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Home My WebLink AboutJARPA - SHX Application A6 V_'Y- Agency P.efererr,Ge: Date Received` JOINT AQUATIC RESOURCES PERMIT APPLICATION FORM (DARPA) (for use in Washington State) PLEASE TYPE OR PRINT IN BLACK INK ❑ 1 am applying for a Fish Habitat Enhancement Project per requirements of RC W 75.20.350. You must submit a copy of this completed DARPA 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 all that apply) ' Local Government for shoreline:❑Substantial Development ❑Conditional Use ❑Variance `Exemption ❑ Revision ❑ Floodplain 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 Nationwide Permits(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 Section 9 Bridge Permit ❑ US Fish&Wildlife Service or National Marine Fisheries Service for Endangered Species Act(ESA)Consultation SECTION A-Use for all permits covered by this application. Be sure to ALSO complete Section C(Signature Block)for all permit applications. ,.APP��..._ MUML�1c.,a.) Cc,�sT C�yw�s ,% N; s�GS MAILING ADDRESS ►O•.30x Q5-4 V1Jloltil wC�, C! g 'Sy Z C>LYMPIAI WA Ct�3s0-7 WOPu D"ONF E-MAIL A DRESS HOME PHONE FAX# If an agent Is acting for the applicant during the permit process,complete#2. 2.AUTHORIJEDAAGENT _NCI MAILING ADDRESS WORK PHONE E-MAIL ADDRESS HOME PHONE FAX# "30obl 1 1 1rJ-s 3 �Saat7 3.RELATIONSHIP OF APPLICANT TO PROPERTY: ❑OWNER ❑PURCHASER ❑LESSEE ❑OTHER: 4.NAME,ADDRESS,AND PHONE NUMBER OF PROPERTY OWNER(S),IF OTHER THAN APPLICANT: 5.LOCATION(STREET ADDRESS,INCLUDING CITY,COUNTY AND ZIP CODE,WHERE PROPOSED ACTIVITY EXISTS OR WILL OCCUR) ceU3 ( r-- "" 10(,0 / VNiuk — Covlw/ LOCAL GOVERNMENT WITH JURISDICTION(CITY OR COUNTY) WATEERRBBODDY /�. ,� RIBUTARY OF RIA# mo C � %SECTION I SECTION I TOWNSHIP I RANGE GOVERNMENT LOT SHORELINE DESIGNATION LATITUDE&LONGITUDE ZONING DESIGNATION IF KNOWN: TAX PARCEL NO: DNR STREAM TYPE,IF KNOWN 3Z�3 2So ' 0 5 o3 JARPA,Revised 12/98,contact Ecology's Permit Assistance Center for latest version,360/407-7037 Page 1 of 4 6.DESCRIBE THE CURRENT USE OF THE PROPERTY,AND STRUCTURES EXISTING ON THE PROPERTY. IF ANY PORTION OF THE PROPOSED ACTIVITY IS ALREADY COMPLETED ON THIS PROPERTY,INDICATE MONTH AND YEAR OF COMPLETION. k-ly c�.,,,.CU� pcK t�l sr1 NU-- IS THE PROPERTY AGRICULTURAL LAND? ❑YES O NO ARE YOU A USDA PROGRAM PARTICIPANT? ❑YES ❑NO 7a. DESCRIBE THE PROPOSED CONSTRUCTION AND/OR FILL WORK FOR THE PROJECT THAT YOU WANT TO BUILD 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. ATTACH A SEPARATE SHEET IF ADDITIONAL SPACE IS NEEDED. 2 L� ov � tS�►1�� hoc �� 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. l�tt2 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.ATTACH A SEPARATE SHEET IF ADDITIONAL SPACE IS NEEDED. Lf,� PmAq -jprc& - 73 STQ5- PREPARATION OF DRAWINGS: SEE SAMPLE DRAWINGS AND GUIDANCE FOR COMPLETING THE DRAWINGS. ONE SET OF ORIGINAL OR GOOD QUALITY REPRODUCIBLE DRAMNGS MUST BEATTACHED. NOTE: APPLICANTS ARE ENCOURAGED TO SUBMIT PHOTOGRAPHS OF THE PROJECT SITE,BUT THESE DO NOT SUBSTITUTE FOR DRAWINGS. THE CORPS OF ENGINEERS AND COAST GUARD REQUIRE DRAWINGS ON d-112 X 11 INCH SHEETS. LARGER DRAWINGS MAYBE REQUIRED BY OTHER AGENCIES. S.WILL THE PROJECT BE CONSTRUCTED IN STAGES? ❑YES ❑NO PROPOSED STARTING DATE: PVC 45<P ESTIMATED DURATION OF ACTIVITY: 9.CHECK IF ANY STRUCTURES WILL BE PLACED: ❑WATERWARD OF THE ORDINARY HIGH WATER MARK OR LINE I=OR FRESH OR TIDAL WATERS:AND/OR ❑WATERWARD OF MEAN HIGH WATER LINE IN TIDAL WATERS 10.WILL FILL MATERIAL(ROCK,FILL,BULKHEAD,OR OTHER MATERIAL)BE PLACED: ❑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) AREA (ACRES) JARPA,Revised 12/98,contact Ecology's Pennit Assistance Center for latest version,360/407-7037 Page 2 Of 4 11.WILL MATERIAL BE PLACED IN WETLANDS? ❑YES Id NO IF YES: A. IMPACTED AREA IN ACRES: B. HAS A DELINEATION BEEN COMPLETED? IF YES,PLEASE SUBMIT WITH APPLICATION. ❑YES QJ,NO C. HAS A WETLAND REPORT BEEN PREPARED? IF YES,PLEASE SUBMIT WITH APPLICATION. ❑YES 50NO 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,&INDICATE IF THEY ARE ON THE COUNTY'S LIST OF HYDRIC SOILS.SOILS INFORMATION CAN BE OBTAINED FROM THE NATURAL RESOURCES CONSERVATION SERVICE(NRCS): 12.WILL PROPOSED ACTIVITY CAUSE FLOODING OR DRAINING OF WETLANDS? ❑YES f17NO IF YES,IMPACTED AREA IS_ACRES. 13.WILL EXCAVATION OR DREDGING BE REQUIRED IN WATER OR WETLANDS? ❑YES NO IF YES: I A. VOLUME: (CUBIC YARDS)/AREA (ACRES) 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 SETA LEAD AGENCY: SEPA DECISION: DNS,MDNS,EIS,ADOPTION,EXEMPTION DECISION DATE(END OF 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. TYPE OF APPROVAL ISSUING AGENCY IDENTIFICATION DATE OF APPLICATION DATE APPROVED COMPLETED? NO. ?V Ctxray ^Z�r E Dr`V 4-Zy-oS 16.HAS ANY AGENCYgENIED APPROVAL FOR THE ACTIVITY DESCRIBED HEREIN OR FOR ANY ACTIVITY DIRECTLY RELATED TO THE ACTIVITY DESCRIBED HEREIN? ❑YES pNO IF YES,EXPLAIN: SECTION B-Use for Shoreline and Corps of Engineers permits only: 7.TOTAL COST OF PROJECT.THIS MEANS THE FAIR MARKET VALUE OF THE PROJECT,INCLUDING MATERIALS,LABOR,MACHINE RENTALS,ETC. 18.LOCAL 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 ADDITIONAL NOTICE-CONSULT YOUR LOCAL GOVERNMENT. NAME ADDRESS PHONE NUMBER JARPA,Revised 12/98,contact Ecology's Permit Assistance Center for latest version,360/407-7037 Page 3 of 4 SECTION C-This section MUST be completed for any permit covered by this application 0.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,SUCH INFORMATION IS TRUE,COMPLETE,AND CCURATE. I FURTHER CERTIFY THAT I POSSESS THE AUTHORITY TO UNDERTAKE THE PROPOSED ACTIVITIES. I HEREBY GRANT TO THE AGENCIES TO WHICH IS APPLICATION IS MADE,THE RIGHT TO ENTER THE ABOVE-DESCRIBED LOCATION TO INSPECT THE PROPOSED,IN-PROGRESS OR COMPLETED WORK. I AGREE TO START WORK ONLY AFTER ALL NECESSARY PERMITS HAVE BEEN RECEIVED. SIGNATU OF APPLICANT OR THORIZ GE ATE IHE BY E ATE TO A M GENT IN MATTERS RELATED TO THIS APPLICATION FOR PERMIT(S). 1 UNDERSTAND THAT IF A FEDERAL PERMIT IS ISSUED, 1 MUST SIGN THE PERMIT. SIGNATURE OF APPLICANT DATE SIGNATURE OF LANDOWNER(EXCEPT PUBLIC ENTITY LANDOWNERS,E.G.DNR) ATE THIS APPLICATION MUST BE SIGNED BY THE APPLICANT AND THE AGENT,IF AN AUTHORIZED AGENT IS DESIGNATED. 18 U.S.0§1001 provides that: Whoever,in any manner within the jurisdiction of any department or agency of the United States knowingly falsifies,conceals,or covers up by any trick,scheme,or device a material fact or makes any false,fictitious,or fraudulent statements or rep(esentations 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$10,000 or imprisoned not more than 5 years or both. Iyi{ nz x ,2. i57 Eli 2, a t � ' Y r sS. ' i ter' fir. ,aa r a - ,E .,t�, �1 4�" ti$Ilk These Agencies are Equal Opportunity and Affirmative Action employers. For special accommodation needs,please contact the appropriate agency in the instructions. JARPA,Revised 12/98,contact Ecology's Permit Assistance Center for latest version,360/407-7037 Page 4 of 4