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Home My WebLink AboutJARPA- Removal of Concrete Pieces - SHX Application - 6/13/2003 Agency Reference# AGENCY USE ONLY . - Date Received:_ Circulated by: (local govt.or agency) JOINT AQUATIC RESOURCES PERMIT APPLICATION FORM (JARPA) (for use in Washington State) M PLEASE TYPE OR PRINT IN BLACK INK f^ .l ❑ 1 am applying for a Fish Habitat Enhancement Project per requirements of RCW 75.20.350. 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 dai [B�ased 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 [I 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 Nationwide Permits(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 Section 9 Bridge Permit ❑ US Fish&Wildlife Service or National Marine Fisheries Service for Endangered Species.Act(ESA)Consultation SECTJON A-Use for all permits covered by this application. Be sure to ALSO complete Section C(Signature Block)for all permit applications. 'APPLICANT MAILWG ADDRESS 106 t^ WORK PHONE E-MAIL ADD SS MOt�PHONE FAX X z- If an agent is acting for the applicant during the permit process,complete#Z AUTHORIZED AGENT MAILING ADDRESS WORK PHONE E-MAIL DRESS r'P HOME PHONE FAX i 3.RELATIONSHIP OF APPLICANT TO PROPERTY. OWNER p PURCHASER p LESSEE ❑OTHER 4.NAME.ADDRESS.AND PHONE NUMBER OF PROPERTY OWNER(S).IF OTHER THAN APPUCANT: 5.LOCATION(STREET ADDRESS.INC4UDING CITY.CO GTTY AND ZIP CODE,WHERE PROPOSED ACTIVITY ExISTS OR WILL OCCUR) �' LOCAL GOVERNMENT WITH JURISDICTION(CITY OR COUNTY) ATERSODY G IBUTARY OF s SECTIbN SECTION TOWNSHIP RANGE GOVERNMENT LOT SHORELINE DESIGNATION 1,2 22 --- LATITUDE&LONGITUDE ZONING DESIGNATION IF KNOWN: DESIGNATION C� i TAX PARCEL N0: DNR STREAM TYPE.IF KNOWN JARPA,Revised 12/98.contact Ecology's Permit Assistance Center for latest version,360/407-7037 1 E T USE OF THE PROPERTY,AND STRUCTURES EXISTING ON THE PROPERTY. IF ANY PORTION OFTHE PROPOSED ACTIVITY IS MONTH AND YEAR OF COMPLETION. ALREADY COMP LETEDON ULTURAL LAND? ❑YES O ARE YOU A USDA PROGRAM PARTICIPANT? ❑YES r1 un 7a. DESCRIBE THE PROPOSED CONSTRUCTION AND/OR FILL WORK FOR THE PROJECT THAT YOU WANT TO BUILD 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 A"WORK WITHIN AND BEYOND 200 FEET OF THE ORDINARY HIGH WATER MARK ATTACH A SEPARATE SHEET IF ADDITIONAL SPACE IS NEEDED- Za %v �' a ��✓S' , 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 INFLUENCEO THE DESIGN 7r-. 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 E FISH SUPPLY. AQUATIC LIFE. ATTACH A SEPARATE SHEET IF ADDITIONAL SPACE IS NEEDED. ND PREPARATION OF DRAWINGS: SEE SAMPLE DRAWINGS AND GUIDANCE FOR COMPLETING THE DRAWING$. ONE SET OF ORIGINAL OR GOOD QUALITY REPRODUCIBLE DRAWINGS MUST SE ATTACHED. NOTE: APPLICANTS ARE ENCOURAGED TO SUBMIT PHOTOGRAPHS OF THE PROJECT SITE,BUT THESE DO NOT SUBOR GOOUTE FOR DRAWINGS THE CORPS OF ENGINEERS AND COAST GUARD REQUIRE DRAWINGS ON d-1i!X 119VCH SHEtTS. LARGER DRAWINGS MAY BE REQ(ARED BY 07NER AGENGES. WILL THE PROJECT'BE CONSTRUCTED IN STAGES? ❑YES C NO PROPOSED STARTING DATE: ESTIMATED DURATION OF ACTIVITY: 9.CHECK IF ANY STRUCTURES WILL BE PLACED: 1.7 WATERWARD OF THE ORDINARY HIGH WATER MARK OR LINE FOR FRESH OR TIDAL WATERS,AND/OR Q WATERWARD OF MEAN HIGH WATER LINE IN TIDAL WATERS rO ILL FILL MATERIAL(ROCK FILL.BULKHEAD,OR OTHER MATERIAL)BE PLACED: WATERWARO 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) DARPA, Revised 12/98,contact Ecology's Permit Assistance Center for latest version, 360/407-7037 FtfAPAC7TE0 IAL BE PLACED W WETLANDS? ❑YES 0 AREA IN ACRES.- NEATION BEEN COMPLETED? IF YES.PLEASE SUBMIT WITH APPLICATION ❑YES CNO C HAS A WETLAND REPORT BEEN PREPARED, IF YES.PLEASE SUBMIT WITH APPLICATION D. TYPE AND COMPOSITION OF FILL MATERIAL(EG ❑YES (3 NO..SAND.ETC.): E. MATERIAL SOURCE F. LIST ALL SOIL SERIES(TYPE OF SOIL)LOCATED AT THE PROJECT SITE.8 INDICATE IF THEY ARE ON THE COUNTYS LIST OF HYDRIC SOILS,SOILS INFORMATION CAN BE OBTAINED FROM THE NATURAL RESOURCES CONSERVATION SERVICE(NRCS): 12.WILL PROPOSED ACTIVITY CAUSE FLOODING OR DRAINING OF WETLANDS? IF YES.IMPACTED AREA IS_ACRES. ❑YES \wNO 13.WILL EXCAVATION OR DREDGING BE REQUIRED IN WATER OR WETLANDS? IF YES: ❑YES 0 A VOLUME. (CUBIC YARDS)IAREA (ACRES) 8. 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? g� ` - SEPA LEAD AGENCY: SEPA DECISION. DNS.MONS.EIS.ADOPTION,EXEMPTION ❑YES �NO SUBMIT A COPY OF YOUR SEPA DECISION LETTER TO WDFW AS REQUIRED FOR A COMPLETE APPLICATION DECISION DATE(END OF PERIOD): 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 REGULATORY COMMISSION LICENSE(FERC),FOREST PRACTICES APPLICATION,ETC.)ALSO INDICATE WHETHER WORK HAS BEEN COMPLETED AND INDICATEALL EXISTING WORK ON DRAWINGS. ,SEPA REVIEW,FEDERAL ENERGY TYPE OF APPROVAL ISSUING AGENCY IDENTIFICATION DATE OF APPLICATION DATE APPROVED COMPLETED �- NO. 6.HAS ANY AGENCY DENIED APPROVAL FOR THE ACTMTY DESCPJBED HEREIN OR FOR ANY ACTIVITY DIRECTLY RELATED TO THE ACTIVITY DESCRIBED HEREIN? ❑YES Q/NO IF YES,EXPLAIN SECTION B-Use for Shoreline and Corps of Engineers permits only: FL COST OF PROJECT. THIS MEANS THE FAIR MARKET VALUE OF THE PROJECT.INCLUDING MATERIALS.LABOR,MACHINE RENTALS.ETC. GOVERNMENT WITH JURISDICTION RPS.COAST GUARD.AND DNR PERMITS.PROVIDE NAMES.ADDRESSES.AND TELEPHONE NUMBERS OF ADJOINING PROPERTY OWNERS.LESSEES.ETC.. PLEASE NOTE SHORELINE MANAGEMENT COAfPLIANCE MAY REQUIRE ADDITIONAL NOTICE-CONSULT YOUR LOCAL GOVERNMENT NAME ADDRESS PHONE NUMBER JARPA, Revised 12/98,contact Ecology's Permit Assistance Center for latest version, 360/407-7037 SECTION C- This section MUST be completed for any permit covered b thisapplication APPLICATION IS HEREBY MADE FOR A PERMIT OR PERMITS TO AUTHORIZE THE ACTIVITIES DESCRIBED HEREIN. I CERTIFY THAT I AM FAMIUAR WITH E TH INFORMATION CONTAINED IN THIS APPLICATION,AND THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF,SUCH INFORMATION IS TRUE,COMPLETE,AND . CCURATE_ I FURTHER CERTIFY THAT I POSSESS THE AUTHORITY TO UNDERTAKE THE PROPOSED ACT1VMES. I HEREBY GRANT TO THE AGENCIES TO WHICH IS APPLICATION IS MADE,THE RIGHT TO ENTER THE ABOVE-DESCRIBED LOCATION TO INSPECT THE PROPOSED,IN-PROGRESS OR COMPLETED WORK I AGREE TO START WORK ONLY AFMR ALL NECESSARY PERMITS HAVE BEEN RECEIVED. SIG TU E APPLICANT OR AGENT r ATE I HEREBY DESIGNATE ACT MY AGENT MATTERS RELATED TO THIS APPLICATION FOR PERMIT(S) I MUST SIGN THE PERMIT. . I UNDERSTAND THAT IF A FEDERAL PERMIT IS ISSUED. M SIGNATURE OF APPLICANT DATE SIGNATURE OF LANDOWNER(EXCEPT PUBLIC ENTITY LANDOWNERS.E.G.DNR) ATE 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.n any,manner wiRvn Rie Ainsdicton of any department or agency of the United States krXm1n9ty falsifies conceals.or tbvers up by any tndc.Scheme,or device a material fad or makes any false fictitious.or fraudulent statements or representations or makes or uses entry.shall be fined not more Run$10.000 or any false wiring or document knowing same to contain any false.fictitious.or fraudulent statement cr vnprrsoned not rtgre than 5 years or both. COMPLETED BY LOCAL OFFICIAL F[pl�ain,floodoway, he existing shoreline. (Describe type of shoreline, such as marine, stream, lake, lagoon, marsh, bog, swamp,flood delta;type of beach, such as accretion, erosion, high bank, low bank, or dike; material such as sand, gravel, k, fiprap;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.frnrn which the variance iz�beirly sought: �j These Agencies are Equal Opportunity and Affirmative Action employers. For special accommodation needs,please contact the appropriate agency in the instructions. .1ARPA, Revised 12/98,contact Ecology's Permit Assistance Center for latest version, 360/407-7037