HomeMy WebLinkAboutJARPA - SHX Application - 8/25/2005 AGENCY USE ONLY
Agency Reference#. Date Received:
Circulated by: (local govL or agency)
JOINT AQUATIC RESOURCES PERMIT APPLICATION FORM(JARPA)
(for use in Washington state)
M PLEASE TYPE OR PRINT IN BLACK INK OR FILL IN ELECTRONICALLY
❑Application for a Fish Habitat Enhancement Project per requirements of RCW 77.55.290. You mast submit a copy of this
completed JARPA application form and the(Fish Habitat Enhancement DARPA Addition)to your local Government
Planning Department and Washington Department of Fish&Widire Area Habitat Biologist on the same day.
NOTE: LOCAL GOVERNMENTS—You must submit arty cowAu nta at Ilia projects 10 WDFW wiiddi 1$working days.
Based on the instructions provided,I am sending copies of this application to the*Mowing: (check all OW apply)
❑✓ Local Govemment for shoreline: ❑Substantial Development ❑Conditional Use ❑variance ❑Exemption ❑Revision
❑Fioodplain Management ❑Critical Areas Ordinance
❑✓ Washington Department of Fists and Wildlife for HPA(Submit 3 copies to WDFW Region)
❑ Washington Department of Ecology for 401 Water Quality Certification(to Regional Office-Federal Permit Unit)
❑ Washington Department of Natural Resouvim for Aquatic Resources the Authorization Notification
❑ Corps of Engineers for; ❑Section 404 ❑Section 10 permit
❑ Coast Guard for. ❑ General Bridge Act Permit ❑Private Aids to Navigation(for non-bridge projects)
❑ For Depwlrne t or Transportation projects only. This project will be designed to meet conditions of the most current
Ecology/Departmert of Transportation Water Quality knPlementing Agreement
? SECTION A-Use for atf permits covered by this appRestion. Be sure to ALSO eomp/ste Section C(SOMItum BbckJ for ail
1
1 pervilltaillpfibadons-
1.APPLICANT
Curt&Jennifer Henniger
f MAILING ADDRESS
5234 Westfield Court,Lake Oswego OR 97035
WORK PHONE E-MAIL ADDRESS HOME PHONE FAX#
503-699-8558
'I
K an agent is ailing for fie applicant during the pen Nt process,complete fll Be sure agent signs Section C(Signature Block)
for ail permR appillandons
.AUTHORIZED AGENT
E94 D' 1`1ffJ0011J
{ MAILING ADDRESS
P.O. Box 368,Beffair WA 98528
WORK PHONE E-MAIL ADDRESS HOME PHONE FAX#
360-276-6382 360-275-6740
3.Relationshipof applicant to property: Q OWNER ❑PURCHASER ]LESSEE ❑OTHER
4.i
F
Name,address and phone number of property owner(s)if other than applicant:
5.Location�srtrset address,•n cy,.couttty and code,where proposed activity exists or will occur)
4 13631 NE North shtxe� RD,Belfatr WA 98528
Local government with Jurisdiction(city or may)
!, Waterbody you are working in Hood Cartel Tritxrtary of WRIA#
is this waterbody on the 303(d)List YES 0 NO Puget Sound
If YES,what parsmeWs)? Shoreline d9tilgriatim Urban Residential
'a For 303d List,
j hftp://www.ecy.wa.gov/programs/wq/303dfindex.htmi Zoning Residential
%section I section Township Ranae Government Lot
DNR stream type if known
a
Latitude and Longitude: Tax Parcel Number 32227-51-00014
ECY 070-15(Revised t 1/04)DARPA, Caftd the Stets of Wastiingl xt Office of Regulatory Assistance for h6d version or call 3W407 7037 or 80Q1917.OW 1
. Descrrtine the current use of ,and structures existing on the property. Have you c�ompietsd any pow of the proposedthe
activity on this property? YES 0 NO
For any portion of the proposed activity akeady corrnpleted on This property,Indicate month and year of completion.
Seasonal Residence
Is the property agricultural land? YES ✓ NO Are you a USDA program participant? YES E NO
TDescribe the proposed work that needs aquatic peurds: Complete plans and specifications should be provided for p work watervvard
o
of the ordinary high water marls or tine,irlCktdng types of equipment to be used If applying for a shoreline permit,describe @I work
within and beyond 200 feet of the ordinary high water mark. If you have provided attached materials to describe your project,you still
must sumrnarfm the proposed work here. Attach a separate sheet If additional space is needed.
PREPARATM OF ORAWWW see sample dr•wlrgs end MWisros for completing the drewGgs. OIfE AW OF ORlGIMMAI.OR GOOD 01AU YREFRODUCBLE
DRAWgrOS MM eEATTA090 NOTE. Appacarsa are encouraged to submit photographs or ate pn rip cl site.but erase o0 Nan substibm nor dwsirgs. THE CORPS
OF6 5AMDCOASTGUARD ORAWWGSONa1nx11A*CHSNEEM LARGERDRANh1=MAYBE REQWWBYOTHERAGENCES.
7b. 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.
Upgrade Existing Bulkhead
c. Describe the potential impacts to characteristic uses of the water body. These uses may include fish and aquatic ire,water quality,
water supply,recreation and aesthetics. identify proposed actions to avoid,minimize,and mitigate detrimental i giects and provide
proper protection of fish and aquatic life. Identify which guidance documents you have used. Attach a separate sheet if additional
space is needed.
7d. For in water construction .will project be in compliance with the State of Washington water quality standards for turbidity
WAC 173.201A-110? El YES (See USEFUL DEFINITIONS AND INSTRUCTIONS
i
. will Me project be constructed in stages? YES M NO[✓�
Proposed starting date: 9/15/05
Estimated duration of activity: Onemounth
. Check if any temporary or permanent structures will be placed:
❑Waterward of the ordinary high water mark or line for fresh or tidal waters AND/OR
❑Waterward of the mom higher high water for tidal waters?
10.1 fill material(rock,fill.bulkhead,or other material)be placed:
Waterward of the ordnary high water mark or line for fresh waters?
If YES.VOLUME(cubic yards) /AREA (acres)
Waterward of the mean higher high water for tidal waters?
If YES,VOLUME(cubic yards) /AREA (acres)
ECY 070-15(Revised 11104)JARPA. Contact the Stolle of Wediinylon Office of Reotratm Assistance for IOW version or cal 3W407 7037 or OM174M 2
11. Will material be placed in wetlands? AYES ✓]NO
ff YES:
A. Impacted area in acres:
B. Has a delineation been completed? ff YES,please submit with application. HYES NO
C. Has a wetland report been preyed? N YES,please submit with application YES Mee
NO
D. Type and composition of Till material(e g.,sand,etc.)
E. Material source:
site.and
F. List an BOB series(type of sap located at the project indicate if they are on the camty's Het ofhydric soils. Soils information
can be obtained from the mural Resources Conservation Service(MRCS).
G. WILL PROPOSED ACTIVITY CAUSE FLOODING OR DRAINING OF WETLANDS? YES ❑✓ NO
IF YES,IMPACTED AREA IS ACRES OF DRAINED WETLANDS.
NOTE: gym pried vA aped greater Um%d an acre d wetland.submit a mii4dm Plan tc the Caps and Eodapy far approYal slurp wih the DARPA tam
NOTE a 401 weer queillr oerMi lion wN be wq*W cram 6wkw inaddition ban awwad milipa w Am if Pff P*d n "wdnnde M arc a)grader then%aas in size.
a b)tidel wa0wKb a walnn&adyscent b tidal wrier.please*&*#a JARPA tam and rrr6g&n plan b EcolMy iar an k dvidnna 4M cwocdm is)orb)apple&
12 Stonnwater Compliance for Nationwide Permits Only:
This project is(or will be)designed to meet ecdogy's most current stormwater manual,YES n✓ NO
or an Ecology approved kcal sbrmwater manual.
ff YES—Which manual win your project be designed to meet?
If NO—For dean water ad Section 401 and 404 permits only—Please submit to Ecology for approval, along with this JARPA
application,documentation that demonstrates the stormwater runoff from your project or activity win comply with the water quality
standards.WAC 173201(A)
13.Will excavation or dredging be required in water or wetlands? ❑YES ro-l-INO
If YES:
A. Volume: (cubic yards)/arm (tee)
B. Composition of material to be removed.
C. Disposal site for excavated material:
D. Method of dredging:
3
14. Has the State Environmental Policy Act(SEPA)been completed YES ✓ NO
SEPA head Agency:
SEPA Decision: DNS,MDNS,EIS,Adoption,Exemption __ Decision Date(end of comment period)
SUBMIT A COPY OF YOUR SEPA DECISION LETTER TO WDFW AS REQUIRED FOR A COMPLETE APPLICATION
15. List other Applications,approvals or certifications from other federal,stab or local agencies for any structures,construction discharges
or other activities described in the appHcatioin Q.&preliminary plat approval,health distrid approval,building permit.SEPA review.
federal energy regulatory commission license(FERC),Forest pradkes application,elm) Also,Htdicate whether work has been
completed and indicate all existing work on drawings. NOTE:For use with Corps Nationwide Permits,ider tY whedw your project has
or will need an NPDES permit for dischaq Ing wastewabr and/or siormweler.
V TTPEMAPPaovAL ISSUP40AGENCY KOMW IMN DKIEMAPPcrcA M 011TEAPP110NED COMPLETED?
No.
Building Permit JN aou ConufA =2%02
HbV MDEM 8\32\02
6. Has any agency denied approval for the activity you're applying for or for any activity directly rimed to the activity described herein?
I YES [E]NO
If YES,explain:
ECY 070 i5(Revieed t 1104)DARPA t,odad the SW of WaaNngbn Office of Regt cry Asastance for IeAeet veraiouu tr can 380/A07 7037 a 800/917-0013 3
u
SECTION B-Use for Shoreline and Coips of Engineers 2wmffs on
7a.Total cost of project. This means the fair market value of the project,inducting materW lab".machine rerrtals.etc.
jq3 &a m ®�perrntls Gent c5og!ltevrlxy 17C
7b. if a project or any p ofi a protect receives funding from a federal agency,that agency is responsible for ESA consultation. PIS
ndicarte if you wi8 receive federal funds and what federal agency is providing those funds. See instructions for Information on ESA.*
EDERAL FUNDING 0 YES NO If YES, please list the federal agency.
8.Local government with jurisdiction:
9. For Corps,Coast Guard and DNR permits,provide names,addresses and telephone numbers of adjoining property owners,lessees,
etc. - Please note: Shortie Marisgin"Comphnoe MY rsquha addUarW nofte—consult your bcaf goviernmont.
NAME ADDRESS PHONE NUMBER
SECTION C-This swdm MUST lie Nor covie► 6%%
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 tht applkattion,and that to the best of my knowledge and belief,such information is true,complete,and
accurate. 1 further certify that I possess the authority to undertake the proposed activities. 1 hereby grant to the agencies to which
is application is made,the right to enter the aboveAescribed location to inspect the proposed,in-progress or completed work. I
gree to start work ONLY after all necessary permits have been received.
DATE
SIGNATURE OF APPLICANT
DATE
SIGNATURE OF AUTHORIZED AGENT
EREBY DESIGNATE TO ACT AS MY AGENT IN MATTERS RELATED TO TH16 APPLICATION FOR
M!T(S). I UNDERSTAND THAT IF A FEDERAL PERMIT IS ISSUED, I MUST SIGN THE PERMIT.
SIGNATURE OF APPLICANT DATE
SIGNATURE OF LANDOWNER(EXCEPT PUBLIC ENTITY LANDOWNERS,E.G. DNR)
THI;R APPLICATION MtW BE SIGNM BY THE APPLICANT AND THE AGENT,F AN AW1100tlZ®AGENT IS DENGW iTED.
18 U.S.0§1001 provides that: Whoever,in any manner within the jurisdiction of any department or agency of the United States knowingl
falsifies,GIs,or covers up by any trick,scheme,or device a material fact or makes any raise,flctitious,or fraudulent statements or
representations or makes or uses any false writing or document knowing same to contain any false,fictitious,or fraudulent statement or
entry,shall be fined not more than$10,000 or imprisoned not more than 5 years or both.
COMPLETED BY LOCAL OFFICIAL
A Nature of the existing shoreline. (Describe type of shoreline,such as marine,stream,lake, lagoon, marsh, bog.swamp,flood
plain,floodway.delta:type of beach,such as accretion,erosion,high bank,low bank,or dike;material such as sand,gravel, mud,day,
rock,ripreP;and extent and type of bulkheading,if any)
B. in the event that any of the proposed buildings or structures will exceed a height of thirty-five feet above the average grade level,
indicate the approximate location of and number of residential units,eoft*V and potential,that will have an obstructed view.
C. if the application involves a conditional use or variance,set forth in full that portion of the master program which provides that the
proposed use may be a conditional use,or,in the case of a variance,from which the variance is being sought:
These Agencies arc Equal Opperltnlh and Afllrmalin Adlon a-pioyers.
For special axamnodellon-sole Please oo-tact the approprtale agency in the kisbudions
ECY 070-15(Rev. 11104) DARPA Confect the Stale or Wash n$an Office of Regulatory Assistance for blest version or cant 3WM7-7037 or OW19174)M