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Home My WebLink AboutSHX2017-00005 Part A - Juvenile Monitoring - SHX Permit / Conditions - 1/31/2017 P��N STgTFO MASON COUNTY Department of Community Services o n o = Planning Division ~ o N T i 615 W Alder St, Shelton, WA 98584 7 N Y y (360)427-9670 OJ �O 1864 Exemption from Shoreline Management Act Case No.: SHX2017-00005 Substantial Development Permit Requirement The Proposal By: HARLOW MENDY C/O HOOD CANAL SALMON ENCHANCE PO BOX 2169 BELFAIR, WA 98528 Parcel Number: 323274200000 Site Address: 767 E PROMONTORY RD SHELTON To undertake the following development: ONGOING HOOD CANAL STEE:LHEAD PROJECT: JUVENILE MONITORING, USE OF ROTARY SCREW TRAPS Within HOOD CANAL and/or its associated wetlands is exempt from the requirement of substantial development because the development is categorized under WAC 173-27-040(2) as being category: P-Fish Habitat Enhancement Proiect Please contact Kell McAboy at ext 365 if you have any questions. Issued:2/7/2017 Authorized Local Government Official SHX2017-00005 February 07, 201 Ir --------------------------------------- ,`' AGENCY USE ONLY WASHINGTON STATE osng=Ts Date received: �n 31 seem•oistrici � � Joint Aquatic Resources Permit Agency reference#: Application (DARPA) Form',2 ►�] Z4W 17 - 0 005 USE BLACK OR BLUE INK TO ENTER ANSWERS IN THE WHITE SPACES BELOW. Tax Parcel#(s): 1 � .: . ; 3z3a7- 42-D6oan -------------------------------------- JAN 31 2017 --= s,,-,�N I.Aer StreF-t Part 1—Project Identification 1. Project Name (A name for your project that you create.Examples Smith's Dock or Seabrook Lane Development) [help] Hood Canal Steelhead Project: Juvenile Monitoring Part 2-Applicant The person and/or organization responsible for the project. hel 2a. Name (Last, First,Middle) Harlow, Mendy, Aquila 2b. Organization(If applicable) Hood Canal Salmon Enhancement Group 2C. Mailing Address (Street or PO Box) PO Box 2169 2d. City, State, Zip Belfair, WA 98528 2e. Phone(1) A Phone(2) 2g. Fax 2h. E-mail 360-275-3575 360-275-0648 mendy@pnwsalmoncenter.org; Additional forms may be required for the following permits: • If your project may qualify for Department of the Army authorization through a Regional General Permit(RGP),contact the U.S.Army Corps of Engineers for application information(206)764-3495. • If your project might affect species listed under the Endangered Species Act,you will need to fill out a Specific Project Information Form(SPIF)or prepare a Biological Evaluation. Forms can be found at http://www nws usace army millMissions/CivilWorks/Regulatory/PermitGuidebook/EndangeredSpecies aspx. • Not all cities and counties accept the JARPA for their local Shoreline permits.If you need a Shoreline permit,contact the appropriate city or county government to make sure they accept the JARPA. 2To access an online JARPA form with[help]screens,go to hftp://www.epermitting.wa.gov/site/alias resourcecenter/iarpa iarpa form/9984/jarpa form.asp For other help,contact the Governor's Office for Regulatory Innovation and Assistance at(800)917-0043 or help(d_)oria.wa.gov. ORIA-16-011 Page 1 of 14 Part 3-Authorized Agent or Contact Person authorized to represent the applicant about the project. (Note: Authorized agent(s) must sign 11 b of this application.) noel ) 3a. Name(Last, First,Middle) David, Clayton, William 3b. Organization (If applicable) Hood Canal Salmon Enhancement Group 3c. Mailing Address (street or PO Box) PO Box 2169 3d. City, State, Zip Belfair, WA 98528 3e. Phone(1) 3f. Phone(2) 3g. Fax 3h. E-mail 360-275-3575 ex 25 360-275-0648 clayton@pnwsalmoncenter.org Part 4-Property Owner(s) Contact information for people or organizations owning the property(ies)where the project will occur. Consider both upland and aquatic ownership because the upland owners may not own the adjacent aquatic land. h[Lel ) ❑ Same as applicant. (Skip to Part 5.) ❑ Repair or maintenance activities on existing rights-of-way or easements. (Skip to Part 5.) ® There are multiple upland property owners. Complete the section below and fill out JARPA Attachment A for each additional property owner. ❑ Your project is on Department of Natural Resources (DNR)-managed aquatic lands. If you don't know, contact the DNR at (360) 902-1100 to determine aquatic land ownership. If yes, complete JARPA Attachment E to apply for the Aquatic Use Authorization. 4a. Name (Last,First,Middle) Manke, Kellen 4b. Organization (If applicable) Manke Timber Company Inc(property owner for Dewatto River trap site) 4c. Mailing Address (Street or PO Box) 826 Fairmount Ave 4d. City, State, Zip Shelton, WA 98584 4e. Phone(1) 4f. Phone(2) 4g. Fax 4h. E-mail 360-426-5536 kellen@mankelumber.com ORIA-16-011 Page 2 of 14 Part 5—Project Location(s) Identifying information about the property or properties where the project will occur. [help] ® There are multiple project locations(e.g. linear projects). Complete the section below and use JARPA Attachment B for each additional project location. 5a. Indicate the type of ownership of the property. (Check all that apply.) [help] ® Private ❑ Federal ❑ Publicly owned (state,county,city,special districts like schools,ports,etc.) ❑ Tribal ❑ Department of Natural Resources (DNR)— managed aquatic lands (Complete JARPA Attachment E) 5b. Street Address (Cannot be a PO Box. If there is no address,provide other location information in 5p.) hel 1001 NE Dewatto Holly Rd 5c. City, State, Zip(If the project is not in a city or town, provide the name of the nearest city or town.) [heI Tahuya, Washington 98588 5d. County [heipi Mason 5e. Provide the section, township, and range for the project location. h[_eivi '/4 Section Section Township Range SE 1/4 27 23 N 03 W 5f. Provide the latitude and longitude of the project location. nel • Example:47.03922 N lat./-122.89142 W long.(Use decimal degrees-NAD 83) 47.453483 N lat. /-123.046438 W long (NAD 83) 5g. List the tax parcel number(s)for the project location. [helms] • The local county assessor's office can provide this information. 323274200000 5h. Contact information for all adjoining property owners. (If you need more space, use JARPA Attachment C.) hel Name Mailing Address Tax Parcel#(if known) Manke Timber Company 826 Fairmount Ave. _..._......-....._......_...._.....__._........_........_......._.......... ......._......_.................._._...-- ------ --- 323270001000 (adjoining to the north) Shelton, WA 98584 Manke Timber Company 826 Fairmount Ave. 323273100010 and _____ _...__..._._........_..........._..........................._..__._.-..._........ -------_ ----- (adjoining to the west) Shelton, WA 98584 323273100000 Manke Timber Company 826 Fairmount Ave. _..__.._....-.._........._._..-...__.._.._.__.___.___..__.._........_............_.._..._.._.._._..----------------__..__.. 323274000000 (adjoining to the south) Shelton, WA 98584 Manke Timber Company 826 Fairmount Ave. 323274100010 (adjoining to the east) Shelton, WA 98584 ORIA-16-011 Page 3 of 14 5i. List all wetlands on or adjacent to the project location. [help 5j. List all waterbodies (other than wetlands)on or adjacent to the project location. hel Dewatto River 5k. Is any part of the project area within a 100-year floodplain? [help] ® Yes ❑ No ❑ Don't know 51. Briefly describe the vegetation and habitat conditions on the property. hpM The property consists of natural stream and riparian habitats with conifer and deciduous trees and shrubs. It is undeveloped land with the exception of Dewatto Road which passes through the property. 5m. Describe how the property is currently used. [he►p] Undeveloped land with the exception of Dewatto Road which passes through the property. Land use is designated forest land. 5n. Describe how the adjacent properties are currently used. [help Undeveloped land and forest land. Land use is designated forest land. 5o. Describe the structures (above and below ground) on the property, including their purpose(s)and current condition. h[ egl NE Dewatto Holly Road (a county road) 5p. Provide driving directions from the closest highway to the project location, and attach a map. [hel From Belfair, take NE WA-300/N Shore Rd. Turn R onto NE Belfair Tahuya Rd. Turn R onto NE Dewatto Holly Rd. Continue on NE Dewatto Holly Rd as it winds down and runs along Dewatto Bay, approximately 4.3 miles. The trap site is located just upstream of the point at which the road meets the river(park at the very first pullout where the river meets the road). ORIA-16-011 Page 4 of 14 Part 6—Project Description 6a. Briefly summarize the overall project. You can provide more detail in 6b. hel Evaluate the effects of a steelhead supplementation project using rotary screw traps to quantify steelhead smolt abundance and juvenile salmonid abundance. 6b. Describe the purpose of the project and why you want or need to perform it. hel The proposed work is for research and management purposes and encompasses juvenile fish composition, population and production measurements, and monitoring and evaluation of supplementation efforts. The Hood Canal Steelhead Project aims to restore indigenous steelhead runs to the Skokomish River, Dewatto River, and Duckabush River. Supplementation of wild populations with native stocks of juvenile and adult fish has been shown to be a viable option for augmenting small populations in a conservation context. A vital part of determining its effectiveness involves monitoring baseline, treatment, and post-treatment smolt abundance. Rotary screw traps will be used in treatment and control streams to capture juvenile salmonids during outmigration periods. 6C. Indicate the project category. (Check all that apply) hel Commercial ❑ Residential ❑ Institutional ❑ Transportation ❑ Recreational ❑ Maintenance ® Environmental Enhancement 6d. Indicate the major elements of your project. (Check all that apply) [help) ❑ Aquaculture ❑ Culvert ❑ Float ❑ Retaining Wall ❑ Bank Stabilization ❑ Dam /Weir ❑ Floating Home (upland) ❑ Boat House ❑ Dike/ Levee /Jetty ❑ Geotechnical Survey ❑ Road ❑ Boat Launch ❑ Ditch ❑ Land Clearing IM Scientific Measurement Device ❑ Boat Lift ❑ Dock/ Pier ❑ Marina / Moorage ❑ Stairs ❑ Bridge ❑ Dredging ❑ Mining ❑ Stormwater facility ❑ Bulkhead ❑ Fence ❑ Outfall Structure ❑ Swimming Pool ❑ Buoy ❑ Ferry Terminal ❑ Piling/Dolphin ❑ Utility Line ❑ Channel Modification ❑ Fishway ❑ Raft ❑ Other: ORIA-16-011 Page 5 of 14 6e. Describe how you plan to construct each project element checked in 6d. Include specific construction methods and equipment to be used. hLelp) • Identify where each element will occur in relation to the nearest waterbody. • Indicate which activities are within the 100-year floodplain. There are two project locations. The project location listed in this JARPA is for the Dewatto River trap. The Attachment B worksheet has been filled out for the additional project location of the Tahuya River trap.Temporary screw traps will be installed in the rivers to enumerate the number of migrating salmonid juveniles.Traps will be installed on a seasonal basis for this multi-year project, to be completed in 2022. 1. The Tahuya (see Attachment B)and Dewatto traps each consist of 2 pontoons and a 5-ft diameter cone. The traps are 10 ft wide x 17 ft 4 in long. 2. Fish traps will be assembled and installed by hand labor and hand tools. 3. Traps will be installed, operated, and removed with minimal disturbance to streambed, banks, and adjacent riparian area. Screw traps will be anchored to the shore with cable running from the traps to trees, as shown on the site drawings. When wrapping cable around trees, nylon material will be used to protect the trees. 4. Traps will be monitored and maintained daily to prevent undue stress, injury, or migration delays to both upstream and downstream migrating adult and juvenile fish, and to insure proper, safe operation of trapping gear and to minimize any possible disturbance to the adjacent landscape. 5. The project sites will be restored to pre-existing natural conditions and configuration upon trap removal. 6. Monitoring, sampling and enumeration techniques shall be in accordance with established protocols developed by WDFW's Fish Program and NOAA's Hood Canal Steelhead Project. All data and findings shall be available to the Science Division in Olympia. 6f. What are the anticipated start and end dates for project construction? (MonthNear) (help) • If the project will be constructed in phases or stages,use JARPA Attachment D to list the start and end dates of each phase or stage. Start Date: March 1, 2017 End Date: June 10, 2022 ❑ See JARPA Attachment D 6g. Fair market value of the project, including materials, labor, machine rentals, etc. h[ ell $43,000 material cost, $20,000 per year operational cost 6h.Will any portion of the project receive federal funding? h[ eM • If yes,list each agency providing funds. N Yes ❑ No ❑ Don't know Part 7—Wetlands: Impacts and Mitigation N Check here if there are wetlands or wetland buffers on or adjacent to the project area. (If there are none, skip to Part 8.) hei 7a. Describe how the project has been designed to avoid and minimize adverse impacts to wetlands. [help] ❑ Not applicable The traps will not affect wetlands because they are designed to float within river channels and are held in place by cables anchored to trees. ORIA-16-011 Page 6 of 14 7b. Will the project impact wetlands? hel ❑ Yes N No ❑ Don't know 7c. Will the project impact wetland buffers? heI ❑ Yes N No ❑ Don't know 7d. Has a wetland delineation report been prepared? [help] • If Yes,submit the report, including data sheets,with the JARPA package. ❑ Yes N No 7e. Have the wetlands been rated using the Western Washington or Eastern Washington Wetland Rating System? hei • If Yes,submit the wetland rating forms and figures with the JARPA package. ❑ Yes ❑ No N Don't know 7f. Have you prepared a mitigation plan to compensate for any adverse impacts to wetlands? [ ] • If Yes,submit the plan with the JARPA package and answer 7g. • If No,or Not applicable,explain below why a mitigation plan should not be required. ❑ Yes N No ❑ Don't know The traps will not affect wetlands because they are designed to float within river channels and are held in place by cables anchored to trees. 7g. Summarize what the mitigation plan is meant to accomplish, and describe how a watershed approach was used to design the plan. N/A 7h. Use the table below to list the type and rating of each wetland impacted, the extent and duration of the impact, and the type and amount of mitigation proposed. Or if you are submitting a mitigation plan with a similar table, you can state (below)where we can find this information in the plan. h[ elpl Activity(fill, Wetland Wetland Impact Duration Proposed Wetland drain, excavate, Name' type and area (sq. of impact3 mitigation mitigation area flood, etc.) rating ft. or type° (sq. ft. or category2 Acres) acres) ORIA-16-011 Page 7 of 14 If no official name for the wetland exists,create a unique name(such as"Wetland 1"). The name should be consistent with other project documents, such as a wetland delineation report. 'Ecology wetland category based on current Western Washington or Eastern Washington Wetland Rating System.Provide the wetland rating forms with the JARPA package. 3Indicate the days,months or years the wetland will be measurably impacted by the activity.Enter"permanent"if applicable. "Creation C,Re-establishment/Rehabilitation R ,Enhancement E ,Preservation P,Mitigation Bank/In-lieu fee B) Page number(s) for similar information in the mitigation plan, if available: 7L For all filling activities identified in 7h, describe the source and nature of the fill material, the amount in cubic yards that will be used, and how and where it will be placed into the wetland. [help] N/A For all excavating activities identified in 7h, describe the excavation method, type and amount of material in cubic yards you will remove, and where the material will be disposed. hel N/A Part 8—Waterbodies (other than wetlands): Impacts and Mitigation In Part 8, "waterbodies" refers to non-wetland waterbodies. (See Part 7 for information related to wetlands.) hel ❑ Check here if there are waterbodies on or adjacent to the project area. (if there are none, skip to Part 9.) 8a. Describe how the project is designed to avoid and minimize adverse impacts to the aquatic environment. Le-1 Pi ❑ Not applicable The traps are designed to be installed, operated, and removed with very little disturbance to the streambed, banks, and adjacent riparian areas. Protocols to minimize impacts to fish and the aquatic environment include 1) removing the trap from fishing operations in high stream flow events, 2) monitoring the trap consistently throughout operation for debris and functionality, 3)sampling and releasing captured fish at least once per day, and 4) minimizing handling of captured fish. 8b. Will your project impact a waterbody or the area around a waterbody? [help] ❑ Yes ® No ORIA-16-011 Page 8 of 14 8c. Have you prepared a mitigation plan to compensate for the project's adverse impacts to non-wetland waterbodies? hel • If Yes,submit the plan with the JARPA package and answer 8d. • If No,or Not applicable,explain below why a mitigation plan should not be required. ❑ Yes ® No ❑ Don't know The traps float on pontoons and are not in contact with the streambed. The traps are held in place using cables anchored to large trees and do not disturb riparian areas. The traps are completely temporary; project sites are restored to pre-existing natural conditions upon trap removal. 8d. Summarize what the mitigation plan is meant to accomplish. Describe how a watershed approach was used to design the plan. • If you already completed 7g you do not need to restate your answer here. [ ] N/A 8e. Summarize impact(s)to each waterbody in the table below. [hel Activity(clear, Waterbody Impact Duration Amount of material Area (sq. ft. or dredge, fill, pile name' location' of impact' (cubic yards)to be linear ft.) of drive, etc.) placed in or removed waterbody from waterbody directly affected If no official name for the waterbody exists,create a unique name(such as"Stream 1")The name should be consistent with other documents provided. 2Indicate whether the impact will occur in or adjacent to the waterbody. If adjacent,provide the distance between the impact and the waterbody and indicate whether the impact will occur within the 100-year flood plain. 'Indicate the days,months or years the waterbody will be measurably impacted by the work. Enter"permanent'if applicable. 8f. For all activities identified in 8e, describe the source and nature of the fill material, amount(in cubic yards) you will use, and how and where it will be placed into the waterbody. N/A ORIA-16-011 Page 9 of 14 8g. For all excavating or dredging activities identified in 8e, describe the method for excavating or dredging, type and amount of material you will remove, and where the material will be disposed. [ftplpj N/A Part 9—Additional Information Any additional information you can provide helps the reviewer(s) understand your project. Complete as much of this section as you can. It is ok if you cannot answer a question. 9a. If you have already worked with any government agencies on this project, list them below. [held Agency Name Contact Name Phone Most Recent Date of Contact NOAA Fisheries Barry Berejikian 360-871-8301 November 2016 WDFW Mark Downen (360)202-7005 November 2016 Mason County Kell McAboy (360)427-9670 ext. 365 December 2016 9b. Are any of the wetlands or waterbodies identified in Part 7 or Part 8 of this JARPA on the Washington Department of Ecology's 303(d) List? [helpi • If Yes,list the parameter(s)below. • If you don't know, use Washington Department of Ecology's Water Quality Assessment tools at: http://www.ecy.wa.gov/programs/wq/303d/. ❑ Yes N No 9c. What U.S. Geological Survey Hydrological Unit Code (HUC) is the project in? hel • Go to http://cfoub.eaa.gov/surf/locatellindex.cfm to help identify the HUC. Hood Canal 17110018 9d. What Water Resource Inventory Area Number(WRIA#) is the project in? hf elal • Go to http://www.ecy.wa.gov/water/wria/index,htmi to find the WR►A#. 15.0420 (Dewatto River), 15.0446 (Tahuya) ORIA-16-011 Page 10 of 14 9e. Will the in-water construction work comply with the State of Washington water quality standards for 9 q Y turbidity? [help • Go to http://www.ecy.wa.gov/programs/wq/swgs/criteria.html for the standards. ❑ Yes ❑ No ® Not applicable 9f. If the project is within the jurisdiction of the Shoreline Management Act, what is the local shoreline environment designation? [help] • If you don't know, contact the local planning department. • For more information, go to: http//www.ecy.wa.gov/programs/sea/sma/laws rules/173-26/211 designations html. ® (Tahuya)Urban ❑ Natural ❑ Aquatic ® (Dewatto)Conservanc ❑ Other: 9g. What is the Washington Department of Natural Resources Water Type? [ilel • Go to http://www.dnr.wa.gov/forest-practices-water-typinri for the Forest Practices Water Typing System. ® Shoreline ❑ Fish ❑ Non-Fish Perennial ❑ Non-Fish Seasonal 9h. Will this project be designed to meet the Washington Department of Ecology's most current stormwater manual? hei • If No, provide the name of the manual your project is designed to meet ❑ Yes ❑ No Name of manual: 9i. Does the project site have known contaminated sediment? hel • If Yes,please describe below. ❑ Yes ® No 9j. If you know what the property was used for in the past, describe below. [help] 9k. Has a cultural resource (archaeological) survey been performed on the project area? hel • If Yes,attach it to your JARPA package. ❑ Yes ® No ORIA-16-011 Page 11 of 14 91. Name each species listed under the federal Endangered Species Act that occurs in the vicinity of the project area or might be affected by the proposed work. (help] Steelhead trout, summer chum salmon, and Chinook salmon 9m. Name each species or habitat on the Washington Department of Fish and Wildlife's Priority Habitats and Species List that might be affected by the proposed work. [hem] Steelhead trout, chum salmon,, coho salmon, Chinook salmon, coastal cutthroat, pacific lamprey, river lamprey Part 10—SEPA Compliance and Permits Use the resources and checklist below to identify the permits you are applying for. • Online Project Questionnaire at hft ://apps.oria.wa.gov/opas/. • Governor's Office for Regulatory Innovation and Assistance at(800) 917-0043 or help(ab-oria.wa.gov. • For a list of addresses to send your JARPA to, click on agency addresses for completed JARPA. 10a. Compliance with the State Environmental Policy Act(SEPA). (Check all that apply.) hel • For more information about SEPA,go to www.ecy.wa.gov/programs/sea/sepa/e-review.html. ® A copy of the SEPA determination or letter of exemption is included with this application. ❑ A SEPA determination is pending with (lead agency). The expected decision date is ❑ I am applying for a Fish Habitat Enhancement Exemption. (Check the box below in 10b.) hei ❑ This project is exempt(choose type of exemption below). ❑ Categorical Exemption. Under what section of the SEPA administrative code (WAC) is it exempt? ❑ Other: ❑ SEPA is pre-empted by federal law. ORIA-16-011 Page 12 of 14 10b. Indicate the permits you are applying for. (Check all that apply.) el LOCAL GOVERNMENT Local Government Shoreline permits: ❑ Substantial Development ❑ Conditional Use ❑ Variance ❑ Shoreline Exemption Type(explain): Other City/County permits: ❑ Floodplain Development Permit ❑ Critical Areas Ordinance STATE GOVERNMENT Washington Department of Fish and Wildlife: ® Hydraulic Project Approval (HPA) ❑ Fish Habitat Enhancement Exemption—Attach Exemption Form You must submit a check for$150 to Washington Department of Fish and Wildlife, unless your project qualifies for an exemption or alternative payment method below. Do not send cash. Check the appropriate boxes ❑ $150 check enclosed. Check# Attach check made payable to Washington Department of Fish and Wildlife. ❑ My project is exempt from the application fee. (Check appropriate exemption): ❑ HPA processing is conducted by applicant funded WDFW staff. Agreement# ❑ Mineral prospecting and mining ❑ Project occurs on farm and agricultural land. (Attach a copy of current land use classification recorded with the county auditor,or other proof of current land use) ❑ Project is modification of an existing HPA originally applied for, prior to July 10, 2012. HPA# Washington Department of Natural Resources: ❑ Aquatic Use Authorization Complete DARPA Attachment E and submit a check for$25 payable to the Washington Department of Natural Resources. Do not send cash. Washington Department of Ecology: ❑ Section 401 Water Quality Certification FEDERAL GOVERNMENT United States Department of the Army permits (U.S.Army Corps of Engineers): ❑ Section 404(discharges into waters of the U.S.) ❑ Section 10(work in navigable waters) United States Coast Guard permits: ❑ Private Aids to Navigation (for non-bridge projects) ORIA-16-011 Page 13 of 14 Part 11—Authorizing Signatures Signatures are required before submitting the JARPA package. The JARPA package includes the JARPA form, project plans, photos, etc. [held 11a. Applicant Signature (required) h[ eM I certify that to the best of my knowledge and belief, the information provided in this application is true, complete, and accurate. I also certify that I have the authority to carry out the proposed activities, and I agree to start work only after I have received all necessary permits. I hereby autho,[i� e e agent named in Part 3 of this application to act on my behalf in matters related to this application. �Vl (initial) By initialing here, I state that I have the authority to grant access to the property. I also give my consent to the permitting agencies entering the property where the project is located to inspect the project site or any work related to the project. (initial) mt vk 4, A - t&) A-X&DLO (pall Applicant Printed Name Applicant Signature Date 11b. Authorized Agent Signature [heipl certify that to the best of my knowledge and belief, the information provided in this application is true, complete, and accurate. I also certify that I have the authority to carry out the proposed activities and I agree to start work only after all necessary permits have been issued. C I&q�,n 1��f I 5�� — I Authorized ent Printed Name Authorized Agent Signature Date 11C. Property Owner Signature (if not applicant) [heipi Not required if project is on existing rights-of-way or easements (provide copy of easement with JARPA). I consent to the permitting agencies entering the property where the project is located to inspect the project site or any work. These inspections shall occur at reasonable times and, if practical, with prior notice to the landowner. Property Owner Printed Name Property Owner Signature Date 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. If you require this document in another format,contact the Governor's Office for Regulatory Innovation and Assistance(ORIA)at(800) 917-0043. People with hearing loss can call 711 for Washington Relay Service. People with a speech disability can call(877)833- 6341. ORIA publication number: ORIA-16-011 rev.09/2016 ORIA-16-011 Page 14 of 14 Part 11—Authorizing Signatures Signatures are required before submitting the JARPA package. The JARPA package includes the JARPA form, project plans, photos, etc. [heipi 11a. Applicant Signature (required) [hel I certify that to the best of my knowledge and belief, the information provided in this application is true, complete, and accurate. I also certify that I have the authority to carry out the proposed activities, and I agree to start work only after I have received all necessary permits. I hereby autho ' e agent named in Part 3 of this application to act on my behalf in matters related to this application. (initial) By initialing here, I state that I have the authority to grant access to the property. I also give my consent to the permitting agencies ent n the property where the project is located to inspect the project site or any work related to the project. (initial) Applicant Priekd Name Applicant Signature Date 11 b. Authorized Agent Signature hf eM I certify that to the best of my knowledge and belief, the information provided in this application is true, complete, and accurate. I also certify that I have the authority to carry out the proposed activities and I agree to start work only after all necessary permits have been issued. C/CtC4 vzq Authorize ent Printed Name Authorized Agent Signature Date 11c. Property Owner Signature (if not applicant) hf !god Not required if project is on existing rights-of-way or easements (provide copy of easement with JARPA). I consent to the permitting agencies entering the property where the project is located to inspect the project site or any work. These inspections shall occur at reasonable times and, if practical, with prior notice to the landowner. 61�FM Property OwM2r Printed Name Propeirtq Owner Signature Date 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. If you require this document in another format,contact the Governor's Office for Regulatory Innovation and Assistance(ORIA)at(800) 917-0043. People with hearing loss can call 711 for Washington Relay Service. People with a speech disability can call(877)833- 6341. ORIA publication number: ORIA-16-011 rev.09/2016 ORIA-16-011 Page 14 of 14 i Part 11—Authorizing Signatures Signatures are required before submitting the JARPA package. The JARPA package includes the JARPA form, project plans, photos, etc. hei 11a. Applicant Signature (required) [helpi I certify that to the best of my knowledge and belief, the information provided in this application is true, complete, and accurate. I also certify that I have the authority to carry out the proposed activities, and I agree to start work only after I have received all necessary permits. I hereby authorize,the agent named in Part 3 of this application to act on my behalf in matters related to this application. (initial) By initialing here, I state that I have the authority to grant access to the property. I also give my consent to the permitting agencies enterl� 'ng the property where the project is located to inspect the project site or any work related to the project. M (initial) 0,V okx) 4,dVLk) q MrAAL, &- t� W"Ll I--L, Applicant Prin d Name Applicant Sign ture Date 11 b. Authorized Agent Signature [help] I certify that to the best of my knowledge and belief, the information provided in this application is true, complete, and accurate. I also certify that I have the authority to carry out the proposed activities and I agree to start work only after all necessary permits have been issued. ( kh :�:L 4 1 -- Authoriz d gent Printed Name Authorized Agent Signature Date 11c. Property Owner Signature (if not applicant) hf d Not required if project is on existing rights-of-way or easements (provide copy of easement with JARPA). consent to the permitting agencies entering the property where the project is located to inspect the project site or any work. These inspections shall occur at reasonable times and, if practical, with prior notice to the landowner. Property Owner Printed Name Property Owner Signature Date 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. If you require this document in another format,contact the Governor's Office for Regulatory Innovation and Assistance(ORIA)at(800) 917-0043. People with hearing loss can call 711 for Washington Relay Service. People with a speech disability can call(877)833- 6341. ORIA publication number: ORIA-16-011 rev.09/2016 ORIA-16-011 Page 14 of 14 1 Part 11—Authorizing Signatures Signatures are required before submitting the JARPA package. The JARPA package includes the JARPA form, project plans, photos, etc. hei 1la. Applicant Signature (required) hel I certify that to the best of my knowledge and belief, the information provided in this application is true, complete, and accurate. I also certify that I have the authority to carry out the proposed activities, and I agree to start work only after I have received all necessary permits. hereby auth ri a he agent named in Part 3 of this application to act on my behalf in matters related to this application. (initial) By initialing here, I state that I have the authority to grant access to the property. I also give my consent to the permitting agencies ent in the property where the project is located to inspect the project site or any work related to the project. (initial) In Applicant Printed Name Applicant Signature Date 11 b. Authorized Agent Signature hel certify that to the best of my knowledge and belief, the information provided in this application is true, complete, and accurate. I also certify that I have the authority to carry out the proposed activities and I agree to start work only after all necessary permits have been issued. Authorized A e t Print d Name Authorized Agent Signature Date 11 c. Property Owner Signature (if not applicant) [helps Not required if project is on existing rights-of-way or easements (provide copy of easement with JARPA). I consent to the permitting agencies entering the property where the project is located to inspect the project site or any work. These inspections shall occur at reasonable times and, if practical, with prior notice to the landowner. to n K t5ws Property Owner Printed Name 7ty Owner Signature Date 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 materia!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. If you require this document in another format, contact the Governor's Office for Regulatory Innovation and Assistance(ORIA)at(800) 917-0043. People with hearing loss can call 711 for Washington Relay Service. People with a speech disability can call(877)833- 6341. ORIA publication number: ORIA-16-011 rev.09/2016 ORIA-16-011 Page 14 of 14