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Home My WebLink AboutJARPA - SHX Application - 12/30/1997 AGENCY USE ONLY Agency Reference #: Date Received: SEPA Lead Agency: Other: - DARPA APPLICATION FORM - - for use in Washington State - PLEASE TYPE OR PRINT IN BLUE OR BLACK INK Based on the preceding checklist, I am sending copies of this application to the following: (check all that apply) Local Government: for shoreline ❑ Substantial Development ❑ Conditional Use ❑ Variance ❑ Exemption; or ❑ Floodplain Management ❑ Critical Areas Ordinance Washington Department of Fish and Wildlife for HPA Washington Department of Ecology Approval to Allow Temporary Exceedance of Water Quality Standards 401 Water Quality Certification Nationwide Permits Corps Engineers for Section 404 or Section 10 permit(s) 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 E tt Q ✓ Mailing Address a `7 y & 0/4 L Garr 1ti' 4 9&-.5' 2bJ Work Phone: Home Phone: (3(-c) I S 9 S 4(4 Fax Number: If an agent is acting for the applicant during the permit process, complete #2 & 3. 2. Authorized Agent Mailing Address Work Phone: ( ) Home Phone: ( ) Fax Number: ( ) 3. Designation of Authorized Agent, if applicable: 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 4. Relationship of applicant to property: X Owner ❑ Purchaser ❑ Lessee ❑ Other ( ) 5. Name, address, and phone number of property owner(s), if other than applicant: Application Page I of 5 6. Location where proposed activity exists or will occur. Waterbody 6W I d N R' V Y q DNR Stream Type (if known) Street Address Tributary of S e I-. AA/t—, AA Legal Description: City, County, State, Zip Code Tax Parcel No.: 3 SO 0 0 n O i4 54 Section Township Range /rC, Al 6 e2 3 tv, tf/,,vl. 7. 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. PViVA-te_ Rks , deAv - e- +- 5Ne Is the property agricultural land? ❑ Yes O No Are you a USDA program participant? O Yes ❑ No 8. Describe the proposed activity, and the activity's purpose. Include expected water quality and fish impacts, and proposed actions to reduce the duration and severity of those impacts and provide proper protection for fish life. 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, and for_Q work if applying for a shoreline permit. If additional space is needed, please attach a separate sheet. M e .v -t , %3 c .�ct / /=e rl �L'%� S c -( el(n rt L3 Y i d g 0 tk'r 1'NY (N n/tev c t99 7 Preparation of drawings: See Appendix A - sample drawings and checklist for completing the drawings. One set of original or good quality reproducible drawings must be attached. NOTE: Applicants are encouraged to submit photographs of the project site, but these do not substitute for drawings. THE CORPS OF ENGINEERS REQUIRFS DRAWINGS ON 8-1/2 X 11 INCH SHEETS. Larger drawings may be required by other agencies. Application Page 2 of 5 9. Proposed Starting Date: /3 S R P Estimated duration of activity: Will the project be constructed in stages? ❑ No , 10. Will any structures be placed: a. waterward of the Ordinary High Water Mark or Line for fresh or tidal waters? ❑ Yes ❑ No b. waterward of Mean High Water Line in tidal waters? ❑ Yes ❑ No 11. Will fill material (rock, fill, bulkhead, pilings or other material) be placed waterward of Ordinary High Water Mark or Line for fresh or tidal waters? ❑ Yes ❑ No a. If"yes," in fresh water indicate volume in cubic yards: b. If"yes," in tidal waters, indicate volume in cubic yards waterward of the line of mean higher high water: 12. Will material be placed in wetlands? ❑ Yes 0-No If yes, impacted area: (acres) If yes: a. Has a delineation been completed? ❑ Yes ❑ No (If yes, please submit with application.) b. Type and composition of fill material (e.g., sand, etc.): c. Material source: d. 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), formerly Soil Conservation Service (SCS). 13. Will proposed activity cause flooding or draining of wetlands? ❑ Yes ff No If yes, impacted area: (acres) 14. Will excavation or dredging be required in water or wetlands? ❑ Yes EY No If yes, volume: (cubic yards) a Composition of material removed: b. Disposal site for excavated material: c. Method of dredging: 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, FERC license, Forest Practices Application, etc.) Also indicate whether work has been completed and indicate all existing work on drawings. Date of Date Completed? Type of Approval Issuing Agency Identification No. Application Approved Yes or No SEPA Lead Agency: SEPA Decision Date: Application Page 3 of 5 16. Has any agency denied approval for the activity described herein or for any activity directly related to the activity described herein? ❑ Yes ❑ No If yes, explain: SECTION B - Use for Shoreline & Corps of Engineers permits only: 17. Total cost of Project. This means the fair market value of the project, including materials, labor, machine rentals, etc. IS. Local government w/jurisdiction: Shoreline Environment designation: Zoning designation: 19. For corps 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. SECTION C - Complete for any permit covered by this application 20. 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 or completed work. Signature of Applicant or Authorized Agent (REQUIRED) Date Signature of Landowner (REQUIRED if other than applicant) Date This application must be signed by the applicant. If an authorized agent is to be designated, the applicant must also sign at Item #3. 18 U.S.0 11001 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 fad 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. Application Page 4 of 5 DO NOT SEND FEDERAL PROCESSING FEE WrM APPLICATION TO BE COMPLETED BY LOCAL OFFICIAL A. Nature of the existing shoreline. (Descnbe type of shoreline, such as marine,stream,lake, lagoon, marsh, bog, swamp, flood plain, floodway, delta;type of beach,such as accretion,erosion,high bank,low bank,or ddw;material such as sand.gravel, mud, clay, rock,riprap;and extent and"of bulkheading,.if any:) B. in the event that any of the proposed buildingwor=sttuctrrres will viceed a height of dsirty-five feet:above the average grade level, indicate the approximate location of a Amunbet:of.residenfial units,existing and potential,that will have an obstructed view- C. if the application involves a conditional use or variance,set forth in full that portion of dm master program which provides that the proposed use may be a.conditional:vac,cr,.in the;casc of a variance,from which the variance in being sought: These Agencies are Equal Opportunity and Affrrmat:ve Aaron employers. For special accommodation needs,please contact the appropriate agency front Appendix A. Application Page 5 of 5