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Home My WebLink AboutJARPA - SHX Application - 7/15/2000 f AGENCY USE ONLY Agency Reference#: Date Received: Other. DARPA FORM �,►_••: (for use in Washington Stale) PLEASE TYPE OR PRINT IN BLUE OR BLACK INK iww 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 ❑Vahance�xemption:or, if applicable ❑ Floodplain Management ❑Critical Areas Ordinance Washington Department of Fish and Wildlife for HPA ❑ Washington Department of Ecology for: ❑Approval to Allow Temporary Exceedance of Water Quality Standards ❑401 Water Quality Certification Nationwide Permits ❑ Washington Department of Natural Resources for:❑Aquatic Resources Use Authorization Notification ❑ Corps Engineers for: ❑ Section 404 ❑Section 10 permit ❑ Coast Guard for: ❑Section 9 Bride Permit 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 Pq ewe e A. MAILING ADDRESS WORK PHONE HOME PHONE FAX# If an agent is acting for the applicant during the permit process,complete#2. 2.AUTHR/ ED AGENT MAULING ADDRESS J3 / �_ Qib�/,�/-/PS Lk �d �/�f ELTO� 4hd 5bS8 WORKPHONE // HOMEPHONE FAX# �l�o vas -s��7 31o1� Spa 7 3.RELATIONSHIP OF APPLICANT TO PROPERTY: NER ❑PURCHASER ❑LESSEE ❑OTHER: 4,NAME,ADDRESS,AND PHONE NUMBER OF PROPERTY OWNER(S),IF OTHER THAN APPLICANT: 5.LOCATION(STREET ADDRESS,INCLUDING CITY.COUNTY AND ZIP CODE,WHERE PROPOSED ACTIVITY EXISTS OR WILL OCCUR) k1A sa,u WATERBODY TRIBUTARY OF lyasDAU �aI1 E- 1/4 SECTION TOWNSHIP RANGE GOVERNMENT LOT SHORELINE DESIGNATION 33 lu ZONING DESIGNATION TAX PARCEL NO.: DNR STREAM TYPE,IF KNOWN �2.33 • �a - boos9 Application Page 1 of 4 U to y e6ed uogl"lddV 31VO ONLLUVIS 03SOdOUd S3A❑ LS3E)V1S NI 031OnH1SNOO 39103fO8d 3HI IIIM'9 S31ON30Y d3H10 AB 03H1!)03H 38 AYIV SJN/MVdO d3JdY7 'S133HS HONI I1 X Z/1-8 NO SJNIMY!!O 3Hin03d OdYnz)1SYOO ONV Sd33NION3 j0 SdM00 3Hl SDNIMV 80 803 31n111S8nS ION 00 3S3H1 ln8'31IS 103ro8d 3H1 d0 SHdV8E)OIOHd imenS Ol 03`JVHnOON3 3UV SINVOIlddV 310N -03HOY11Y 38.L PV S`JNIMYtlO 37B1On o d3d AlnVn0 GOOD d0 7YNIOId0 d0l3S 3NO 'S`JNIMVHO 3H1 E)NI13ldVV00 UOd 1SllHO3H0 ONV SEJNIMVHO 3ldViVS-V XION3ddV 33S :SDNIMVUO d0 NOLLVUVd3Ud 711 rnrl V CY - Pit�►d rPrlrvq 31-i'lbdo1 �3y'30vv of--y N01103108d 83dOUd 301AOUd ONV'S1OVdW1 IVIN3WI8130 31YOUIV4 ONV'3ZIVIINlA'OIOAV OI SNO110V 03SOdO8d A UN301 'SOI13H1S3V Pue'NOIIV3UO3U'A1ddnS U31VM'AanvnO U31VM'3_11 OI1VnOV ONY HSU 30n1ON1 AYN S35n 3S3H1 A009 U31VM 3H1 d0 S3Sn 0LLSl8310VbVH0 01 SIOVdhl 1V11N310d 3H13918OS30 'OL HUOM 03SOdOUd 3H130 3SOdUnd 3HI 39183S30 AL G�N�b mb7s QL 0-3NPly-LLV' >-P(2C? o---7v-:;; , h/ rC ,"01 -tar?�LSGYOJ �'--Y1�4 Q� �� ,8 l;)nalscy? HO NUM U31VM H01H AHVNIOUO 3H1 30 OHVMU3IVM NUOM 71V UOd 0301AO8d 39 O1nOHS SNOLLV013103dS ONV SM/ld 313ldW00'NUOM 03SOdO8d 3H1391UOS30 'it O 3A❑ UNVdl01.Ldvd YVVUEJOUd vOSn v nOA 3UV O S3A❑LONvi ivUnllnoiwov AlU3d0Ud 3H1 SI D�trS �3S770P/lTtog 3�vq ��acv�P�s� 1.71'vb_J 37hrYIS NOLL3ldV400 d0 VV3A ONV H1NOIN 31V0IONI'AlU3dO8d SIHL NO 03131dWOO MW3HlV SI A11AI10V 03SOdO8d 3H130 N01180d ANV JI 'AI83dOUd 3H1 NO ONIISIX3 S38n1OnU1S ONV'A 83dO8d 3H1 j0 3Sn 1N3U8nO 3HI 38IUOS30 9 y 'ESTIMATED DURATION OF ACTIVITY: XJ (-'D AJ a! T70 Art S 9.CHECK IF ANY STRUCTURES WILL BE PLACED: {_I t ERWARD OF THE ORDINARY HIGH WATER MARK OR UNE FOR FRESH OR TIDAL WATERS;AND/OR ❑WATERWARD OF THE MEAN HIGH WATER LINE IN TIDAL WATERS 10.WILL FILL MATERIAL(ROCK,FILL,BULKHEAD,PILINGS OR OTHER MATERIAL)BE PLACED. 7W ESE- 40/2/xJ S 2C AjD AJS 14 E ❑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) 11.WILL MATERIAL BE PLACED IN WETLANDS? ❑YES,-6%0 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,6 INDICATE IF THEY ARE ON THE COUNTY'S 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? ❑YES lid NO IF YES,IMPACTED AREA IS _ACRES 13.WILL EXCAVATION OR DREDGING BE REQUIRED IN WATER OR WETLANDS? ❑YES NO IF YES. /4 A.VOLUME:_(CUBIC YARDSVAREA_(ACRES) B.COMPOSITION OF MATERIAL TO BE REMOVED: C.DISPOSAL SITE FOR EXCAVATED MATERIAL D.METHOD OF DREDGING: 14,UST 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. TYPE OF APPROVAL ISSUING AGENCY IDENTIFICATION NO. DATE OF APPLICATION DATE APPROVED COMPLETED? 4!z L /�ffQs �Du N SEPA LEAD AGENCY �� >Q�AJ�ti 6 SEPA DECISION: PC�t,�a/� SEPA DECISION DATE. 15. 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: Application Papa 3 of 4 SECTION B - Use for Shoreline and Corps of Engineers permits only: 16. TOTAL COST OF PROJECT. THIS M S THE FAIR MARKET VALUE OF THE PROJECT,INCLUDING MATERIALS,LABOR,MACHINE RENTALS,ETC. 17. LOCAL GOVERNMENT WITH J RISDICTION: / 18. FOR CORPS,COAST GUARD,AND DNR PERMITS,PROVIDE NAMES,ADDRESSES,AND TELEPHONE NUMBERS OF ADJOINING PROPERTY OWNERS,LESSEES,ETC PLEASE NOTE: SHOREUNE 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. 19. 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 ACCUR E. I FURTHER CERTIFY THAT I POSSESS THE AUTHORITY TO UNDERTAKE THE PROPOSED ACTIVITIES. I HEREBY GRANT TO THE AGENCIES TO HI THIS APPLICATION IS MADE,THE RIGHT TO ENTER THE ABOVE-DESCRIBED LOCATION TO INSPECT THE PROPOSED,IN-PROGRESS OR COMPLETED K.I AGREE TOO SSTTART RK Y AFTER AL ECESSARY PERMITS HAVE BEEN RECEIVED. SIG LICANT 'THORIZED AGENT DATE I HEREBY DESIGNATE /1.�64 TO A MY AGEN IN MATTERS RELATED TO THIS APPLICATION FOR PERMIT(S). I UNDERSTAND THAT IF A FEDERAL PERMIT IS ISSUED.I MUST SIGN THE PERMIT. r SIGNATURE OF APPLICAN DATE SIGNATURE OF LANDOWNER(EXCEPT PUBLIC ENTITY LANDOWNERS,E.G.DNR) DATE 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 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. 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 from Appendix B. Application Pape 4 of 4