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Home My WebLink AboutJARPA - SHX Application - 9/29/2005 AGENCY USE ONLY HF-CEIVED Agency Reference#: Date Received: Cuudated by: (local govL or ) JOINT AQUATIC RESOURCES PERMIT APPLICATION f t(. W) M (for use in Washington State) PLEASE TYPE OR PRINT IN BLACK INK. TO FILL IN ELECTRONICALLY,USE F11 TO MOVE THROUGH THE FORM ❑ Application for a Fish Habitat Enhancement Project per requirements of RCW 77.55.290. You must submit a copy of this completed JARPA application form and the(Fish Habitat Enhancement JARPA Addition)to your local Government Planning Department and Washington Department of Fish &Wildlife Area Habitat Biologist on the same day. NOTE: LOCAL GOVERNMENTS—You must submit any comments on these projects to WDFW within 15 working days. Based on the instructions provided, I am sending copies of this application to the following: (check a#that apply) Local Government for shoreline:[]Substantial Development []Conditional Use []Variance wr ption []Revision� []Criticalloodplain Management Critical Areas Ordinance ® Washington Department of Fish 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 Resources for Aquatic Resources Use 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 Department of Transportation projects only: This project will be designed to meet conditions of the most current Ecology/Department of Transportation Water Quality Implementing Agreement SECTION A-Use for all permits covered by this application. Be sure to ALSO complete Section C(Signature Block)for all permit applications. 1. APPLICANT SS MAILING ADDRESS 01-7 A mor Nve, shotq(Mg WORK PHONE E-MAIL ADDRESS lbtorqZl- OME P NE FAX# q 6 If an agent is acting for the applicant during the permit process,complete#2. Be sure agent signs Section C(Signature Block) for all permit applications 2.AUT �GENT MAIL ADDRESS WORK PHONE E-MAIL ADDRESS HOME PHONE FAX# f / 3. Relationship of applicant to property: OWNER ❑ PURCHASER [] LESSEE ❑ 4. Name, address and phone number of property owner(s)if other than applicant: 5. Location(street address, incl mg city county and zip code,where proposed activity exists or will occur) 13(0, 1 0� N� I o r4 sh v re 0 ' QE i��I- W1� G �S 2 cy Local government with jurisdiction(city or county) ) o Waterbody you are working in Tributary of WRIA# Is this waterbody on the 303(d)List'* YES—[-] NO ❑ �q'/ If YES,what parameter(s)? Shoreline designation Ull I � "For 303d List, 4 http://www.ecy.wa.qov/programstwq/303d/index.html Zoning designation %Section I Section Township Range Govemment Lot SW �17 & DNR stream type if known ��//,� Latitude and Longitude: Tax Parcel Number �2Z'L_7-51—WV I ECY 070-15KRev. 11/04) JARPA Contact the State of Washington Office of Regulatory Assistance for latest version or call 360/407-7037 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 property agricultural land? YES NO Are you a USDA program participant? YES NO 7a. Describe the proposed work 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. If applying for a shoreline permit, describe all 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 summarize the proposed work here. Attach a separate sheet if additional space is needed. Q.Q.move. OW eap , o r m and Cons-6-uc+ ne-w (_q On 6Lktk keod and taw p OA- 6, can e� s<h n9 Ba-,ck-h ead PREPARATION OF DRAWINGS: See sample drawings and guidance for completing the drawings. ONE SET OF ORIGINAL OR GOOD QUALITY REPRODUCIBLE DRAWNGSMUST BE ATTACHED. NOTE: Applicants are encouraged to submit photographs of the project site.but these DO NOT substitute for drawl ngs. THE CORPS OF ENGINEERS AND COASTGUARD REQUIRE DRAWINGS ON 6-112 X 11 INCH SHEETS. LARGER DRAWINGS MAYBE REQUIRED BY OTHER AGENCIES. 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. 6moue oId, eap a/,vd oons�rac-J- ntti 0o p u4n guy kkerej 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 and aesthetics. Identify proposed actions to avoid, minimize, and mitigate detrimental impacts 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 wo ,will your project be in compliance with the State of Washington water quality standards for turbidity WAC 173201A-110? YES NO (See USEFUL DEFINITIONS AND INSTRUCTIONS) 8. Will the project be construct in stages? NO Proposed starting date: R/I S/q 5 Estimated duration of activity: A 9. Check if any temporary or permanent structures will be placed: Waterward of the ordinary high water mark on line for fresh or tidal waters AND/OR Waterward of the mean higher high water for tidal waters? 10. Will fill material(rock, fill, bulkhead,or other material)be placed: YJO Waterward of the ordinary 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) 1 AREA (acres) V ECY 070-15(Rev. 11104) JARPA Contact the State of Washington Office of of Regulatory Assistance for latest version or call 36D/407-7037 or 8W/917-0043 II,I 11. Will material be placed in wetlands? YES NO If YES: A. Impacted area in acres: B. Has a delineation been completed? If YES, please submit with application. YES C. Has a wetland report been prepared? If YES, please submit with application YES D. Type and composition of fill material(e.g., 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 county's list of hydric soils. Soils information can be obtained from the natural Resources Conservation Service(NRCS). G. WILL PROPOSED ACTIVITY CAUSE FLOODING OR DRAINING OF WETLANDS? YES If YES, IMPACTED AREA IS ACRES OF DRAINED WETLANDS. #T NOTE:If your project will impact greater than%of an acre of wetland,submit a mitigation plan to the Corps and Ecology forapproval along with the JARPA form. NOTE:A 401 water quality certification wig be required from Ecology in addition to an approved mitigation plan if your project impacts wetlands that are: a)greater than'A acre in size, or b)tidal wetlands or wetlands adjacent to tidal water. Please submit the JARPA form and mitigation plan to Ecology for an individual 401 certification if a)or b)applies. 12. Stormwater Compliance for Nationwide Permits Only: This project is(or will be)designed to,meet ecology's most current stormwater manual, or an Ecology approved local stormwater manual. YES NO If YES—Which manual will your project be designed to meet? If NO—For clean water act 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 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. Volume: (cubic yards)/area (acre) B. Composition of material to be removed: C. Disposal site for excavated material: D. Method of dredging: 14. Has the State Environmental Policy Act(SEPA)been completed YES NO SEPA Lead Agency:_ X 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, state or local agencies for any structures, construction discharges or other activities described in the application(i.e. preliminary plat approval, health district approval, building permit, SEPA review, federal energy regulatory commission license(FERC), Forest practices application, etc.). Also, indicate whether work has been completed and indicate all existing work on drawings. NOTE: For use with Corps Nationwide Permits, identify whether your project has or will need an NODES permit for discharging wastewater and/or stormwater. TYPE OF APPROVAL ISSUING AGENCY IDENTIFICATION DATE OF APPLICATION DATE APPROVED COMPLETED? NO. s' o� 16. Has any agency nt approval for the activity you're applying for or for any activity directly related to the activity described herein? YES NO If YES, explain: ECY 070-15(Rev. 11/04) JARPA Contact the State of Washington Office of Regulatory Assistance for latest version or call 3601407-7037 or 800/917-004.3 SEP-14-2005 04 :00 PM LINCOLN 360 275 6740 P_ 02 SEC"ON B-U"for Shot* *and EOM of mill m 7a.Tote(oollt of This M"M tM fwr mafm val(w of the kndudktg ' br,ialaor.m7lolthts rentaks,etc C3 i�I�� Pt S WS4- 4F der riu/5 ano 1hpejr /� IQP red Tb.If e ( 0� � �� Pa o is Peron oho Project receives funding from 8 federal agency,that agency Is responsible for EGA consultation_ Pea indicate N you will receive fademl 701r federal agency Is providing those funds. See instructions for information on ESA.' EDERAL FUNDING Q YES Y0,please list the federal agency. 8. Local govamment with jurisdiction 19_ ForMet Guard andDNR permits,provide names, add and telephone numbers of adjoining property owners, lessees, etc. - Weaas Noll/: Sbon*w AQv wg&mwd Campdance nosy AmpAm eddbarW nonos-cmxo yow kcw government NAME ADDRESS PHONE NUMBER SEC A2N C-T>tibe xecOm SlWrbs camwAwaid Aw coYar+od >yrM4 empgawkw Applkoallon is hereby made for a permit or permits to suftrize the activities described herein. I certify that I am familiar with the infomtation contained in this application,and that to the best of my knowledge end belief,such information Is true, complete,and aacutIft t further CW t that I possess the auft ft to undertake the proposed activities. i hereby grant to the agencies to which Oft Application is made,the right to enter the Above-desctibed location 10 inspect the proposed,in-progress or completed work t agree to start wok C�1j--y alter ail necessary permits have been received. �1 DATE SIGNATURE OF APPLICANT DATE __V &2=0� wm'n IREWjOTHRIZED AGENT I HEREBY DESIGNATE �/ L. /IQ TO ACT AS MY AGENT IN MATTERS RELATED To THIS APPLICATION FOR I RMtT(S), i UNDER AN[ b4T-IF-A DERAL PERIM IS ISSUED, I MUST&kON THE PERMIT. ZL S93NATURE APPLICANT DATE SIGNATURE OF LANDOWNER(EXCEPT PUBLIC ENTITY LANDOWNERS, E.G. DNR) TM A1aPLJCA MN MW BE-SIGMED By THE APPLV WT AM)THE AGENT,iF AN AUTNtaR M AGENT 13 DESAf M71SD. 18 U.8.C 64001 Provkdas thafi Whoevr ,r,In any manner within the 1wisdindon of any deportment or agency of the United States knowingly, faisMas, conceals,or covers up by any trick, scheme,or device a rrharbWWI fad or makes any raise,fictitious,or fraudulent statements or representations or rrMkea or uses any false writing or document knowing same to w teln any raise, fictitious,or fraudulent statement or entry,shall be Heed not more than$10,000 or Imprisoned not more than S years or both. COMPLETED BY LOCAL OFFTCIAI_ A_ Nature of the aWs"shors&w (Describe type of shoMine,such as marfrte,stream,h ft lagoon,marsh,bog,sviamp,flood plain,fldodway,deft:type of beach,such as acaeljpn,erosion, high bank, low bank,or dike,mate S1 such as sand,gravel. mud,day, rock,nano;and WdWA and type of bulkheadMg N any) B. In the event that any of the proposed buildings or struchxns w111 oweed a height of thMy-live feet above the averege grade level, indicate the spprmftols Woffhon of and number of rosldenflel units, mdssing and potArttfal,that will have an obatruotdd view: C. H the application Involves a conditional use or variance,$et forth in M that portion of the master program which Provides that the Proposed use may be a ca"diNpnal uee�or,in the case of a vedanee,from which the variance is being sought fton Me we For epedst s= nndP*m needpleads cmdactt the opprgprlate fammr In Vis inetnrdlotrr ECY 07r-1s(Rev. 11104) JARPA CoMsat tha Stale of NHas**0n 4ffte of Reg �Y�lalii0bl[�i4 for leh*version or ad 9e01407-7007 or WM17-0043