary high water made or litre for fresh or tidal waters AND0011
Walerward of the mean hWw high water for tidal waters?
10.Will tit mei erial(rock,tit,buidwed,or other meterk*be placed:
❑ Wakwward of the ordinary high water mark or line for fresh waters?
If YES,VOLUME(cubic yards) /AREA (acres)
❑ Waberward of the mean higher high water for tidal waters?
If YES,VOLUME(cubic yards) i AREA (acres)
ECY 070.18(Rev 11/04) .IARPA Contact no Stale of Waehinglon Qftof Ren dotty Assishanoe for latest version or call 3W/407-7037 or tlM17-0043
Will,material be placed in wedarnds? ❑ YES NO
If YES:
A. Impacted area in acres:
B. Has a delineation been completed? K YES,please submit with application. ❑ YES ❑ NO
C. Hasa wedend report been prepared? If YES,please submit with application ❑ YES ❑ NO
D. Type and composition of fill material(eg.,sand.etc.)
E. Material source:
F. List all soil series(type of soil)located at the project site.and indicate if they are on the ty's list of hyddc sods. Soils information
can be obtained from the natural Resources Conservation Service(NRCS).
G. WILL PROPOSED ACTIVITY CAUSE FLOODING OR DRAINING OF WETLANDS? [] YES ❑ NO
If YES,IMPACTED AREA IS ACRES OF DRAINED WETLANDS.
NOTE:ti roe p*dwil Ynpact gmalortran%of an acre d wobnd,submit a n iigiallon pan to to Corps and Ecology for apposed Abne wb to JAWA tam.
NOTE A 401 water qu oer11111 0 nwil be rat ad tom txobgp 1n a0lon lo an appraied 1190. pan 11yore picod tripods trot are: a)greater Iran%acre in shn.
orb)Idalwetsrds orudemb adlaaerrt io Nd watx Please submit the DARPA form and rrftdm plan to F_oobgy loran 401 carbTicaton i a)or b)apples.
12. StorrrnMaber Compliance for Nationwide Permits Only. This project is(or will be)designed to ecology's most current
stormwater marmal,or an Ecology approved local stormwater manual. ❑ YES ❑ N
If YES—Which manual will your project be designed to meet?
If NO—For clean water act Section 401 and 404 penntis only—Please submit to Ecology for approval, along with this JARPA
motion,documentation that demonstrates the stonrmrater runoff from your project or activity will comply with the water quality
standards,WAC 173.201(A)
13.Will excavation or dredging be required in water or wetlands? ❑ YES NO
If YES.
A. Vohrrm (cubic yards)/area (acre)
S. Composition of material to be removed:
C. Disposal site for excavated material:
D. Method of dredging: j
14. Has the State Environmental Policy Act(SEPA)been completed ❑ YES NO
SEPA Lead Agency.
SEPA DaciWm DNS,MDNS,EIS,Adoption,Exemption Decision Date(end of comment period)
SUBMIT A COPY OF YOUR SEPA IDECISIOM LETTER TO WDFW AS REQUIRED FORA COMPLETE APPLICATION
15. List other Appticatlorrs,approvals or oertitiorrs from other federal,stye or local agencies for structures,construction discharges
or other activilies described in the application(I.e.prekninary plot approval,heati o h district ,building permit,SEPA review,
federal energy regtdatory commission license(FERC).Forest practices gvkMti w%etc.). Also. whetherwork has been
completed and Indicate all existing worts on drawings. NOTE:For use with Corps Nationwide .Mentdy whether your project has
or will need an NPDES permit for discharl OV wastewater and/or slormwater.
TYPEaFAV"OVAL ISSUING AGENCY D®iYn:ICATM oA'X09&F 4TM DATEAPPraovm COMPLETID?
f ,& /L�4 No.
r
B. Has any agency denle approval for the activity You're applying for or for any activity directly led to the activity described herein?
❑ YES NO
If YES,explain:
EiCY 070.15(Rev. 11M) DARPA Contact the State of waeNoon Ofk*of Regulatory Assistaunce for latest version or rat 360f407-7037 or BMI7-0043
A
SECTION B- Use for Shoreline and Corps of Engineers pwmits on/
7a.Total coat of project. This means the fair market value of the project,kw*x irg notep .181XF.machine rentals.etc.
is-'f -4'r
1
7b.If a pn)jeci or any portion of a project receives funding from a t that
ndicate if you will receive federal funds and federal agency rOSPOnsibis for ESA consultation. Please
agency Pig ilaose funds. See for information on ESA.*
EDERAL FUNDING ❑ YES NO If YES,please list the talent agency.
18.focal govenwrrent with won:
9.For Corps,Coast Guam and DNR pewits,provide names,addresses and leiepihone rrtnntm of agokft property owners.lessees,
etc. - Plftasa now: Shore m AAanagsment Ganpaarrce may require addWor W nodes—consalt YOM kxW government.
NAME ADDRESS PHONE NUMBER
SECTION C-This.sacBon MIST be cwn~for ajW VwzWt aovwed bv drys 8VpMjc8ftn
. Application is hereby made for a perm or permits to authorize the activities described herein. certify that I am faim�ar with the
knforma8on cmdained in this application,and that to the Kest of my knowledge and beW,such irrFo maton is true.complete,and
accurate. 1 further certify that I possess the authority to undertake the proposed activates. 1 he y grant to the agencies to which
this application is made,the right to alter the above-described location to Inspect the proposed.kmxogress agree b start workk O�Y_afbr all ray permits have been received. or completed work. I
DATE
SIGNA /
DATE
SIGNATURE OF AUTHORmED AGENT
I HERE13Y DESIGNATE TO ACT AS MY AGENT IN MATTERS REUkTED TO THIS APPLICATION FOR g
PERMIT(S). I UNDERSTAND THAT IF A FEDERAL.PERMIT IS ISSUED,I MUST SIGN THE PERMIT.
k
SIGNATURE OF APPLICANT DATE
SIGNATURE OF LANDOWNER(EXCEPT PUBLIC ENTITY LANDOWNERS,EC,DNR)
THIS APPL)CA TION MW BE SWW BY THE AP,PL#CANTAND 77EAGEW.I AN U IN X t MD AGENT IS DESIGNATED.
18 U.S.0§1001 provides that Whoever,in any manner within the jurisdiction of any department or i 980CY of the United States knowingly
falsifies.conceals.or covers up by any VW ad me,or device a rrwlerial fad or makes any false.fictitious,or fraudulent statements or
16"98enlatons or makes or uses any false wrong or document knowing same b contain any false,
entry,shall be fined not more than$10,000 or knprisoned not more than 5 years or both.0003
.or fraudulent statement or
:.
00
A: Nt g�th
�� �� ��t;thtsr �, k�ke, ttitrstt..�no9. fknod
Rom• � �, Vie. su�fi as sand; carrel r
B Inn 9 mud clay. :
fA
' t�f "f S, a � • ,�%y��'I[grade level,
low
tat
pad Use 8hpl�tBiopp tn7� 'fl 11f b - wlNdr Provides that theAL
-
These Agericles are Equal Opporlurty acid AflN7riatire Action envloyar
....
For ao mvnodatlon needs,Please contact the PPrOPriate agency in Vm
ECY 070-15(Rev. 11104) .IARPA Corned ftre Stale of Washington Office pf$may ANkftnce for ta/est or call 360r407-7037 or 8W/91-1-0043
A
Certification of Consistency with
the Washington Coastal Zone Management Program
RE: Department of the Army Permit
Application No.
Applicant:
Section 307(c) of the Coastal Zone Management Act (CZM) of 1972 as amended by
16 USC 1456(c)(3) requires the applicant for a Federal permit to conduct an
activity affecting land or water uses in the Washington coastal zone to provide
certification that the activity will comply with the Washington Coastal Zone
Management Program.
The proposed activity described in your permit application is within the 15
coastal counties in Washington, and the following certification is required
before your application can be processed to Public Notice. Upon receipt of
the signed, dated certification, the Public Notice will be issued and will
include the certification statement. The Public Notice will be forwarded to
Washington Department of Ecology for its concurrence or objection. Please
note, the Shoreline Permit determination process, State Environmental Policy
Act (SEPA) compliance, Water Quality, and Air Quality review must be completed
prior to the Department of Ecology's determination of consistency.
CERTIFICATION STATEMENT
I certify that, to the best of my knowledge and belief the ct,ivity described
in the Department of Army Permit Application dated " 4 7 complies
with the approved Washington Coastal Zone Management Program (CZM), and will
be conducted in a manner consistent with that program. I have started the CZM
process Yby, applying for my shoreline permit or lettr f exemption from
S h El�'o 4 Mit SOAl (city/county) on 6 — '7 g 7 (date applied).
Signature of licant G� ^� Date
Applicant or gent Print or Type Name
and Title
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Please provide the following information about your Shorelines Substantial
Development Permit. (If you have not yet applied, please explain in the
"Remarks" section of this form.)
i
Shorelines Permit
Date applied j
Number assigned A D�
City/County
Date approved*
Date exempted* a
*Please provide a• copy of the letter announcing the Shorelines decision.
Remarks:
k
NPS Form 1145-4
(Replaces NPS Form 383)
I
Jun 88 (Rev)
HYDRAULIC PROJECT
APPLICATION
(R.C.W.75.20.100)
(R.C.W.75.20.103)
600 Capitol Way North (R.C.W.75.20.160)
Olympia,Washington 98501-1091
(360)902-2534 PLEASE PRINT OF TYPE
DO NOT WRITE IN SHADED AREA
LAST NAME S O / FIRST NAME CONTACT PHONE(S) a
STREET OR RURAL ROUTE
'716 NC 1 -3 rA. SIL �� r&
r ` r
n
CITY STAIF ZIP : v s
3 J4 .��
WATER TTARY TO PE OF PRO EC
M E /E - RI U 1PQ E f S OLI K� ��
QUARTER SECTION SECTION TOWNSHIP RANGE(E•W) COUNTY 1
a fS Q. O YI*sow Fba T /Al Ro- 4IX
Ulm IN 1111gil
IPAu ,4e- S'` a o At E 4./ -
1S`' 7*-A E/L E x S j N � ��i. eo,,cc� ,b cl l f,4 -ra rn4E4( 4616 , D^/E 13,0c"4E A 44 nIEC�FysAc
q .cr fod /,,S
I
PROPOSED STA ,TE ` �u S PROPOSED FINISHING D/g s
SEPA LEAD AGENCY,DETERMINATION,AND DATE OF DETERMINATION v
OTHER PERMITS —
!R 150 �O s� 4 � ,C3��j,��/n,_ PE Ply-AR �+ S �'ky. /✓f1 io�Wr E
IT IS UNDERSTOOD THAT NO WORK WILL BE STARTED SIB WURE DATE
UNTIL A SIGNED APPROVAL IS RECEIVED fA-11 / , /^ Q
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INSTRUCTIONS FOR COMPLETING
HYDRAULIC PROJECT APPLICATION
The Hydraulic Code(RCW 75.20.100, and 75.20.103, and 75.20.160) provides that any person or government
agency desiring to construct any form of hydraulic project or to perform other work that will use, divert,
obstruct, or change the natural flow or bed or any of the salt or fresh waters of the state, must submit
plans for the proposal to the Department of Fish and Wildlife (WDFW). WRITTEN APPROVAL MUST BE
OBTAINED FROM WDFW BEFORE COMMENCING CONSTRUCTION OR WORK.
An application shall contain: 1) general plans for the overall project; 2) complete plans and specification of
the proposed construction or work within the ordinary high water line of state water; and 3) complete
plans and specifications for the proper protection of fish life. This information may be entered in Block 16,
on the back of the application, or attached. AN INCOMPLETE APPLICATION MAY DELAY ISSUANCE OF THE
APPROVAL.
Mail the application to the address below:
Washington Department of Fish and Wildlife
Habitat Management Program - -
600 Capitol Way North
Olympia,WA 98501-1091
TYPE OF PROJECT: Enter only that portion of the project within the ordinary high water line (i.e., Culvert
Installation., Bank Protection, etc.
WATER: Identify water by legal or common name (if unknown, enter unknown) and first named receiving
water(i.e., Jones Creek, tributary Skagit River).
QUARTER SECTION: Enter legal description (section, township, range). If unknown, checK with county
auditor's office.
'I SEPA AGENCY/DATE OF DETERMINATION: The State Environmental Policy Act(SEPA) may require a
determination of the environmental impact of your proposal. If your project also requires a permit from
another agency(State, City, or County), you may be required by them to complete an environmental
checklist. If only the Hydraulic Project Approval is required, removal of 50 or more cubic yards of
streambed material or a channel realignment may require a completed checklist by WDFW. A
determination of the impacts-will be m�ade-f-rom:t- a information— nAhis checklist as required by SEPA.
Modifications to your project may be required to lessen any Impacts. If this process has been completed,
attach a copy of the determination or specify the agency, date, and determination. BY LAW, THE
HYDRAULIC PROJECT'APPROVAL CANNOT BE ISSUED PRIOR TO COMPLETION OF THE SEPA PROCESS.
OTHER PERMITS: List other permits required. Identify by title and identification number. Examples are:
Corps of Engineers (Federal)
Water Rights; Flood Zone (Department of Ecology)
Forest Practices (Department of Natural Resources)
Shorelines, Building, Conditional use(County of City)
Water Quality Modifications-Any project which will affect water quality, including turbidity, may require
an order from the Department of Ecology(DOE) authorizing a short-term modification of water quality
standards. Applications for authorization should be submitted to the appropriate DOE regional office at
least 30 days prior to starting your project. For additional information, call (360) 459-6000.
The completed forms should be submitted as far In advance as possible. Up to 45 days should be allowed
for Investigation and processing of concerning your
application, you should write or phone the appropriate WDFW regional office.
1
- AGENCY E1SE ONLY
Agency Reference
Tate, el mod.
JARPA FORM
(for use if Washinsan S:u)
s
PLEASE TYPE OR PRINT IN BLUE OR BLACK INK
Based on the preceding checklist,1 am sending copies of this application to the following: (check all that apply)
Local Government for shoreline: ❑Substantial Development ❑Conditional Use ❑Variance Exemption:or,if applicable
O Floodplain Management ❑Critical Areas Ordinance
Washington Department of Fish and Wildlife for HPA
14 Washington Department of Ecology for. Approval to Allow Temporary Exceedance of Water Quality Standards
p 401 Water Quality Certification Nationwide Permits
❑ Washington Department of Natural Resources for,p Aquatic Resources Use Authorization Notification
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)for all permit
applications.
I �?uCA,vT
\114 NE 9 J04 4
M. LING L OR£SS O O c
7/0 3 139 � s� �C�,�,�..�A x �
V.cRx HONE f
-/ HOMEPHONE FAx
co* 4cr PhaKE V69- 0 371 S* 't � Ss66- 7?0
If an agent is acting for the applicant during the permit process,complete-_Z
F
AU T HORI-M AGENT
Flo a/ J 4DE l�
�•�:u.NG ACDR=ss 04
.S /YI r � /l �—C� /`I ''�/ • / .
':.JAK PHONE
MOM,PHONE FAX•
366 — g(.4 - a 3 '1 3G0-CMG -0 3 '7 6C--7 70
3 R-ELATIONSHIP OF APPLICANT TO PROPERTY: wNER 0 PURCHASER 0 LESSEE O OTHER:
NAME.A:.OR:SS.ANO PHONE NUMBER OF PROPERTY OwNER(S).IF OTHER THAN APPLICANT: q
I,
i.LOCATION(STREET ADORESS.INCLUOING Cr.Y.COUNTY ANO'ZIP COOS,VMERE PROPOSED ACTNM EXISTS OR v4LL CCCU.R) 1;
AT_RSOOY
'/ / /� .y� TRtBUT Y OF i
se
SECTION TOwNSHt? RAN Gc GOVERNMENT LOT SHORELINE DESIGNATION
'S
a o NIA ZONING DESIGNATION
� aw
%A PARCEL NO.: DNR STREA%I TY?_,IF K.-40.?1
I
i
6. DESCRIBE THE CURRENT USE OF THE PROPERTY,A.VD STRUCTURES EXISTING ON THE PROPERTY. IF ANY PORTION OF i='c PROPOSED ACTTvrTy IS AL.R=ADY COMPLE i EO
ON THIS PROPERTY,INDICATE MONTH AND YEAR OF COMPLETION.coo A _if 14� u S E o F Pe,) P E S i�✓9 �E
Skecc T u � ES OA( S � �E' • ! ,�3
I IS THE PROPERTY AGRICULTURAL LAND?O YES O NO ARE YOU A USDA PROG,"%i PARTICIPANT? Cl YES O NO
7a. OESCRIBE THE PROPOSED WORK COMPLETE PLANS AND SPECIFICATIONS SHOULD BE PROVIDED FOR ALL WORK WATERWARO OF THE ORDINARY HIGH WATER MARK OR
LINE INCLUOING TYPES OF EOUIPm_NT TO BE USED. IF APPLYING FOR A SHORELINE PER.AIIT.DESCRIBE I ; WORK WITHIN AND BEYOND 2:0 FEET OF THE ORDINARY HIGH
v:ATER MARK ATTACH A SEPARATE SHEET IF ADDITIONAL SPACE IS N=EDEO. /�'09
Pa u e � � /l �� fiti%G x a � d�E� Se
O � o T (
�`i� �( 5 �ca ��
/,-k 4- a g Ac
).q 65 At
' L /S
/VF� C �SS 4 y
7 t, C_SCR!B_i H_PURPOS_OF THE PROPOSEO vRORK 60 D L
L o/ ��S �oo Sr �c �ioM
j�00 �i °`�9 - w �v
�b 7' ,eo oS E-� XOR4
DESCRIBE THE POTENTIAL IMPACTS TO CHAAACTERISTIC USES OF THE WATER BODY. THESE USES AWAY INCLUDE FISH AND AOUATIC LIFE.WATER DUALITY,WATER
SU?PLY.REC7.E i ION,and A_--SIHEyT:CS. IDENTIFY =-
PROPOSED ACTIONS TO AVOID.MIN0At .ANO MITIGATE OETRI[M=_l rAL IMPACTS AND PROVIDE PROPER PROTECTION
OF:ISH ANO ADUATIC LIFE.wc)
T /oc� s a
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f
3 -
' ?7?PARATION'OF DRAWINGS: SEE APPENDIX A-SAMPLE DRAWINGS AND CHECKLIST FOR COMPLETING THE ORA'MNGS ONE S_"T OF ORIGINAL OR GOOD QUALITY
R°?.QO0UCI3L E OR AW7NGS MUS BE ATTACHED. NOT= APPLICANTS ARE ENCOURAGEO TO SUBMIT PHOTOGP kPHS OF ?R0:_CT SITE,BUT THESE 00 NOT SUBSTITUTE
THE CORPS OF ENGINEERS AND COAST GUARD REOUIRE DRAWINGS ON 11-in X 11 INCH SHEETS. LARGER OR A WINGS MAYBE R_OUIREO BY OTHER_
SECTION B-Use for Shoreline and Cotes of Engineers permits only:
15. TOTAL COST OF PROJECT. MEANS THE FAIR#�IRICT VALUE OF THE PROJECT.INCLUDING MATERL1LS,LABOR,MACHUN_ Eh TALS•ETC.
9 0 00
17. LOCAL GOVER.vMENT V',ITH JURISDICTION:
13. FOR CORPS,COAST GUARD,A.vO ONR PERMITS.PROVIOE NAMES,ADDRESSES.AND TcL=PMON=NUMBERS OF AOJoiNING PROPERTY OINERS.LESSEES.ETC.PLEASENOTE: SHORE-LIVE MANAGEMENT COMPLIANCE MAY REQUIRE ADOmONAL NOTICE-CONSULT YOUR LOCAL GOV=FtNhIE:vi.
NA161E ADDRESS I PHONE NUMBER
e i P-ex 44 4 v"•s o X O Ae. f 7 7
Meg Mrs llog X�, AA,1 A V Z/ .3 A/ .v o C Pa A LAN o c 7.t
SECTION C -This section MUST be completed for any permit covered by this application.
19. ,APPLICATION IS HEREBY MADE FOR A PERMIT OR PERMITS TO AUTHORLZ=THE ACTIVITIES DESCRIBED HEREIN. I CER IFY THAT 1 AM FAMILIAR WTrH TH'c
INFORMATION CONTAINED IN THIS APPLICATION,AND THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF,SUCH INFORMATION IS TRUE.COMPL_°Tc,AND
ACCU.4AT� I FURTHER CERTIFY THAT I POSSESS THE AUTHORITY TO UNDERTAKE THE PROPOSED AC;IV I=S. I HERESY GRANT TO THE AGENCIES TO
.'•KCH THIS APPLICATION IS MADE,THE RIGHT TO ENTER THE ASOV=_-OESCRISEO LOCATION TO INSPECT TI.1=PROPOSED.I.V.PROGRESS OR COMPI_ET'co
_ REF TO START 4':ORK ONLY AFTER ALL NECESSARY PERMITS HAVE SEEN RECEIVED.
S,G.vATURE 0:APPLICANT OR AU IZ=-O AGENT DATE
I MEREBY DESIG.vATE 9/0 Val D kik—
TO ACT AS MY AGENT IN MATTERS RELATED TO THIS APPLICATION FOR P t1R(S). 1 UNDERSTAND THAT IF A FEDERAL PER.%tr,Is ISSu O.I MUST S:GN THE PERMIT.
S:G7:ATURE OT APPLICANT DATE
S:G.-':ATURE OF LANDOWNER("EXCEPT PUBLIC ENTRY LANOOVYNERS•E.G.ONR) OAT
H:S APPLICATION Mr• r BE SIGNED BY THE APPLICANT AND THE AGENT,IF AN AUTHORt2=0 AGENT is DESIGNATED.
t 3 U.S C;t:O I>ro•roes=t: Whoe•er,n any manna'.r"Lte ii+is on of any aepar:mett or agencY Uneed Stars iuw.r,S,y'a:sfis, au.or Co, 69 h any tntlt,a0vne,or_<rce a 14:1nal IaC Or mates any taise,4=-Qus,or Iraueuient s Comenta or n "antuupns or m+hes or wes"L@LS*wreak•,or oocanert sane to Oanu.t any few,(....,or
���ert s:arer.+ert or ar-:y.stria}l rr ro rot more Ltan f IO.CCO oe im;nspsed not non-tans years ar bcL%
COMPLETED BY LOCAL OFFICIAL
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A. Nature of the existing shoreline: '(Describe type*of shon:•line,'su'C as marine,stream,lake,lagoon,marsh,bog,swamp,flood
plain,floodway, delta;type of beach,such asaccretion,erosion,high bank, low bank, or dike:m terial such as sand,'gravel.
mud, clay, rock, riprap;and extent and type of bulkheading,if any:) .......
S. 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
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 Opportuncj and Affirmative Action ernproye.
r
For special aCCOMMCdadon needs,please car•.:act the appro;r.'a:e agency fm.^A:cenCrr a.
3.WILL THE PROJECT BE CONSTRUCTED IN STAGAS7 CI YES p No
PROPOSED STARTING DATE:
ESTIMATED OURATION OF ACTMT'Y: A S
9.CHECK IF ANY STRUCTURES WALL BE PLACED:
XA—'ERWARD OF THE ORDINARY HIGH WATER MARK OR LINE FOR FRESH OR.TIDAL WATERS:A.YDIOR
WATERWA.RD OF THE MEAN HIGH WATER LINE IN TIDAL WATERS
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tJ.W7LL FILL-%uTERIAL(ROCK FILL.BULKHEAD,PILINGS OR OTHER MATERIAL)3E PLACED:
O WATERWARD OF THE ORDINARY HIGH WATER MARK OR LINE FOR FRESH WATERS? IF YES.VOLUXIE(CUBIC YARDS) /AREA (ACRES
�LVA i ccr'tSVARD OF THE MEAN HIGHER HIGH WATER FOR TIDAL WATERS? IF YES.VOLUME(CUBIC YARDS)Z'AREA (ACRES)
1 I..V_L MATERIAL BE PLACED IN WEiLANOS? „S O NO
IF YES:
A.IMPACT=O AREA IN ACRES O 3.HAS A DELINEATION BEEN COMPLETED? IF YES,PLEASE SUBMIT WITH APPLICATION. p YES &90
t
f C HAS A W E, O REPORT BEEN PREPARED? IF YES,PLEASE SUBMIT WR'H APPLICATION. O YES �g
I t,/� C
O.TYPE AN�;O COMPOSRION OF FILL MATERIAL(E.G..SAND,ETC):( 40,F( / `�1 YE
E.MATERIAL SOURCE: H y
)ems c/'` �'+� X / ,7 K
I F.LIST ALL SOIL SERIES(TYPE OF SOIL)LOCATED AT THE PROJECT SITE,S INDICATE IF THEY E ON THE COUNTYS LIST 0:HYORIC SOILS. SOILS INFORMATION CAN BE
C37AINEO FROM THE NATURAL RESOURCES CONSERVATION SERVICE(MRCS): S'
12L'-%'LL PR,^,POSEO ACTIVITY CAUSE FLOODING OR DRAINING OF WETLANDS? r lT p YES 04lo
IF YES.IMPACTED AREA IS O ACRES
¢Ei I 13 ::LL EXCAVATION OR OREOGING 3E REOUIREO IN WATER OR WETLANOS? Cl YES p NO
k' IFYES.
p! A.VOLUME. (CUBIC YARDSyv'tEA f� (ACRES)
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k 3.COMPOSITION OF MATERIAL TO BE REMOVED: S ry, &eji v E /��1 J `/ L/C
C.DISPOSAL STE FOR EXCAVATEO MATERIAL: dd / c �jb�/1,'N IL+9 4 P �!L 4 17", .4 C •
0 ME711CO OF OR_OC:NG: ?C
I I+ LIST OTHER APPLICATIONS.APPROVALS.OR CERTIFICATIONS FROM OTHER FEDERAL,STATE OR LOCAL ACENCIES FCR AXY STRUCTURES.ConSTRUCT10N,OISCHARGES.
i
7R C ThER ACT.VG;=S DESCRIBED IN THE APPLICATION(LE..PRELIMINARY PLAT APPROVAL,HEALTH OISTR:CT APPROVA-3U:LOING PEPa/T•$EPA aEv!EVi,FERC LICENSE,
CR_37».:C7;CE S APPLICATION,ETC.)ALSO INDICATE WHETHER WORK HAS BEEN COMPLETEO ANO INDICATE ALL EX:STINC; 4RK ON ORANANGS.
TYPS OOF APPROVAL ISSUING AGENCY tOENTIFICA.TION NO. DATE OF APPLICATION OAT=APPROvEO ( COMPLETEO?
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3"A LEAD AGENCY SEPA DECISION. SEPA DECISION OATS:
:5 HAS ANY AGENCY DENIED APPROV R THE ACTIVITY DESCRIED HEREIN OR FOR ANY ACTIVITY DIRECTLY RELATED TO THE ACTIVITY
Dc��n13ED HEREIN?❑YES 6,140 IF YES,EXPLAIN:
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