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HomeMy WebLinkAboutJARPA - SHX Application � pott'SfoB PD � lay 3-,G-o, ..................... ..:.......:... ....: .. ..:.?:. x•n:f :• » ' f /. F.•::i:•;•ih,%+•;:�1;;•\,:,.t.•:::::::::xsS:•iii::•::•i:::::::>:::r??�F{,•:::::::rn•::::::::::-:::i'? ..n f. f }r ,M} .,: ffr¢ /YA'! ..¢Y. n• xi:•:::...r,/., -•F �? F'ff r:...;�.;;: r ? ./•. : f:rr''::.%Ss';? xsb;%:;:;:>:•:::.�::::1........•x.{ „{;...;<<.?»:;?::t:%::s::......:..r. :;:;1+• C•l. -� � �: r .7 n•v:' r•%f'iiv{{ii:•ii:Yr:i:�i:j'fi.(: {ti':?vN::is 'i:}T:if3, ?:Hj-0C•%l?1C.,, f,/ J ,c �+?2''• r.;.,`: :;:;:i�yf?.;:ii:•.:::�r.../l, :.;{,,?., `:;�r.:.�r:/.?.:.ter::. :r�.?:.•,4;.•y.•:•frY?f ?x �if: �'rir•.u�.#.&�,••.��:.yy.:>�,iy,:?.f...�:?y;:,n?.::::•::.ryr,,L,7;:..;�?:::5::i::;r:?;.;:%<;•::;r,/.,:.ns.•?.�??.;:;r::. '"'+"`F`��:' �r::%ir F :� .ti :vr.` •�'�r�•X�'� w?,>.f:::5:'f iy"i/::;•::'y,•:•f :/ r:;:::;:,fyi•,'•{•M1?5;f�• ::.{::: .•`�'%:k''�: :'r?F'•.;;•,/:: h'�•'r '' i.f i;Gf ..:'•f•:F :/ti,d.^�+.,r , •r .�'?,.•'; +:�"�.x..::. :n4:•:.•�:r.'�;rh;fik:� ::!" :f ... £�••�"•{C r'n;.f•:. v: �::;: f : ::%::r$<:F::F.:;:;';%:r;•::% :'.''rfi.2; •: .""?r :.: Fff..... .......:..: f•'l.{: ... ..: }:;:$:,^.,.•,-:;i:.•' •..'42;:?ifi::;,:?:i:`ii,'?yiY'lj�ff'::fi :?::.:$ '.:il''Sf%��+"{ :::�:•�i"Si .•hy?,•:;:•.r��,,�( ..�„? f :?• � ,f4, :.:k?c�,;.,?.?�,,r'r''><f..,Y:'..,:r:•'•:'.::.'•,:o::f;.p:,Fr•S�•. l%�:f.•.'•%:>•.'•.'•.'•.'<:: '".fr.. .r:?,•.:•f:`:5�; ?'TG'3.:f%/ �::"J'. `r. {;n�'°:'.'S'<: +. ;:;wF^.:#••yff„•:/;:y;:::?.: ':,.Fff;:::f,.r>:i� •?f,; '2'•<:::..?u•;: .f?>:;:r•{•'•?# `r,',:.. v. •3:� .,r,.;5�1.?.> ::.� .'•rt:;•).f•/.•:::<,::. f iSr.;y,:.r: �: : `•.i:::,.; ,�M,'::$�?`.k.?.h:;tri•.:.:n;?r�/;;�:f>?.:??:::ri.:h'f,7,,?.;:/::si.::.>.:?:::. ..•,c.t Yr ri::.� J1 h.. :•;>..,.3'�,�'�.•�'r,,.�':.:.,n,. ., r:.:.:::::::.:::: :hYA �}ii.i. %? 1'f1 •:ii%:ji .rn :i:FiSn.<i?:i:iiiiii::YifJ:i?i�::?•:tihiii:4ii: ii'F.!•:•'•.�}:•'ri:i>iti:ii'ii :':;•,,,,,.,.,,M�:1.....::.........:n........................ ................................................................................................................................:..................::.:.......::......................:...........:..........::'vi:: is JARPA FORM �•_�*.� (for use in Washington State) o b Y PLEASE TYPE OR PRINT IN BLUE OR BLACK INK 1°~ Based on the preceding checldist,I am sending copies of this application to the following: (check aN that apply) . Local Government for shoreline: ❑Substantial Development ❑Conditional Use ❑Variance ❑ 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 Corps Engineers for.❑Section 404 ❑Section 10 permit ❑ Coast Guard for. ❑Section 9 Bridge Permit - SECTION A-tJse for all permits covered by this application. Be sure to also complete Section C(Signature Block)for all permit applications. 1.AP CANT I e. c kQ MAILING ADDRESS S1 s `v \S�ako/ W/_e ' 0 `� WORK PHONE HOME PHONE FAX# Kan agent is acting for the appfkar►t during the permit process,complete#2 2 AUTHORIZED AGENT MAILING ADDRESS WORK PHONE HOME PHONE FAX# S.RELATIONSHIP OF APPLICANT TO PROPERTY: OWNER O PURCHASER 0 LESSEE 0 OTHER: 4.NAME, SS,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 R) E, • (o01 We ed 64Nc0 C.IN WATvie r t TRIBUTARY OF 1/4 SECTION `A TOWNSHIP RANGE GOVERNMENTT LL1rOT SHORELINE DESIGNATION ;23 :2o i 9K ZONING DESIGNATION TAX PARCEL NO.: ` DNR STREAM TYPE,IF KNOWN 22-o Z3 -TS ©40 I--2 o Application Page 1 of 4 0. DESCRIBE THE CURRENT USE OF THE PROPERTY.AND STRUCTURES EXISTING ON THE PROPERTY. IF ANY PORTION OF THE PROPOSED ACTNRY IS ALREADY COMPLETED ON THIS PROPERTY,wmmTE MONTH AND YEAR OF COMPLETION. V acawf (aikd , m <-iroc4uves , sf airs Trivillej 01118 IS THE PROPERTY AGRICULTURAL LAND?❑YES)(NO ARE YOU A USDA PROGRAM PARTICIPANT`? ❑YES❑NO 7a DESCRIBE THE PROPOSED WORK COMPLETE PLANS AND SPECIFICATIONS SHOULD BE PROVIDED FOR ALL WORK WATERWARD OF THE ORDINARY HIGH WATER MARK OR r 76.DESCRIBE THE PURPOSE OF THE PROPOSED WORK r rr reM�0_m 5.44 t rs "T'-o a 8QG comlxA T'-v , 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 /vflhe PREPARATION OF DRAWINGS: SEE APPENDIX A-SAMPLE DRAWINGS AND CHECKLIST FOR COMPLETING THE DRAWINGS. ONE SET OF ORIGINAL OR GOOD QUALITY REPROD1ICIBLE DRA WN11GS MUST BE ATTACHED. NOTE APPLICANTS ARE ENCOURAGED TO SUBMIT PHOTOGRAPHS OF THE PROJECT SITE,BUT THESE DO NOT SUBSTITUTE FOR DRAWINGS. THE CORPS OFENG/NEERS AND COAST GUARD REQUIRE DRAWINGS ON 8-1/2 X 11 INCH SHEETS. LARGER DRAWINGS MAYBE REQUIRED BY OTHER AGENCIES S.WILL THE PROJECT BE CONSTRUCTED IN STAGES? /� A ❑YES)(NO PROPOSED STARTING DATE j}'rlcad� cow,a�_-AccLI ESTIMATED DURATION OF ACTIVITY: ��11 `` V!�w++`7t W 11V�99' 9.CHECK IF ANY STRUCTURES WILL BE PLACED: ❑WATERWARD OF THE ORDINARY HIGH WATER MARK OR LINE FOR FRESH OR TIDAL WATERS;AND/OR r� )(WATERWARD OF THE MEAN HIGH WATER LINE IN TIDAL WATERS � ,J�W 4 r� d o! rn j-f f4 W, A of- al H U) 10.WILL FILL MATERIAL(ROCK FILL,BULKHEAD,PILINGS OR OTHER MATERIAL)BE PLACED: V ❑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) 11.WILL MATERIAL BE PLACED IN WETLANDS? ❑YESXNO IF YES: A.IMPACTED AREA IN ACRES: B.HAS A DELINEATION BEEN COMPLETED? IF YES,PLEASE SUBMIT WITH APPLICATION. ❑YES ❑NO C.HAS A WETLAND REPORT BEEN PREPARED? IF YES,PLEASE SUBMIT WITH APPLICATION. ❑YES ❑NO 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,3 INDICATE IF THEY ARE ON THE COUNTYS UST OF HYDRIC SOILS. SOILS INFORMATION CAN BE OBTAINED FROM THE NATURAL RESOURCES CONSERVATION SERVICE(MRCS): 12.WILL PROPOSED ACTIVITY CAUSE FLOODING OR DRAINING OF WETLANDS? ❑YESXNO Application Page 2 of 4 IF YES,IMPACTED AREA IS_ACRES 13.WILL EXCAVATION OR DREDGING BE REWIRED IN WATER OR WETLANDS? O YES NO IF YES: A.VOLUME_(CUBIC YARDSXAREA_(ACRES) B.COMPOSITION OF MATERIAL TO BE REMOVED: C.DISPOSAL SITE FOR EXCAVATED MATERIAL D.METHOD OF DREDGING: 14.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 O.E.PRELIMINARY PLAT APPROVAL,HEALTH DISTRICT APPROVAL,BUILDING PERMIT,SEPA REVIEW,FERC LICENSE, FOREST PRACTICES APPLICATION,ETC.)ALSO INDICATE WHETHER WORK HAS BEEN COMPLETED AND INDICATE ALL EXISTING WORK ON DRAWINGS. TYPE OF APPROVAL ISSUING AGENCY IDENTIFICATION NO. DATE OF APPLICATION DATE APPROVED COMPLETED? SEPA LEAD AGENCY SEPA DECISION: SEPA DECISION DATE: 15. HAS ANY AGENCY DENIED AP VAL FOR THE ACTMTY DESCRIBED HEREIN OR FOR ANY ACTIVITY DIRECTLY RELATED TO THE ACTIVITY DESCRIBED HEREIN?❑YES NO IF YES,EXPLAIN: SECTION B-Use for Shoreline and Corps of Engineers permits only: 18. TOTAL COST OF PROJECT.THIS MEANS THE FAIR MARKET VALUE OF THE PROJECT,INCLUDING MATERIALS,LABOR,MACHINE RENTALS,ETC. 17. LOCAL GOVERNMENT WITH JURISDICTION: 18. 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 REWIRE ADDITIONAL NOTICE—CONSULT YOUR LOCAL GOVERNMENT. NAME ADDRESS PHONE NUMBER Application Page 3 of 4 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 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 ACCURATE I FURTHER CERTIFY THAT I POSSESS THE AUTHORITY TO UNDERTAKE THE PROPOSED ACTIVITIES. I HEREBY GRANT TO THE AGENCIES TO WHICH THIS 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. SIGNATURE O OR GENT / DATE I HEREBY DESIGNATE TO ACT AS MY AGENT IN MATTERS RELATED TO THIS APPLICATION FOR PERMIT(S). I UNDERSTAND THAT IF A FEDERAL PERMIT IS ISSUED,I MUST SIGN THE PERMIT. SIGNATURE OF APPLICANT DATE SIGNATURE OF N Q�@ICTITY LANDOWNERS,E.G.DNR) DATE THIS APPUCA N MUST BE SIGNED 971H1E 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 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$10,000 or imprisoned not more than 5 years or both. i;::i::i::;;::::::i:::;i::;:::;;:::;:::ii::::;::i::i::;:2:r:::::;::i;;::i::ii::i;;:;;:;tt::::::::;;:;;:;;;;:::S;:dii::i::;::;;:;;::::::::::::ii:;:;:::;;::;;::::::;:Y;::::;:;`,•'::;�::::�!>�,:�:i;:::;:i::;::�:n�A ::.:.:............................:................::::::::::::::.:..........::::................:.r0 ............... e �or''[ana... >: » vrn d. ..:. u....:.....# ... .................. ...................:: .:::::::::::.::::::..............................:.::::::::::::...:::.::::::::.::::... ......... .................................:.....: ,.. ..... laackr"<: . ::s$::�ca, a .::.... . ............................................�:::::::::: : al z :.>Bxt�r�tat{d:::.......>cfiti ............ situ ,...................... .: . ::.............9: Y . :: . ::.:::.::::::::::._::.:::::.::.::::.:.;:.;:.;:.:.;:.;:.: ;:;``;fit . » `: ;n#:. :: €�t iuc4#r? ::+►r4:e�c > >.... ::::..:.. ::::::: Vie::::.::::: ;;:.;:.;:.: ::::::::::: Y :.. ..........: ......... .......:..:: .:::::::.:::. .::::..::::._... ............_ ..................... .:. ...... .... ::::: i :.. f.: i3:I#ki'$€:4'? 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L`srbdivatwrt:. aa :.;•::::::.::::.:::.::::::::.:::»lrertia........ :.:::::::::::::::::::::.::.::..::::::...............................................::.:::.:::::.:.;:.;::::<:.;:.;:.;:.:::;:.;:.;:;.: ...................... .......,,,,,,,,,,,.<-r..�. .........................:.................. ... .................. flft;::>`j><`>< s <>"`<'<'«< >z< <��''> ` >i><z< z#?``:'<1 ''`><> isrG ': Ez`: `:``: '`°'` s'?S`" `• i `:'`: z `< ?i` [ >? > ><>? t<' »? < < ?> >>?` ` '?< ><'> # >?><>>[ i`: ::: >::{i::iiF::i::`.�•:::i::::i: i::::::i}:;i:;i:;:i::i::f�i:5;ii::::v:::::ii}i}iiiiiii}}:{i}fiiij<}:%;{:}'Fi:......::: ::::::iv ::iii1}}i: ::::ii::isisii:>:? 417W:F i:Jii};iiiiiiiiiii:.iii:4i:•iii:4:<•i:.iiiii:.?iiiii:iti•ii:titi^:Cii::•iiiii:L:4i:S ?;i:4:?i:4:::;{:::;+iiiii??}iiii:4X':%'.ii:-0i:titiGi:.iiiii:vii ititi4i:is iiJiiii i•iiJJiiiiiiiiiii:.:ii:^iiiiiiiii}iiiJiiiiii}},y}}};n;.;:iiii}}iiiii:y: These Agencies are Equal Opportunity and At)tmteUw Action employers. For special accomiodation needs,please contact the appropriate agency t'rom Appendix B. Application Page 4 of 4