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HomeMy WebLinkAboutFPA2400402 SKEPA - FPA Application - 2/24/1994 FOREST PRACTICES APPLICATION/NOTIFICATION kFPA Number:PRO 'ESS AND CONDITIONS '� ��o Date Received: Reviewer Comments Final Due Date: Due: Shutdown Zone: Lj NAME OF OPERATOR NAME OF LANDOWNER NAME OF TIMBER OWNER �� sp �a R �h40Se SubdivisioniSection(s) TWP Nth RGE E/W CLASS ICATION 3 s a i..1 ❑ CLASS ❑ CLASS III Type of 0 eration ❑ CLASS III-P t p Total Acres CLASS IV-G ❑ CLASS IV-S APPLICATION VED CONDITIONS ❑TO THIS ' APPLICATION ION / NOTIFIC ATION THIS OPERATION IS SUBJECT TO: a HYd-❑ Ear�W C3«;cl;sc ❑ Comokred FPA Form Mav Project nS AM*cl a OtherShorr;ap ��Act ❑ Additional Condiaau A¢uaed ❑ Other APPROVAL CONDITIONS: LANDOWNER IS REQUESTED TO CONTACT JIM PARKS AT THE SKOKOMISH TRIBE AT 426 4232. ❑ PRE-FILE REVIEW COMPLETE ❑ APPLICATION INCOMPLETE ❑ APPLICATION ON HOLD APPLICATION COMPLETE ❑ APPLICATION DISAPPROVED DEPARTMENT OF NATURAL O CFS SIGNATURE Ti7I.E_ DATE: �Q -7-9 ION: AGENCY COPIES SENT: FINAL COPIES SENT: EFFECTIVE DATE: EXPIRATION DATE COPIES DISTRIBUTED TO: FP FORESTER �J ECOLOGY FISHERIES O-WILDLIFE AFFECTED INDiAN TRIBE: OTHERS:__ 7 LOCAL GOVERNMENT: AFFECTED IIJDIAN TRME: f /%h/ OTHERS. O LOCAL GOVERNMENT AFFECTED AI IIdDIA TRIBE: OTHERS LOCAL GOVrANMrN-r '�� w�ym �„rarzcsvrwm.ro, FOREST PRACTICES FPA Number: Natural Rosouzcas APPLICATION / NOTIFICATIONS Refer to the Instruction Sheet to assist in the completion of this form. Type or rin p ermanent�in `K. I. GENERAL INFORMATION SECTIO d Q fl /? . U 1. FULL LEGAL NAME.AND /OR 2. FULL LEGAL NAME AND /OR COMPANY /DIVISION .NAME OF OPERATOR AME AND /OR COMPANY /DIVISION NAME OF LANDOWNER COMPANY/DIVISION NAME OF TIM137WNER BUSINESS ADDRESS BUSINESS ADDRESS BU�INESS ADESS�—� ,� .73& y ---- ; 13 CITY STATE ZIP CITY STATE ZIP CITY STATE ZIP sh6/1e"v yr s�s� o/y,� ��- '�- ��s� s�E/�A/ av�- 9ess_� PHONE: �6C ) 'SrZ,a 6 3 S U PHONE: (20(- 7 7 3—��p�. !r( PHONE: (ZG�) y.2 6 lv 35'C7 Unified B;sine�ss Identifier (or #) UBI f i Unified Business Identifier (or SSN #) UBI ,� z' ,r G— C�1. .[ SSN l 1 ified Busine —IrTen ier r } UBI I 1 SSN [ I SSN I ) 4. TYPE OF LEGAL ENTITY TYPE OF LEGAL ENTITY I 1 CORPORATION TYPE OF LEGAL ENTITY i ( I OTHER (specify) I I CORPORATION I I OTHER (specify) ( I CORPORATION I NER SOLE OWNER TNERSHIP K PARTNERSHIP PARTNERSHIP I ! OTHER (specify) I ] SOLE OWNER I I SOLE OWNER FOR TAX INFORMATION CALL 1-800-548-8829 5. FOREST TAX REPORTING ACCOUNT No: 6. [ 1 YES [ NO - IS THE OPERATION WITHIN CITY LIMITS? �OO 0 Zip o316 NAME OF CITY(s): i. 7. [ 1 YES NO - IS THE OPERATION WITHIN A PUBLIC PARK? If yes, an Environmental Checklist is re uired. [ ) YES [,� NO - IS THE OPERATION WITHIN 500 FEET OF A PUBLIC PARK? q NAME OF PARK: �I 8. LEGAL SUB-DIVISION OF OPERATION(S): (INCLUDE PARCEL OR TAX LOT NUMBER) t` I SUB-DIVISION (1/4, 1/4) SECTION(S) TWP =AN PARCEL OR TAX LOT ��. W; W NUMBERS Z 2 A✓ 5� W V2- -33-00070 MiNZ.er/ 5 S/eOVzG �q YES [ ) NO - WAS THE LAND PLATTED AFTER JANUARY 1, 1960 (INCLUDING SHORT PLATS)?(You May Contact County Assessor for Verification).- If Yes, Environmental Checklist Is Required. 0. YES ( ) NO - LANDOWNER INTENDS TO CLEAR, IMPROVE OR DEVELOP LAND WITHIN THREE YEARS? NOTE: 1. If yes, attach a completed Environmental Checklist. 2. A local government clearing and/or grading permit may be required. 3. See the instructions for more information relating to conversions.. 1. [ 1 YES NO - DO YOU HAVE AN APPROVED CONVERSION OPTION HARVEST PLAN (COHP)?.ti If yes, include a copy of the approved plan. NOTE: Not all Local Governments accept COHP's. 671A - �- RM DNR 00-19 (4-93) II. WATER SECTION You must answer all questions in this Section. All work within Type 1-3 Waters will require a Hydraulics Project A an HPA. Completion of this section will serve as your request for an HPA from the Department of Fisheries or ife You are operating within 200 feet of a T Approval (HPA). Work within T Type 1 or 1 + Water, contact the local Type 4-5 Waters ma require information. government for shoreline man If 12. LIST ANY ACTIVITIES THAT WILL BE WITHIN OR OVER THE ORDINARY HIGH WATER MARK OF Check 1./) the activities you will be doing in each t ANY WATER. shown on the base map. Culvert Base Map informationemus include culvert lengthhe location all diameter,Land t bridges must if pipe). Bridge location information must show whether the bridge is temporary or permanent. type (round or halt Water Road Water Type Constr.odFalling / Yarding Crossing Bucking Cable / suspend Yarding Yarding / Operate A Ground Equipment Chemicals Other Activity (Show under uestion 29) 2 3 4 5 13. 11 YES X NO - WILL THERE BE ANY ACTIVITIES WITHIN 200 FEET OF A TYPE 1 - 3 WA . FEET If Yes, how close? TERS. 4. 1 1 YES NO - WILL BE ANY ACTIVITIES WITHIN 25 FEET OF TYPE 4-5 WATERS? 5. 11 YES NO - ARE YOU AWARE OF ANY WATER INTAKES IN YOUR UNIT OR WITHIN 112 MILE DOWNSTREAM OF THIS OPERATION? i III• WETLAND SECTION ou must answer all questions in this section. I 1 YES >4 NO - DO WETLANDS EXIST WITHIN YOUR FOREST PRACTICE? If YES, check ( ,/ ) the appropriate classification of all Forested etands over 5 a in cres s inlsi e, and alll ClassAand B Wetlands on the wetland typing information see WAC 222-16-035.)) describing Your work, and show the location and e Activity Map. (For � Wetland Road Water Type Constr. Crossing Yarding Operate q ipme Chemicals Other E ui ment Activity (Show under A uestion 29) B Forested I l '%S c, NO -�� DRAINING A WETLAND? WILL YOUR PROJECT BE FILLING OR I . I --- ,A ) If Yes, how many acres will you be filling or draining? �j A mitigation plan and a SEPA checklist must accompany this application oa 0 draining more than 1/2 acre of any wetland. if You are filling or FORM DNR QQ-19 (4-93) IV. ROAD CONSTRUCTION SECTION f you'will not be doing any work involving roads go to Section V. 8. ROAD CONSTRUCTION: (Complete all blocks that apply and LABEL EACH TYPE SEPARATELY ON MAP.) TYPE OF CONSTRUCTION TOTAL LENGTH IN FEET LENGTH OF ENDHAUL STEEPEST SIDE CONSTRUCTION SLOPE ROAD (in lineal feet) CROSSES ( NEW PERMANENT ROAD in ercent NEW TEMPORARY ROAD EXISTING ROAD RECONSTRUCTION EXISTING ROAD MAINTENANCE C� f I ROAD ABANDONMENT V. TIMBER HARVEST SECTION f you will not be harvesting timber, go to Section VI. - 9. TIMBER HARVEST INFORMATION UNIT TYPE OF POST METHOD OF # HARVEST HARVEST ACRES PERCENT OF ESTIMATED (even-aged, HARVEST a9•e TREES VOLUME To VOLUME TO BE uneven-aged PER ACRE (see #19 in the (per BE CUT HARVESTED and/or salvage) instructions type sof FOR for choices) harvest)t (in MBFI Show the location of each UNEVEN- harves:type on Map. AGED HARVEST o & -Litre 7 �I i ` For even-aged harvests, provide surrounding stand information on the map as required under WAC 222-30-025. See map instructions. II [ ) YES X NO - WILL YOU BE HARVESTING TIMBER OR LEAVING TREES WITHIN TWO TREE LENGTHS OF ANY OVERHEAD POWER LINES? (If yes, the applicant needs to notifythe appropriate Power Company.) {� � INDICATE HOW THE FOLLOWING WILDLIFE RESERVE TREES WILL BE LEFT: (Check all that apply) WILDLIFE RESERVE TREES GREEN RECRUITMENT TREES CLUMPED how on Map) X X ED won Map) X 1! ISTRIBUTED (Throughout Unit) TRIBUTED (Throughout Unit) [) YES ri NO - WILL YOU BE REMOVING TREES WITHIN THE MAXIMUM WIDTH RIPARIAN MANAGEMENT ZONE THAT ARE PROVIDING CANOPY COVER TO THE STREAM? IF YES, GIVE THE MIDPOINT ELEVATION AND EXISTING CANOPY COVER OF ALL STREAM REACH(s) AND LABEL THE STREAM REACH(s) ON THE MAP: STREAM REACH #1. _ % COVER.'ELEV., 'ELEV., '- `�� ,ri STREAM REACH #2. _ % COVER. ' STREAM REACH #3. 'ELEV., % COVER, STREAM REACH #4. o 'ELEV., _ /e COVER. [ ) YES /�) NO - WILL YOU BE LEAVING A DOUBLE-WIDE RMZ(s) FOR GREEN-UP7 INDICATE DOUBLE-WIDE RMZ LOCATION(s) ON MAP ^ 1, REFORESTATION METHOD: Reforestation is required for lands harvested after January 1, 1975 as shown under WAC 222-34-010 (West of Cascades Summit), or WAC 222-34-020 (East of Cascades Summit). PLANTING (Species: [ ) NATURAL (Applicant must s mit a Reforestation Plan - See Instructions.) DNR QQ-19 (4-93) 3 V1. AERIAL CHEMICAL APPLICATION SECTION If this forest practice does not involve the application of any pesticides or fertilizer, go to Section VII. 25. TYPE OF CHEMICAL APPLICATION: _ [ j FERTILIZER APPLICATION For fertilizer applications answer question 28. ! L G S 5 [ ] PESTICIDE TREATMENT - NET ACRES ( [ - For pesticide applications answer questions 26, 27 and 28. (Please describe the type of pesticide treatment s) you are proposing in the "General Description Section".) 26. LIST THE EPA REGISTRATION NUMBERS, TRADE NAMES, AND RATES OF APPLICATION FOR ALL CHEMICALS PROPOSED, INCLUDING ALL ADJUVANTS. =EPAREGE. N:o. Trade Name of Chemical Application Unit of Measure Rate er acre 27• [l YES NO WILL THIS PESTICIDE BE USED UNDER A DEPARTMENT OF AGRICULTURE EXPERIMENTAL USE PERMIT? If yes, include a copy of the Experimental Use Permit. 28. CHEMICAL INFORMATION CONTACT PERSON PHONE # ( �� VII. GENERAL DESCRIPTION SECTION 29. Provide any details that will give a better understanding of your project. '6`u'rra—✓ /Le�`r�-t—C- 62 i Compliance with this application/ notification does not ensure compliance with the Endangered Species Act, or other federal, state, or local laws. SIGNATURE BLOCKS We affirm that the information contained herein is true, and understand that this proposed Forest Practice is subject to the current rules and regulations of the forest practices act, as well as any applicable Federal. State or Local rules and regulations. OPERAT015TLANDOWNER TIMCER OWNER/ igngt a Si li Si na r / � 1 1 Print Print Print 1Jo�v� //J ff u�sr-.v FORM DNR QQ-19 (4-93) j 4 �k '- OREST PRACT I CF MAP TOWNSHIP 22 NORTH , RANGE 04 WEST ( W . M SECTION 35 APPLICATION / / 19 207 224 ©0 iI} � r ® ® EB ;f / 189 206 1 223 I -roe- 3 4EB iI � 205 SCALE llI 0 1000 2000 ....-:• 1 3000 4000 5000 6000 FEET 1 Mile uaeo It) MAP DATE J wy 18, 1994 �I CONTOUR INTERVAL: 40 Feet i' LE6EN0: See Instructions NAD 27 DISCLAIMER: See Legend .k'L�R'�!w•i. .l �� Ott ::;..•., .` — Dow Phu VoL 00.-Order No -a SKETCH OF PROPERTY SET UT IN ATTACHED ORDER To assist in locating the premises. It is of based on it survey, and the company, assumes no liability for variations, if any, in dimensions and location. f. �n Tr. 6 + t ` v Tr. 4 ` 'rra4' f x ;y I ECT RTY 7-61' -w Tr TC�7 Tr.S 5� N lof 17 ;52 N 2 Tr. 3 i r rt' S' of L 3 T 7 1t" S= of LoT/S - - -1-7 1=x x I I t A li I �''••"'� I '� .26 I e //` Sete,- , �• Y v!f'� Note—This map does not purport to show all highways, roads or easements affecting the property. _ Daa Plat VnL r1O. Ord.,No, SKETCH OF PROPERTY SET UT IN ATTACHED ORDER To assist in Iocating the premises. It is of based on a survey, and the company, assumes no liability for variations, ' any, in dimensions and location, of o I,! 17 I , 7 r_ N •ter, Zk • �G•p�; 1.•ti. . eealf w-!Lr J � [.Y�C � � , � r ... I 'rj 11 Lcr 1•.w• _•r ,,• I T �e1'TAIL� "�Q 7'' � 1� 117_ C•OIJ.... r Y Or- ,..1 dV y ' Cti•.i as � IV IV G.:r� ' ,► � d f ,'� U e.._•ems T�; ILA t'b 0 0 -( � f+ `, r r I n ..�..�_ •_y I���t� ` � r� �.jam' �t � .. '`�`. J J�Ste•. - .., IO> >pi � ? 1. '/'• -/"•f� t , F• .•� .r. - - w•..i aa.,v t..t+..0 t. '1-w 'J .: !'r r 1 t,I i'1. r:r.1 t v r...ti Ipp• 7 ou—This ma p does not purport to show all h izhways, roads � i •�'- .;���.)-.J I •L'• t r Y 1• t•♦ I .. . r•: s ! -. r—f r t � t t v • 4; r � 1 � - _ ♦ 4 ♦ -.r ♦ f Skokomish Indian Trib e Tribal Center (206) 4264232 N.80 Tribal Center Road Shelton, WA 98584 SKOKOMISH ENVIRONMENTAL PROTECTION ACT [SKEPA] ENVIRONMENTAL CHECKLIST The purpose of the Environmental Checklist is to provide information to help you and the Skokomish Tribe identify impacts from your proposed project (and �lo reduce or avoid impacts from the proposal , if it can be done) and to help the Skokomish Tribe decide whether an Environmental Impact Statement (EIS) is required. The Environmental Checklist asks you to describe some basic information about your proposal . Please answer the questions briefly, most precise information known, or give the best description the can. p you You must answer each question accurately and carefully, to the best of your knowledge. In most cases , you should be able to answer the questions from your own observations or project plans without the need to hire experts. If you do not know the answer, or if a question does not apply to your proposal , write "do not know" or "does not apply" . Giving complete answers to the questions now may avoid unnecessary delays later. Some questions ask about certain governmental regulations. Answer these questions if you can. Should you have trouble answering some of the questions please contact the Skokomish Tribal Planner for assistance. The checklist questions apply to all parts of our if you plan to do them over a y Proposal , even rent parcels of land. Attach any additional linformation ime othat will r on helpdescribe your proposal or environmental impacts . The Skokomish Tribe may ask you to explain your answers or provide further information reasonably related to determining if there may be significant adverse impact. A. BACKGROUND 1. Name of proposed project (,if appligable) : 2. Name of applicant: / 3 . Address and phon n mber of applicant: 2 3 C- -7 206 4 . Name, a dre s, and phone number of contact person: SKEPA ENVIRONMENTAL CHECKLIST PAGE 2 5 . Date checklist prepared : 6 . Proposed timing or schedule (including phasing, if applicable) . Please be as specific as you can. Answers such as "as soon as possible" are not acceptable: _ 7. Give a brief, but complete description of the proposed project. Include proposed uses , size of the project, and location of the project. Give sufficient informati to understand the precise location off he proposed proj Provide a legal description, -)site plan,(gicinity map, anC 'topographic map, if reasonably available. y � , 7CLo 8 . Do you have any plans for future additions , expansion, or further activity related to or connected with this proposal? If yes , explain. �, cry LX'`r ��o- ►2. - — -7 Cit 9 . List any "other governmen al/agency permits or approvals that will be needed for your project, 10 . Do you know whether applications are pending for governmental ,�a2 (I approvals of other proposals directly affecting the property covered by your proposal? If yes , explain. I I 11. Lisa any environmental information you know about that has been prepared, or will be prepared, directly related to this proposal (include references to documents , studies , or reports as appropriate) . _ - y SKEPA ENVIRONMENTAL CHECKLIST PAGE 3 B. ENVIRONMENTAL ELEMENTS 1. What is the proximity of th roject site ' to the Skokomish River, Annas Bay (Hood Cana•1) , aWther surface water creeks, swamps, wetlands , ponds, lakes , etc. ) ? (streams , 2. Will the project require any work over, in, or adjacent to (within 200 feet) the above described waters? If yes, describe and provide plans. //VL.O 3 . Will the proposal require surface water or groundwater withdrawals or diversions? Give general description, purpose, and approximate quantities if known. 4. Does the proposal involve any discharges of waste materials to surface waters? If so, describe the type of waste and anticipated volume of discharge. •fib 5. Will the proposal result in the loss or alteration of any fish or shellfish habitat or in the natural production of fish or shellfish? If so, describe the loss or alteration of habitat (alterations might included changes to the shoreline; placement of instream structures; alteration of gravel bars , etc. ) and quantity of fish loss, including species and life history stage. 6. Will the proposal interfere with an established Treaty fishery? Describe. 7. Could the proposal potentially impact any future expansion of a Treaty fishery? Describe. /l2 0 SKEPA ENVIRONMENTAL CHECKLIST PAGE 4 8. Will groundwater ' be withdrawn, or will water be discharged to groundwater? Give general description, purpose , and approximate quantities if known. �U 9 . Describe waste material that will be discharged into the ground from septic tanks or other sources , if any (for example: Domestic sewage; industrial , containing the following chemicals . . . ; agricultural ; etc. ) . Describe the general size of the systems , the number of houses to be served (if applicable) , or- the number of animals or humans the system(q) are expected ��, serve. � G � l�CC�ri -off'+'- ' 10. Describe the source of water runoff (including storm water) and method of collection and disposal , if any (include quantities , if known) . Where will this water flow? Will it flow into other waters? If so, describe. 11. Could other waste materials enter ground or surface waters? If so, generally describe._ /y2� � ��l, �!_-G���yyLG-�-•��� ��u GCS f C 12. Describe proposed measures to reduce or control surface runoff water impacts, if any. Generally describe the potential for erosion that could result from the proposal . 1 13. Describe proposed measures to reduce or control erosion, or other impacts to the earth, surface waters or groundwater. SKEPA ENVIRONMENTAL- CHECKLIST PAGE 5 ' 14. Describe the purpose, type, and approximate quantities of any filling or grading proposed either on the earth or in or adjacent to (within 200 feet) -surface waters . Indicate the source of fill . 15. Are there any environmental health hazards , including exposure to toxic materials, risk of fire and explosion, spill , or hazardous waste that could occur as a result of this proposal? describe. Also describe the measures that will be taken to reduce or control environmental health hazards, if any. r 16 . Describe the types and levels of noise that would be created by or associated with the project. Indicate the hours of the day that the noise would come from the site. 17. Describe any landmarks or evidence of historic, archaeological , or cultural importance known to be on or near the site. In particular, describe the significance of the site to the culture and history of the Skokomish Tribe. Include in Your tion the steps taken to ascertain the historical and culturaldescri itof the site, if any. _ mporance 18. Describe the steps that will be taken to reduce or minimize impacts to any determined historic or associated with the site. cultural importance SKEPA ENVIRONMENTAL CHECKLIST PAGE 6 The above answers are true and complete to the best of my knowledge. I understand that the Skokomish Tribe will be making a decision on the proposed project based in part on the above answers. v Signature c� Date submitted r gam. 4 ' �1 a� HOOD CANAL IL �...Id I'll- hare o Come_ I'll-dMr� ~a� �rl HNef►w� . • �•�^••. t!�school N wow low.. ® W NM D Tle.t�we�N plant The Skokortysh kxIan Reser�vadw F'� home Wit _ EXISTING LAND USES L0'