HomeMy WebLinkAboutJARPA Bridge Repair - SHX Application - 1/10/2008 • w '�� I � RECEIVED
AGENCY USE ONLY JARPA FORM LAST,JAI6"1��1A I091,2007
Agency Reference#: Date Received:
Circulated by: (local govt.or agency) /�
Project Tracking Number: MASON COUNTY.
0Washington State JOINT AQUATIC RESOURCES PERMIT APPLICATION (JARPA) Form „+
Step 1:Get Ready Step 2:Complete Form Step 3:Check Work Step 4:Copy and Send In
Go to vN w.epennittinr.org Use black ink. Use internet"Help" Use final review See JARPA Contacts at
for correct form and Check correct buttons to answer checklist at www.CV tmittin,.or for
instructions. permit boxes. questions completely. �p�+_�}.gpcinit,titig,igg. correct mailing addresses.
❑ Fish Habitat Enhancement Projects per RCW 77.55.181. You must submit copy of completed JARPA form and Fish Habitat
Enhancement JARPA Addition to your Local Government Planning Dep't and WA Dep't of Fish and Wildlife(WDFW)Area Habitat
Biologist on same day. Note for Local Governments:You must submit comments to WDFW within 15 working days.
Based on instructions at www.epermitting.org, I am sending copies of this application to the following: (check all that apply)
❑Local Government for Shoreline: nSubstantial Development nConditional Use aariance xemption []Revision
nFloodplain Management []Critical Areas Ordinance
G xrl ashington Department of Fish and Wildlife for Hydraulic Project Approval(Submit 2 copies to WDFW Region)
L ]Washington Department of Ecology for 401 Water Quality Certification(to Regional Office-Federal Permit Unit)
tf k,❑Washington Department of Natural Resources for Aquatic Resources Use Authorization Notification
❑Corps of Engineers for: Section 404 permit nSection 10 permit
❑Coast Guard for: ❑General Bridge Act Permit nPrivate Aids to Navigation(for non-bridge projects)
[]For Department of Transportation projects only: This project will be designed to meet conditions of the most current
Ecology/Department of Transportation Water Quality Implementing Agreement
PROJECT TITLE: !�
PROJECT DESCRIPTION:
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
MAILING ADDRESS�� ���� �'^� C•
RI1 HONE E-MAIL ADDRESS HOME PHO� L/ 7Cf FAX#
Li ZIf an agent is acting for the applicant during the permit process,complete#2. Be sure agent signs Section C(Signature Block)for
all permit applications
2.AUTHORIZED AGENT
MAILING ADDRESS
WORK PHONE E-MAIL ADDRESS HOME PHONE FAX#
3. Relationship of applicant to property: 0--OWNER ❑ PURCHASER ❑ LESSEE ❑
4. Name, address and phone number of property owner(s)if other than applicant:
5. Location(street address, includio city,county an zip code,where proposed activit exists or will occur)
Local government with jurisdiction(city or county)
Waterbody you are working in (�n 11;h IV? r' Tributary of WRIA#
' Is this waterbody on the 303(d)List ❑ YES ❑ NO r7
If YES,what parameter(s)?
Shoreline designation
Zoningdesi nation
'/.Section Section Township Range Government Lot
3 ° DNR stream type if known
Latitude and Longitude: Tax Parcel Number (a _-1 5 _el 00 a U
Office of Regulatory Assistance,JARPA JARPA FORM LAST UPDATED:March 19,2007 For help call 800-917-0043 or visit www.epermiffing.org 1
3Co
6. Describe(a)the current use of the property, (b)structures existing on the property,and(c)existing environmental conditions.
Have you completed any portion of the proposed activity on this property? ❑ YES Z3-'NO
For any portion of the proposed activity already completed on this property, indicate month and year of completion.
IM Is the property agricultural land? ❑ YES 2/NO Are you a USDA program participant? ❑ YES 0 NO
O, 7a. Describe the proposed work 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. If you have provided attached materials to describe
your project, you still must summarize the proposed work here. Attach a separate sheet if additional space is needed.
PREPARATION OF DRAWINGS: See sample drawings and guidance for completing the drawings. ONE SET OF ORIGINAL OR GOOD QUALITY REPRODUCIBLE
DRAWINGS 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 8-112 X 11 INCH SHEETS. LARGER DRAWINGS MAYBE REQUIRED BY OTHER AGENCIES.
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 dgsign.
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. Identify which guidance documents you have used. Attach a separate
sheet if additional space is needed.
S, � Sire-ch
L c- t�,P"
7d. For in-water construction work,will your project be in compliance with the State of Washington water quality standards for
turbidity(WAC 173.201A-410)? BYES ❑ NO
8. Will the project be constructed in stages? ❑ YES NO
Proposed starting date:
Estimated duration of activity:
9. Check if any temporary or permanent structures will be placed: '/�
❑ Waterward of the ordinary high water mark or line for fresh or tidal waters AND/OR Y ` A
❑ Waterward of the mean higher high water for 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)
Office of Regulatory Assistance,JARPA JARPA FORM LAST UPDATED:March 19,2007 For help call 800-917-0043 or visit www.eoermitting.org 2
` 11. Will material be placed in wetlands? ❑ YES NO
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, and indicate if they are on the county's list of hydric soils. Soils
information can be obtained from the natural Resources Conservation Service(NRCS).
G.WILL PROPOSED ACTIVITY CAUSE FLOODING OR DRAINING OF WETLANDS? ❑ YES dO
If YES, IMPACTED AREA IS ACRES OF DRAINED WETLANDS.
NOTE:If your project will impact greater than 1/10 of an acre of wetland,submit a mitigation plan to the Corps and Ecology for approval along with the JARPA form.
NOTE:A 401 water quality certification may be required from Ecology in addition to an approved mitigation plan if your project wetland impacts are greater than 1/10 acre in size.
Please submit the JARPA form and mitigation plan to Ecology for 401 certification review.
`3 12. Stormwater Compliance: This project is(or will be)designed to meet ecology's most current
stormwater manual,or an Ecology approved local stormwater manual. ❑ YES ❑ NO A
If YES—Which manual will your project be designed to meet?
If NO—For Clean Water Act Section 401 and 404 permits only—Please submit to Ecology for approval,along with this JARPA
application,documentation that demonstrates the stormwater runoff from your project or activity will comply with the water quality
standards,WAC 173.201 A
13. Will excavation or dredging be required in water or wetlands? M' YES ❑ NO
If YES: J
A. Volume: (cubic yards) /area (acre)
B. Composition of material to be removed:
C. Disposal site for excavated material:
D. Method of dredging:
MCI 14. Has the State Environmental Policy Act(SEPA)been completed ❑ YES NO
SEPA Lead Agency: �t
SEPA Decision: DNS, MDNS, EIS,Adoption, Exemption Decision Date(end of comment 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. NOTE: For use with Corps Nationwide Permits, identify
whether your project has or will need an NPDES permit for discharging wastewater and/or stormwater.
TYPE OF APPROVAL ISSUING AGENCY IDENTIFICATION DATE OF APPLICATION DATE APPROVED COMPLETED?
NO.
16. Has any agency denied approval for the activity you're applying for or for any activity directly related to the activity described
herein?
❑ YES G� NO
If YES,explain:
Office of Regulatory Assistance,JARPA JARPA FORM LAST UPDATED:March 19,2007 For help call 800-917-0043 or visit www.epermitting.org 3
SECTION B - Use for Shoreline and Corps of Engineers permits only:
17a. Total cost of project. This means the fair market value of the project, including materials, labor, machine rentals,etc.
17b. If a project or any portion of a project receives funding from a federal agency,that agency is responsible for ESA consultation.
Please indicate if you will receive federal funds and what federal agency is providing those funds.
FEDERAL FUNDING ❑ YES ❑ NO If YES, please list the federal agency.
18. Local government with jurisdiction:
19. 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
SECTION C-This section MUST be completed 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, in-progress or completed
wor . I agree to start work ONLY affe#11 necessary permits have been received.
DATE
--- - C
S E OF APPLICANT
DATE
SIGNATURE OF AUTHORIZED AGENT
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.
SIGNATU OF APPLICANT DATE
SI OF LANDO NER(EXCEPT PUBLIC ENTITY LANDOWNERS, E.G. DNR)
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
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.
COMPLETED BY LOCAL OFFICIAL
A. Nature of the existing shoreline. (Describe 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 dike; material such as sand,gravel, mud, clay,
rock, riprap;and extent and type of bulkheading, if any)
B. In the event that any of the proposed buildings or structures will exceed a height of thirty-five feet above the average grade level,
indicate the approximate location of and number of residential 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 the master program which provides that the
proposed use may be a conditional use,or, in the case of a variance,from which the variance is being sought:
These Agencies are Equal Opportunity and Affirmative Action employers.
For special accommodation needs,please contact the appropriate agency in the instructions
Office of Regulatory Assistance,JARPA JARPA FORM LAST UPDATED:March 19,2007 For help call 800-917-0043 or visit www.eoermitting.org 4