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Home My WebLink AboutJARPA - SHX Application - 2/8/2000 ..................................................................................................................................................................:.::::::.::............................................................:........:........ ..................................................................................................... ....................................................................... ................................ ................................:..:..........r..f.{<{?4'•:i•}}}}}}}:.. }.4..................... .... ...........nv ..x::::::::v:r•:::.v........nf..l:. .r....... ........................................ :::j$`};:•5:;:}y'•S$$}::ii'>i:>:Y:ii}S:�iiiii:>}vir�?+i.'•Si'i:;}:�Y%::}i 4:•ff.•}}i'.y:r:.:�:•:.::.v::.v:::r: ........................n........n.::::.v:::::::::.v::::::::•i:{{v:•}}}::•i}:}:}:;?•}:{4;•i}i:i{{:::4ii:!.:. :::::::::..................... ..4ii•}:.r ii<:%: :;:;::•}}•:; M�,! 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Be sure to also complete Section C(Signature Bloch for all permit applications. 1.APPLICANT j/1/V/1 MAILING ADDRESS W3 Ak,CEV /Iff:K.tAl aA -70576 WORK PHONE HOME PHONE FAX# 360 - 5 33-03-,A Z I 36o-S33-466S' If an agent Is acting for the applicant during the permit process,complete#2. 2.AUTHORIZED AGENT A&AINY MAILING ADDRESS WORK PHONE' HOME PHONE FAX# Ab u26-37(a-7 3.RELATIONSHIP OF APPLICANT TO PROPERTY:)I%OWNER ❑PURCHASER ❑LESSEE ❑OTHER: CQ gTaA(f:;rO(L 4.NAME,ADDRESS,we PHONE NUMBER OF PROPERTY OWNER(S),IF OTHER THAN APPLICANT: so I IC S.LOCATION(STREET ADDRESS,INCLUDING CITY,COUNTY AND ZIP CODE,WHERE PROPOSED ACTNITY EXISTS OR WILL OCCUR) E 2 S701 Nl M0.0 LA CC D2. C-A-yj RWW16tdzt(o WATERBODY TRIBUTARY OF NI�j AJ L�1 Cam" 1/4 SECTION TOWNSHIP RANGE GOVERNMENT LOT SHORELINE DESIGNATION �E 429�— ZONING DESIGNATION TAX PARCEL NO.:222-3 �2. DNR STREAM TYPE,IF KNOWN 3 aoy,3 Application Page 1 of 4 8. DESCRIBE THE CURRENT USE OF THE PROPERTY,AND STRUCTURES EXISTING ON THE PROPERTY. IF ANY PORTION OF THE PROPOSED ACTIVITY IS ALREADY COMPLETED ON THIS PROPERTY,INDICATE MONTH AND YEAR OF COMPLETION. CUA?&VT I Z&- - 2C-CXMn�14r,oL s1MfCT11 -S aMi L Y' IS THE PROPERTY AGRICULTURAL LAND?❑YES Ifp NO ARE YOU A USDA PROGRAM PARTICIPANT? ❑YES4—NO 7a. DESCRIBE THE PROPOSED WORK:COMPLETE PLANS AND SPECIFICATIONS SHOULD BE PROVIDED FOR ALL WORK WATERWARD OF THE ORDINARY HIGH WATER MARK OR if fx'R-A LX/)�T�c� [1�� 768 SO 7b,DESCRIBE THE PURPOSE OF THE PROPOSED WORK. 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 /IlU i"lk-73 Tu a4ivn QuAur,1' o2 A4u&Z G/GC PREPARATION OF DRAWINGS: SEE APPENDIX A-SAMPLE DRAWINGS AND CHECKLIST FOR COMPLETING THE DRAWINGS. ONE SET OF ORIGINAL OR GOOD QUALITY REPRODUCIBLE DRAWINGS e1USrBEATTACHED. 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 84/2 X 11 INCH SHEETS. LARGER DRAWINGS MAYBE REQUIRED BY OTHER AGENCIES 8.WILL THE PROJECT BE CONSTRUCTED IN STAGES? ❑YES 50 PROPOSED STARTING DATE: A134P ESTIMATED DURATION OF ACTIVITY: Na P 9._CCHECCK IF ANY STRUCTURES WILL BE PLACED. IG WATERWARD OF THE ORDINARY HIGH WATER MARK OR LINE 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 �ju ❑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 cf -1 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,&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) ❑YES6'NO Application Page 2 of 4 IF YES,IMPACTED AREA IS ACRES 13.WILL EXCAVATION OR DREDGING BE REQUIRED IN WATER OR WETLANDS? ❑YEO IF YES: 7'„1 A.VOLUME:_(CUBIC YARDS)/AREA_(ACRES) B.COMPOSITION OF MATERIAL TO BE REMOVED. C.DISPOSAL SITE FOR EXCAVATED MATERIAL: D.METHOD OF DREDGING: 14.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 p.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? SEPA LEAD AGENCY SEPA DECISION. SEPA DECISION DATE: 15. HAS ANY AGENCY DENIED APPR VAL FOR THE ACTIVITY DESCRIBED HEREIN OR FOR ANY ACTIVITY DIRECTLY RELATED TO THE ACTIVITY DESCRIBED HEREIN?El YES A NO IF YES,EXPLAIN: SECTION B -Use for Shoreline and Corps of Engineers permits only: 16. TOTAL COST OF PROJECT. THIS MEANS THE FAIR MARKET VALUE OF THE PROJECT,INCLUDING MATERIALS,LABOR,MACHINE RENTALS,ETC 17, LOCAL GOVERNMENT WITH JURISDICTION: 18. 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 Application Page 3 of 4 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 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 WORK I AGREE TO START WORK ONLY AFTER ALL NECESSARY PERMITS HAVE BEEN RECEIVED. SIGNATURE APPLJAOR(UTHORiZEDAGEf4T D 7E I HEREBY DESIGN 1 TO ACT AS A NT IN MA RELA TO THIS APPLICATION FOR PERMrr(S). I UNDERSTAND THAT IF A FEDERAL PERMIT IS ISSUED,I MUST SIGN THE PERMIT. a S/ vv SIGNATURE OF APPLICANT 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. LLJ 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$10,000 or imprisoned not more than 5 years or both. .:. ._.._... ..i iC6MPL.E..T.....E. DBY LOCAL OFFICIAL i s:;>::........ . - t A Not ureoftt►laexlsii gsh relii3e {t.....b$ty t�€t5hcue(ine such as Tnarrnt, strew, lake lagoon, marsh, tog, s,tiamp, flood pJat�;#lcoti�Itay; ielte;fpeu€beech;such as aocretron, erosion, high tank, low bank, or dike. rtiatorial such as sand, gavel, rnud,otay,rocJ4 rl�rap;a stertt'artd'tyie cithulkheading'if any:) S. tp the evert that any nr......o btttirtings'or structures will exceed a kt ht of thirty fnro t"eet above the average grade leVeE, rids attstt e pproxtiTlate{ocatl�s# of and number of residentiai`tinitsr ezlsttrng end pf�tenttal,tEiat will have i�r, c bstructk Vtew C.. if the applies.. involves a conditional its0 or v 3iance, set fYittFi'fIn full that portion of the master program which prvvl(ti?N that the propa&ed rasa may be a conditional Use, or, In the case of variance, from which the Variance is being sought: L.4c #0n at proposed evelvpme ❑ Fldfxlvvayi # 1t►4 ye t�lcadpia T ❑ '%*-Vow FkKx:Pl zin Cl (�4ide Surety Alen L1'at i�txcr+C cirxrg lE;e i FEMA FIRM Gomrrrurt*y P rief Numfx:r 71W txa'w 100-yys'ut Ftot)d(r(ain ele vw el ri cx rhsPth nurrA"*+t ttua rinvctloPmnrd aitn is i The*#ovmst possib4^x building eltwati rrn t 1r et, [Huilding and Construction Documentation: Caitcatirur§vagtr�ed t£catianRacaaed' _ S veyu�Archiigct`in <na�t. u F1cNid-f'rc�t,itrn�_ f'rm-tacstxstru:fir�rx Fist-Cottafructicul Ftevated Housvf g Pre Cnryatrucia m ._.0 _ pact C mstnrcri ....... ......... ....... ....... ArttNBt of 1f,W6te :;;:;;:;;:<;;:;::....:: x::2:.::,:....:•.•.:. »:,::;:::;iC°:;::; :.:<'::S......':::::;;:.: .:::::::::::::::::: .; NOTES These Agencies are Equal Opporturllly and AMrTnative Action employers. For special accommodation needs,please contact the apprWriato agency from Appendix B. Application Page 4 of 4 �YA7"my .,� name o F. waker-60�� • � c��at� Prod - . •- � �4rrtNdu-d i . � I c7i • I -of Y Y W Ltd oF�dk�t ��ire' Nc►`cxd Oar k(i n c �ar�� a-" ' I Dl�c�a. Ocx Rocf d Prnvidcll L`otla•i pcad, c �Ot�taZx 1`ronWdcr wd Fax (.77�L.ocdw dor"f t1f7lNY oc�DAL To T-oc or Nd,-d B a n k l i n e. Oa a Crl�ft�dm�ProtcdfocL (K w .Ors r`F� G�055 5�`GTK�N . comas of App[.FCIInw 13Y US is arc ouur a TKe NrORUATM aEQcn o PROJECT /lDDRCSS: DATE pE p{"CtmottSAETIIILs k 'ECiFfCAT{OttS MPRaPR1JlTE fOR PROPOSED PROJECT. tHE�T � AQ � t \ 1 �,• '0 � 11Q �•� � o' 10 og A r ° ` 15ArrPt.� sn-& ' . � t SP�� 1. f�1� �•'R.iL,�, F'AVR1tVr PR Wo2A�� - KY CavurY� WA O i' Y 3 39. Far/ST/,✓& JzXzt Oe� ay eG G49A(7& V-sLb Vl R1oPaf� �o� a Kc. Z )o2 — PlU► �CQ/� � ,� yo � 330 � 38' . zo iU�D�oy'Y L/nl�