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Home My WebLink AboutFPA2400402 SKEPA - FPA Application - 1/24/1994 FOREST PRACTICES APPLICATION/NOTIFICATION FPA Number: PROCESS AND CONDITIONS LDateeceived: Reviewer Consents Final Due Date:Due: Shutdown Zone: 9L , —� - 9 � _ _ NAME OF OPERATOR NAME OF LANDOWNER ha � ��• i �k S� ��r � N y � NAME of TIMBER OWNER �0`1a�C� � � Kh4ase� SubdivisionlSection(s) ) TWP Nth RGE E/W ass ICAT10N 11CLASS ASSASS IIIASS III-PType of Operation Total AcresC- IASS ZV-G IV-S ❑ APPLICATION APPROVED CONDITIONS TO THIS APPLICATION TH_s OPERATIOx Is sJaJEcT / NOTIFICATION ❑ EavuDDmmtal Chcctiist ❑ C—Dk--d FPA Form O Ma9 ❑ Hydraui�ca Project Approval ❑ 5horrLna Maas;cmrnc Act APPROVAL orm ❑ Addiuoaal CoDdiDvna A¢acaed Otber CONDITIONS: LANDOWNER IS REQUESTED TO CONTACT JIM PARKS AT THE SKOKOMISH TRIBE AT 426 4232. ❑ PRE-FILE REVIEW COMpT_= ❑ APPLICATION INCOMPLETE ❑ APPLICATION ON HOLD APPLICATION❑ APPLICATION DISAPPROPED 7.� DEPARTMENT OF NATURAL O CFS:S1G:NATU7RE- DATETITTf 9INIML ION: AGENCY COPIES SENT: FINAL COPIES SENT; EFFECTIVE DATE EXPIRATION DATE-- COPIES DLST?,MUTED TO: FP FORESTER /16 (� ` � ` ECOLOGY FISHERIES O-WWILDLIFE E: 1-z AFFECTED INDTAN TRIBE r OTHERS. LOCAL GOVERNMENT AFFECTED INDIAN TRIBE: , O OTHERS LOCAL GOVERNMENT AFFECTED INDIAN TRIBE: OTHERS-- LOCAL GOVERNMT{NT rOj „nrt o. �r FOREST PRACTICES FPA Number: Natur°`1 R.scurc.s APPLICATION / NOTIFICATION Refer to the Instruction Sheet to assist in the completion of this form. Type or rin p �il� � ermanent In I. GENERAL INFORMATION SECTIO D G � FF- _)0_/y4 ULL LEGAL NAME AND /OR 2. FULL LEGAL NAME AND /OR 3. FULL LEGAL NAME AND /D�R�_Lw__ PANY /DIVISION NAME OF OPERATOR COMPANY /DIVISION NAME OF LANDOWNER COMPANY/DIVISION NAME OF TIMBER WNER //� �it/w�s�s� �y At BUSINESS ADDRESS BUSINESS ADDRESS 23C,7 �� 57-��y� BUINESS AD ESS 13 T�cv CITY STATE ZIP CITY STATE ZIP - CITY STATE ZIP shy/f�� ss�rs� 0/ t PHONE: fL�C^ 1 �-r-ip �j.3 O PHONE: (ZO�) ��3��p3 S� PHONE: (�G6 ) 3S0 Unified Business Identifier (or SSN A) U81 I I Unified Business Identifier (or S�SN #)�UUBI �Z �7�Z C L SSN I I 1 1 fied Bu�e —Iden' ier i UBI I I I ) SSN II 4. TYPE OF LEGAL ENTITY TYPE OF LEGAL ENTITY I I CORPORATION ( I OTHER (specify) TYPE OF LEGAL ENTITY P YI 1 1 CORPORATION [ ) OTHER (specify) I I CORPORATION I I OTHER (specify) I I PARTNERSHIP PARTNERSHIP SOLE OWNER Y( PARTNERSHIP I I SOLE OWNER O SOLE OWNER FOR TAX INFORMATION CALL 1-800-548-8829 5. FOREST TAX REPORTING ACCOUNT No: Boo z� 036 [ ] YES [A NO - IS THE OPERATION WITHIN CITY LIMITS? o NAME OF CITY(s): [ ] YES [� NO - IS THE OPERATION WITHIN A PUBLIC PARK? If yes, an Environmental Checklist is required. [ ] YES [,� NO - IS THE OPERATION WITHIN 500 FEET OF A PUBLIC PARK? f NAME OF PARK: I LEGAL SUB-DIVISION OF OPERATION(S): (INCLUDE PARCEL OR TAX LOT NUMBER) SUB-DIVISION (1/4, 1/4) SECTION(S) TWP RANGE PARCEL OR TAX LOT �. VV , S W (E)(W) NUMBER IS) � If � Z Z Al W Zz 3s-33-Oa07 0 � MiNeRU,q 7-�s-�,�c� �4c�ss 35 a1.�' �Gv az 3S- 5-f d70026 ( 19 i YT YES [ ] NO - WAS THE LAND PLATTED AFTER JANUARY 1, 1960 (INCLUDING SHORT PLATS)? II (You May Contact County Assessor for Verification). If Yes, Environmental Checklist Is Required. ). 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. • ( ] YES NO - DO YOU HAVE AN APPROVED CONVERSION OPTION HARVEST PLAN (COHP)?,If yes, include a copy.of the approved plan. NOTE: Not all Local Governments accept COHP's. /s tM ONR 00-79 (4-93) / _ I 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 YOU are operating within 200 feet of a T Approval (HPA). Work within T Type 7 or 1 + Water, contact the local Type 4-5 Waters may require Information. es or Wildlife. If government for shoreline management 12. LIST ANY ACTIVITIES THAT WILL BE WITHIN OR OVER THE ORDINARY HIGH WATER MAR Check (.� the activities you will be doing in each tr. K OF ANY WATER. shown on the base map. Culvert Base MaP informationemus include culvert lengthhe location , all culverts diameter, and t bridges must if Pipe). Bridge location Information must show whether the bridge is temporary or permanent. type (round or halt Water Road Water FallinType Constr. Crossing Buck9 Yarding/ Suspend Yarding g Cable Cables Groun / Equipment te Apply Other Activity Equipment Chemicals iShoW under uestion 29) 2 3 4 5 3. [ ] YES X NO - WILL THERE BE ANY ACTIVITIES WITHIN 200 FEET OF A TYPE 1 - 3 WAT FEET If Yes, how close? ERS. [ ] YES NO - WILL BE ANY ACTIVITIES WITHIN 25 FEET OF TYPE 4-5 WATERS? [ ] YES NO - ARE YOU AWARE OF ANY WATER INTAKES IN YOUR UNIT OR WITHIN 112 MILE DOWNSTREAM OF THIS OPERATION? III• WETLAND SECTION i u must answer all questions in this section. [ ] YES P< NO - DO WETLANDS EXIST WITHIN YOUR FOREST PRACTICE? If YES, check ( ,/ ) the a ' classification of all Forested appropriate sover 5 acres uares in the following alll ClassAand B Wetlands on th wetland typing describing Your work, and show the location and g information see WAC 222-16-035.)) e Activity Map. (For Wetland Road Water Type Constr. Crossing Yardin Ground quipmOperate Apply Other Equipment Chemicals Activity (Show under A uestion 29) B Forested [ ] Y'As NO - WILL YOUR PROJECT BE FILLING OR DRAINING A WETLAND? I I., ��q 1 If Yes, how many acres will you be filling or draining? draining n ore than 1lan d/2 acre of SEPA c nyklist wetla must accompany this application if you are fillip or FORM ONR QQ-19 (4-93) IV. ROAD CONSTRUCTION SECTION you'will not be doing any work involving roads go to Section V. 3. 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 I I NEW PERMANENT ROAD inpercent) NEW TEMPORARY ROAD EXISTING ROAD RECONSTRUCTION b EXISTING ROAD MAINTENANCE f I ROAD ABANDONMENT V. TIMBER HARVEST SECTION You will not be harvesting timber, go to Section VI. 3. TIMBER HARVEST INFORMATION i i UNIT TYPE OF POST HARVEST HARVEST MHARV D OF ACRES PERESTCENT OF ESTIMATED (even-aged, TREES VOLUME i 0 VOLUME TO BE uneven-aged PER ACRE (see 1113 in the (per BE CUT HARVESTED and/or salvage) type of FOR instructions harvest) (in MBFI ( i Show the location of each UNEVEN- for choices) harvee;type on Map. AGED HARVEST i I " For even-aged harvests, provide surrounding stand information on the map as required under WAC 222-30-025. See map instructions. �Y ��,{ li [ 1 YES 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.) �I 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 i ISTRIBUTED (Throughout Unit) ED won Map) X TRIBUTED (Throughout Unit) "''• ;A [l YES )< 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. 'ELEV., % COVER. STREAM REACH #2. 'ELEV., _ % COVER. _ STREAM REACH #3. 'ELEV., _ % COVER. STREAM REACH #4. o y ELEV., /e — COVER. [ l YES X1 NO - WILL YOU BE LEAVING A DOUBLE-WIDE RMZ(s) FOR GREEN-UP? INDICATE DOUBLE-WIDE RMZ LOCATION(s) ON MAP I ' 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 pp �((A licant mus�=Mit a Reforestation Plan - See Instructions.) NR OQ-19 (4-93) 3 VI. 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: ( I FERTILIZER APPLICATION - For fertilizer applications answer question 28. [ ] 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. EPA REG. No. Trade Name of Chemical Application Unit of Measure Rate 2er acre 27• (] YES �j 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. c i /Y, L 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. OPERATOR_.__ LANDOWNER TIMCER OWNERS i) ignat a Si Si na 'r / / Print Print Print i FORM DNR QQ-19 (4-93) !' Y d O RE S TPRACT CLE BASE MAP TOWNSHIP 22 NORTH , RANGE 04 WEST ( W . M ) SECTION 35 APPLICATION I 1 J 19 ®07 oa 224 3 d / 189 206 � 223 I I' iN ' 3 i I 4 lAA i 0 SCALE 1000 2000 3000 4000 5000 6000 FEET 1 Mlle uzeo re) MAP DATE J=y 1� W4 CONTOUR INTERVAL: 40 Feet LEGEND: See Instructions �I NAD 27 DISCLAIMER: See Legend �' I � t �j - t. •.^u . ,,t .,;••7�# ,tl i�ir..i D��. Plu VoL 0G. Oniv No. Ila . :�: ,: ter' -.�• . 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 Iiabllity for eariadons, if any, in dimensions and location. n Tr. 6 ' i3 'I _ Tc 9 �: `• . Tr a T n! x ,\ •� A j �` •C i ECT RTY L\ / Try/ i .� Tr.Jr 5� IV �o'I-_-f=/ '� /y i Tr--3�r:' S of L 3 T /7 A' S= OF LOT-/8 JFX7r! I i - D li I Tie T Gv �-S�t� yR�,�;i,;, ;.boys Note—This trap does not purport to show all highways, roads or easements affecting the property- . lfW Vel. rf0. Oedv :�./.. No. SKETCH OF PROPERTY SET UT IN ATTACHED ORDER To assist in locating the premises. It is o ara f based on it Company, and the comp=a assumes no liability for vitions, any, in dimensions nd location. 7 •S JECT PE - na,Tattu, ` �7j� N � for .�• R • _ •� � T N 3 1 --loo• r • \ � - n � :� C s•c tal p C=)/w'TAI` "'� =' '• +J^ - .� na_ co.JU rgl�Opr• 31. •�G�:rl y y d F C 07 �.; �.y� _ 1.�=� \ ` � '�•y • `.jam' `t I � t A S V •v pop• 1 I Ai Aqww4f ,te—This map OAO" °d, does not Durnart en sti.,ef _n � _L �� r •�.. J-•J �'L ' ti' f' ! f..t ♦•'♦1♦ .r�.-,� t t �.♦ � ♦ ♦ ♦ 4 ♦ � t ►tY S � !'•f 't t }� t-••f .ry �:_t..F Y i ►♦ r ♦ f �-T♦ v. { ► t•t ♦ ♦ t .t f_, ! `i'r'�-� H —ram.• Tt ♦+ r-I / �-� ♦ ♦� r. r - I . Skokomish Indian Tribe Tribal Center (206) 426-4232 N. 80 Tribal Center Road Shelton, WA 98584 SKOKOMISH ENVIRONMENTAL PROTECTION ACT [SKEPAJ 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 o 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 the 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 on parcels of land. Attach any additionallinformationimeothat willerent help describe 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 Uf applicable) : 2. Name of applicant: , 3 . Address p7hon7`nNumber o��n� D-�-�•�• �, LC J�� V-v 2- -Z�G �Sri /6 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:,4.ev r-d'�`_, aF y 7. Give a br�ef, 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 ofhe proposed prof Provide a legal description, )site plan,l'-4iicinity map, ana `r opographic map, if reasonably available. I / 7t:Le 7e6e"z-- /G _ h i 8 . Do you have any plans for future additions , expansion, or further activity related to or connected with this proposal? If yes , explain. -,t c w _ 9L �C 9 . List any vother governmen al/agency permits or approvals that will be needed for your tproject, if known. ��n�� C'�e-e�-�� 'r.��-u-c_ bu��o�c 3�o,°✓I f3 F �. 10. Do you know whether applications are pending for governmental approvals of other proposals directly affecting the property, covered by your proposal? If yes , explain. 11. List 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) . -� � � 2 ol— 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-l ) , 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 . 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. 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. - I ' - I 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. /�2 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. rYj-b 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 (g) are expected to serve. 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. T 11. Could other waste materials enter ground or surface waters? If so, generally describe. 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 . 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 s of any filling or grading proposed either on the earth orainloreadjacent 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? If so, 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. _ / 2Ltfirtl� 0 � 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. Incition the steps taken to ascertain the historicallude and culturalin Yourdt of the site, if any. imporance 18 . Describe the steps that will be taken to reduce or minimize impacts to any determined historic or cultural importance associated with the site. 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 LIZc� Date submitted '-�- 19.�•..w•w w P AN MOM 0 A414 ,u...,.u..,..o,,,.•......v:11 M r......,.,y•w„.,, 64"N 4r.. .3 P. 4 6009 p 01 rr �•+4••p uo.4.wM..W y V•vy w iY.Wei pwM 041 r Mel h *aloe s • .• = \ I + I ^ I� �� F