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Home My WebLink AboutJARPA - SHX Application - 5/7/2007 AGENCY USE ONLY Agency Reference#: Date Received: Circulated by: (local govt.or agency) JOINT AQUATIC RESOURCES PERMIT APPLICATION FORM (JARPA) (for use in Washington State) PLEASE TYPE OR PRINT IN BLACK INK. R�,,,, = TO FILL IN ELECTRONICALLY, USE F11 TO MOVE THROUGH THE FORM Oa ❑ Application for a Fish Habitat Enhancement Project per requirements of RCW 77.55.290. You must submit a copy of this completed JARPA application form and the (Fish Habitat Enhancement JARPA Addition)to your local Government Planning Department and Washington Department of Fish &Wildlife Area Habitat Biologist on the same day. NOTE: LOCAL GOVERNMENTS-You must submit any comments on these projects to WDFW within 15 working days. Based on the instructions provided, I am sending copies of this application to the following: (check all that apply) Local Government for shoreline: []Substantial Development ❑Conditional Use ❑Variance [-]Exemption ❑Revision ❑Floodplain Management ❑Critical Areas Ordinance Washington Department of Fish and Wildlife for HPA(Submit 3 copies to WDFW Region) Washington Department of Ecology for 401 Water Quality Certification(to Regional Office-Federal Permit Unit) ❑ Washington Department of Natural Resources for Aquatic Resources Use Authorization Notification ❑ Corps of Engineers for: ❑ Section 404 ❑ Section 10 permit ❑ Coast Guard for: ❑ General Bridge Act Permit ❑ Private 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 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 I ,__) (e eS MAILI D RE WO K PHONE E-MAIL ADDRESS HOME PHONE FAX# 360 732 ?35 6-1-1✓,41V &d7,pP, E35"y6 If 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# 7 3. Relationship of applicant to property: TXLOWNER ❑ PURCHASER ❑ LESSEE ❑ 4. Name, address and phon n mber of property owner(s)if other than applicant: 5. Location(street address,includin city, unty and zip code, her oposed activity exists or will occur) 2 3 0 A/ aL �J l �ti j .Q�->�� % r^ w ��35ZE3 Local government with jurisdiction(city or county) 41 Waterbody you are working in Q v% ^ c v-,4.c r 2a .nA Tributary of WRIA# Is this waterbody on the 303(d)List" YES ❑ NO Z If YES, what parameter(s)? "For 303d List, Shoreline designation http://www.ecy.wa.gov/programs/wg/303d/index.html � <<,, � Zoning designation � � �+�5�1 7 T" Section I Section Township Range Government Lot 2 -Z 3Nl 0 t v DNR stream type if known Latitude and Longitude:Z1,7-�,cfss95_4,1 /"Z2,,8�.7o ax Parcel Number -Z 32 g '0 p v U ECY 070-15(Rev. 11/04) JARPA Contact the State of Washington Office of Regulatory Assistance for latest version or call 360/407-7037 or 800/917-0043 1 6. Describe the current use of thelaToperty,and structures existing on the property. Have you completed any portion of the proposed activity on this property? !p�5' YES ❑ NO ' a For any portion of the proposed ac'vity alre/ady completed on this property, indicate month and y/gar of fPmpletion. /•,g C. S�K7 � Oea. i[S. /�S•oftuc-c a Q�+� /��r7 G�wc/( i�� /uKi�N/� c. /e ��ce w•e i o f 01 C c.(v CrT Is the property agricultural land? ❑ YES NO Are you a USDA program participant? ❑ YES NO 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. ®' r ,`v2 wd •� ;J ?z� Ge / e g r•�c6c c� &-,-j- (v��re�w ��► Z'•� y� /o�e% 7� C.Jvl.r'f i5 >a 4-C /�eo01wc+.�-/ 1 34 cc,&e-fl a.// 2 l2— b( ,STu r�Qr�/ r�f5 y arms a /pv.c/ �t_ Si p �/ve c�r2 (s PREPARATION OF DRAWINGS: See sample drawings and guidance 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 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 design. /�Zte �1 L%/ y �c� w� 3, /A r��- a w«v,,i s o ! trG(� r� S a.�C v1� Gc�fS tw•OUat/ Or�`QS� / 1lvNS �2 /Ra� jj^� V} 4- L4-N L.n w�.•c .Q,, s riKS /+ ✓ / -t- ae(dr ti re fevG�, ✓� G-r I�t DC! I(/Q /S 7O !e Ai/� �'�t �A�✓`a 5� r r y � P 9 > �(Q./1z-t pi a �AG��arcQutiQvL.7 1 S�ro 6 V S l b C-t d )1=0. ar tr- � ulv�r-f t..�c•�� o-��o� �or iv� Cf� rJv�d' aS �e�..c/`ctRWV S 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. A h separate sheet if additional space is needed. L—c F e cw .c w P /�',�tf-t, s'�o ur� �¢. �//a,.��T S�h c A- 7��..�t'� l � vto G� S -Flo &r- rGl LA.O T'i /�/� c►.io w.� t-Cl a-�0�5 '(" vt wo y w d'// (�C- �•-P/ rr)/J ar'f f eSTv rar�o�^ P�o'^ W L Z/ 7d. For in water construction wo ,will your project be in compliance with the State of Washington water quality standards for turbidity WAC 173.201A-110? Z YES NO (See USEFUL DEFINITIONS AND INSTRUCTIONS) 8. Will the project be constructed in stages? YES ❑ NO Proposed starting date: Sl/10 7 Estimated duration of activity: Z /n-Ov o 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 ❑ 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 watermark or line for freshwaters? If YES,VOLUME (cubic yards) /AREA (acres) ❑ Waterward of the mean higher high water for tidal waters? If YES,VOLUME(cubic yards) /AREA (acres) ECY 070-15(Rev. 11/04) JARPA Contact the State of Washington Office of Regulatory Assistance for latest version or call 360/407-7037 or 800/917-0043 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 ❑ NO If YES, IMPACTED AREA IS ACRES OF DRAINED WETLANDS. NOTE:If your project will impact greater than%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 will be required from Ecology in addition to an approved mitigation plan if your project impacts wetlands that are: a)greater than''/:acre in size, or b)tidal wetlands or wetlands adjacent to tidal water. Please submit the JARPA form and mitigation plan to Ecology for an individual 401 certification if a)or b)applies. 12. Stormwater Compliance for Nationwide Permits Only: This project is(or will be)designed to meet ecology's most current stormwater manual,or an Ecology approved local stormwater manual. ❑ YES ❑ NO 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? ❑ YES NO If YES: A. Volume: (cubic yards)/area (acre) B. Composition of material to be removed: C. Disposal site for excavated material: D. Method of dredging: 14. Has the State Environmental Policy Act(SEPA)been completed 0' YES ❑ NO SEPA Lead Agency: M450— Guv�- SEPA Decision: DNS, MDNS, EIS,Adopti n, 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 NO If YES, explain: ECY 070- v - 15(Re 11/04) JARPA Contact the State of Washington Office of Regulatory Assistance for latest version or call 360/407 7037 or 800/917 0043 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. See instructions for information on ESA.* FEDERAL FUNDING ❑ YES ❑ NO If YES, please list the federal agency. 18. Local government with jurisdiction: 19. 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 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 0. 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 applicatio is made,the right to enter the above-described location to inspect the proposed, in-progress or completed work. I agree to st wo k ONLY afte all necessary permits have been received. DATE SIGNATUR OF APPLI ANT 66? 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. SIGNATURE PPLIC DATE SIGNATU OF LAN WNER(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 ECY 070-15(Rev. 11/04) JARPA Contact the State of Washington Office of Regulatory Assistance for latest version or call 360/407-7037 or 800/917-0043 4 w � F T6 � Q l I�