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HomeMy WebLinkAboutJARPA-Remodel Dock - SHX Application - 2/28/1998 +GE C SE NI» `✓ t wt i�� _ �y2 :;T�''T�t'"te kL"'Y �T � z• �1. 6£�.�a.�?�'b ! �Y�3 +� 6sT"k {�fi T JARPA FORM ""� .T.,� (for use In Washington State) o a �1 bM 1 PLEASE TYPE OR PRINT IN BLUE OR BLACK INK Based on the preceding checidist,I am sending copies of this application to the following: (check all that apply) ❑ Local Government for shoreline: ❑Substantial Development ❑Conditional Use ❑Variance ❑Exemption;or,if applicable ❑ Roodplain 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 Bridge Permit SECTION A -Use for all pernilts covered by this application. Be sure to also complete Section C(Signature Block)for all permit applications. 1.APPLICANT MAILING ADDRESS / NO (Yql ` WORK PHONE H H FAX 1 l 33a3 - � � �-�s�f If an agent is a ing for the applicant during the permit process,complete#2. 2 AUTHORIZED AGENT MAILING ADDRESS WORK PHONE HOME PHONE FAX• 3.RELATIONSHIP OF APPLICANT TO PROPERTY OWNER ❑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 C DE,WHERE PROPOSED ACTIVITY EXISTS OR WILL OCCUR) G � !� WATERBODY TRIBUTARY OF 114 SECTION TOWNSHIP RANGE GOVERNMENT LOT SHORELINE DESIGNATION ZONING DESIGNATION TAX PARCEL NO.: 17 DNR STREAM TYPE,IF KNOWN Appl�cation Pape 1 of 4 6. 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. IS THE PROPERTY AGRICULTURAL LAND?❑YES[3 NO ARE YOU A USDA PROGRAM PARTICIPANT? ❑YES D NO 7a. DESCRIBE THE PROPOSED WORK COMPLETE PLANS AND SPECIFICATIONS SHOULD BE PROVIDED FOR ALL WORK WATERWARD OF THE ORDINARY HIGH WATER MARK OR 7b.DESCRIBE THE PURPOSE OF THE PROPOSED WORK. ?7 ot- 7c. DESCRIBE THE POTENTIAL IMPACTS TO CHARACTERISTIC USES OF THE WATER BODY. THESE USES MAY WLUDE 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 PREPARATION OF DRAWINGS: SEE APPENDIX A-SAMPLE DRAWINGS AND CHECKLIST 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 DRAW i NG S. THE CORPS OF ENGINEERS AND COAST GUARD REQUIRE DRAWINGS ON 8-1,12 X 11 INCH SHEETS. LARGER DRAWINGS MAY BE REQUIRED BY OTHER AGENCIES 8,WILL THE PROJECT BE CONSTRUCTED IN STAGES? Q YES ❑NO PROPOSED STARTING DATE: Appj�&t#on Page 2 of 4 F9. ESTATED DURATION OF ACTTY:ESTIMATED IF ANY STRUCTURES WILL BE PLACED: Q WATERWARD OF THE ORDINARY HIGH WATER MARK OR LINE FOR FRESH ORADAL,WATERS.AND/OR Q WATERWARD OF THE MEAN HIGH WATER LINE IN TIDAL WATERS 10.WILL FILL MATERIAL(HOCK FILL.BULKHEAD.PILINGS OR OTHER MATERLAL)BE PLACED:' 1;�O? q THE ORDINARY HIGH WATER MARK OR LINE FOR FRESH WATERS? IF YES.VOLUME(CUBIC Y Q WATERWARD OF . Q WATERWARD OF THE MEAN HIGHER HIGH WATER FOR TIDAL WATERS? IF YES VOLUME(CUBIC YARDS) /AREA (AC�RES) 11.WILL w.TERIAL BE PLACED IN WETLANDS? Q YES I NO IF YES: A.IMPACTED AREA IN ACRES: S.HAS A DELINEATION BEEN COMPLETED? IF YES,PLEASE SUBMIT WITH APPLICATION. ❑YES UNO C.HAS A WETND REPORT BEEN PREPARED? IF YES.PLEASE SUBMIT WITH APPLICATION. Q YES ©'Nb LA D.TYPE AND CO pOSRION OF FILL MATERIAL(EG..SAND,ETC.): E.MATERIAL SOURCE: F.UST ALL SOUL SERIES(TYPE OF SOIL)LOCATED AT THE PROJECT SITE&INDICATE IF THEY ARE ON THE COUNTrS UST OF HYDRIC SOILS. SOILS INFORMATION CAN BE OBTAINED FROM THE NATURAL.RESOURCES CONSERVATION SERVICE ONRCS$ t2.WILL PROPOSED ACTIVITY CAUSE FLOODING OR DRMNING OF WETLANDS? Q YES 'NO J IF YES,IMPACTED AREA IS_ACRES I&WALL EXCAVATION OR DREDGING BE REOU111ED IN WATER OR WETLANDS? ❑YES Ell NO WETLANDS? IF YES: A.VOLUME:_(CUBIC YARDS)lAREA_(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 ON DR,SEPA REVIEW.FERC LICENSE, FOREST PRACTICES APPLICATION,ETC.)ALSO INDICATE WHETHER WORK HAS BEEN COMPLETED AND INDICATE ALL STING WORK ON DRAWINGS TYPE OF AL ISSUING AGENCY IDENTIFICATION NO. DATE OF APPLICATION DATE APPROVED COMPLETED? SEPA LEAD AGENCY SEPA DECISION: 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 pi NO IF YES,EXPLAIN: Applcst.on Page 3 o1 4 SEC770N B-Use for Shoreline and Corps of Epgineens permits on/v: lA. TOTAL COST OF PROJECT. MEANS THE FAIR MARKET VALUE OF THE PROJECT.W40LMNG MATERIALS,VISOR.MACHINE RENTALS.ETC. 17. LOCAL GOVERNMENT I& FOR CORPS.COAST GUARD.AND ONR Pmmrrs.Amm NAMES,ADDRESSES,AND TELEPHONE NUMBERS OF ADJOINING PROPERTY OWNERS.LESSEES,ETC.PLEASE NOTE SHORELINE MANAGEMENT OOLOUANCE MAY REQUIRE ADDIT}ONAL NOTICE—CONSULT YOUR LOCAL GOVERNMENT. NAME ADDRESS PHONE NUMBER SECTION C-This section MUST be completed for any permit covered by this application. III. 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 W KNOWLEDGE AND BELIEF.SUCH INFORMATION IS TRUE,COMPLETE,AND ACCURATE. I FURTHER CERTIFY THAT 1 POSSESS THE AUTHORITY TO UNDERTAKE THE PROPOSED ACTIVITIES. I HEREBY GRANT TO THE AGENCIES TO WHICH THIS APPLCATION IS MADE,THE RIGHT TO ENTER THE ABOVE-DESCRIBED LOCATION TO INSPECT THE PROPOSED.WROGRESS OR COMPLETED WORK I AGREE TO START WORK Q=AFTER ALL NECESSARY PERMITS HAVE BEEN RECEIVED. SIMUM0fAPKMMJ.9RA4tTti10fiIZ®AQFLR9QA7E FAY DESIGNATE TO ACT AS MY AGENT IN MATTERS RELATED TO THIS APPU(.ATION FOR PERMIT(S). I UNDERSTAND THAT IF A FEDERAL PERMIT IS wuEO.I MUST SIGN THE PERMIT. SIGNATURE OF APPLICANT DATE SIGNATURE OF ER(IXC BUC ERS G ONR) DATE Tw APPLICATION MUST BE SIGNED BY THE APPLICANT AND Tfd AGENT,IF AN AUTHOfi=AGENT IS DESIGNATED. IS US.0§1001 provides that Whoever,in any mamer within the kxisdiction of arty department or agency of the United States knowingly Wstfes,conceals,or covers up by any trick scheme,or device a material fad or makes any false,fictitious,or(rauGdent statements or representations or makes or uses any false writing or document knowing same to contain any false.fictitious,of kaudlda t stalemeru or an!ry,shad be feed not more than$10,000 or Imprisoned not more than S years or both. P D to Y t � t ni ea M k � In v ? k t t,x �� eMl.rl_ Fp Q'S J9• r �I�{r� L }f� }d, V j R+£'. l' elhe a te�Oca nc� b+� �?es Est cte�f z ,M,,� Cp, .}, ,s' Y, f ,•i. .Eris v$Sr These Agencies are Equal Opportunity and Affirmative Action employers. For special accommodation needs,please contact the appropnate agency from Appendix B. App41catan Page 4 of 4