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Home My WebLink AboutJARPA Attachment A and B - SHX Application - 1/12/2012 ��STAlp 1---------------------------------------i L•r K i M i AGENCY USE ONLY us 1 WAS H I NGTON STATE Date received: Joint Aquatic Resources Permit 1 Application (JARPA) [hey Agency reference#: Tax Parcel#(s): ' 1 1 1 ' 1 1 1 1 Attachment A: For additional property owner(s) [heid TO BE COMPLETED BY APPL.ICANT[helpi - -i Project Name: Hood Canal Steelhead Project:Juvenile Monitoring ; Use this attachment only if you have more than one property owner. Location Name(if applicable):Tahuya access to trap site Complete one attachment for each additional property owner 1_----------------------------------------- impacted by the project. Signatures of property owners are not needed for repair or maintenance activities on existing rights-of-way or easements. Use black or blue ink to enter answers in whites aces below. 1. Name(Last, First, Middle)and Organization (if applicable) Brewer, Richard and Susan 2. Mailing Address(Street or PO Box) 1520 S 2nd St 3. City, State, Zip Shelton, WA 98584 4. Phone(1) 5. Phone(2) 6. Fax 7. E-mail Address or tax parcel number of property you own: 322144390050 Signature of Property Owner 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. C�,.rk V, ,,, Printed Name Signature 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-16-012 rev. 10/2016 JARPA Attachment A Rev.10/2016 Page 1 of 1 r --------------j------------ a 200 Q i AGENCY USE ONLY JJ �� US Army Corps .a eav,i tt i Date received: WASHINGTON STATE s Joint Aquatic Resources Permit Application (JARPA) Form heI Agency reference#: Tax Parcel#(s): JARPA Attachment A. For additional property owner(s) [help] ; TO BE COMPLETED BYAPPLICAN-r hel ; UPI#: Use this attachment only if you have more than one property owner. ; Project Name: Hood Canal Steelhead Project:Juvenile Monitoring Use black or blue ink to enter answers in whites aces below. =--------------------------------------- 4a. Name (Last, First, Middle)and Organization (if applicable) Brewer, Richard and Susan 4b. Mailing Address (Street or PO Box) 1520 S 2nd Street 4c. City, State, Zip Shelton, WA 98584 4d. Phone(1) 4e. Phone(2) 4f. Fax 4g. E-mail Address or tax parcel number of property you own: 322144390050 4a. Name (Last, First, Middle)and Organization (if applicable) 4b. Mailing Address(Street or PO Box) 4c. City, State, Zip 4d. Phone(1) 4e. Phone(2) 4f. Fax 4g. E-mail ( ) ( ) ( ) Address or tax parcel number of property you own: If you require this document in another format,contact The Governor's Office of Regulatory Assistance(ORA). People with hearing loss can call 711 for Washington Relay Service. People with a speech disability can call (877)833-6341. ORA publication number: ENV-020-09 JARPA 2009 Attachment A:Additional property owners(see JARPA Part 4) Page 1 of 1 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) Applicant Printed Name Applicant Signature Date 11 b. Authorized Agent Signature ,el 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. Authorized Agent Printed Name Authorized Agent Signature Date 11c. Property Owner Signature (if not applicant). bei Not required if project is on existing rights-of-way or easements. 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. Richard & Susan Brewer Jan 12, 2012 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 of Regulatory Assistance(ORA). People with hearing loss can call 711 for Washington Relay Service. People with a speech disability can call(877)833-6341. ORA publication number: ENV-019-09 JARPA 2010 v1 3/30/2010 Page 14 of 14 2010 --------------------------------------- Z O A I AGENCY USE ONLY i �' US Army Corps i ; WASHINGTON STATE Se me9ose 5° ; Date received: Joint Aquatic Resources Permit Application (DARPA) Form Agency reference#: Tax Parcel#(s): ; JARPA Attachment B: TO BE COMPLETED BY APPLICANT hel ; For additional project locations) [hel , Project Name: Hood Canal Steelhead Use this attachment only if you have more than one project location. Project: Juvenile Monitoring Use a separate form for each additional location. Location Name(if applicable):_Tahuya River --------------------------------------' Use black or blue ink to enter answers in whites aces below. 5a. Indicate the type of ownership of the property. (Check all that apply.) [hel ❑ State Owned Aquatic Land (If yes or maybe,contact the Department of Natural Resources(DNR)at(360)902-1100) ❑ Federal ❑ Other publicly owned (state,county,city,special districts like schools,ports,etc.) ❑ Tribal X Private 5b. Street Address (Cannot be a PO Box. If there is no address,provide other location information in 5n.) Le � 5c. City, State, Zip(If the project is not in a city or town, provide the name of the nearest city or town.) hel� Tahuya, Washington 98588 (Tahuya River trap site) 5d. County i,eld Mason 5e. Provide the section, township, and range for the project location. h[ eM '/4 Section Section Township Range SE 1/4 14 22 N 03 W 5f. Provide the latitude and longitude of the project location. LheM • Example:47.03922 N lat./-122.89142 W long(NAD 83) 47.38895 N lat. / 123.02063 W long. (NAD 83) 5g. List the tax parcel number(s) for the project location. [helo • The local county assessor's office can provide this information. 322144390050 JARPA 2009 Attachment B:Additional project locations(see JARPA Part 5) v1 04/07/2010 Page 1 of 3 5h. Contact Information for all adjoining property owners. (if you need more space, use JARPA Attachment C.) [Lejpj Name Mailing Address Tax Parcel # (if known) Kirsten Rohde 414 Lakeside Ave S #3 322144300040 ------- ------ - Seattle, WA 98144 Lonnie Evans 7426 NE 155th St. 322144400000 Kenmore, WA 98028 5i. List all wetlands on or adjacent to the project location. I,. lOj 5j. List all waterbodies (other than wetlands) on or adjacent to the project location. h 101 Tahuya River 5k. Is any part of the project area within a 100-year flood plain? X Yes ❑ No ❑ Don't know 51. Briefly describe the vegetation and habitat conditions on the property. [hem The property consists of undeveloped land with stream and riparian habitats containing conifer and deciduous trees. An open field is adjacent to the riparian zone. 5m. Describe how the property is currently used. je Undeveloped land 5n. Describe how the adjacent properties are currently used. hei.r)j Residential and forest land l JARPA 2009 Attachment B:Additional project locations(see JARPA Part 5) vi 04/07/2010 Page 2 of 3 5o. Describe the structures (above and below ground) on the property, including their purpose(s). [nic,,r None 5p. Provide driving directions from the closest highway to the project location, and attach a map. Empl From Belfair, take NE WA-300/N Shore Rd. Turn R onto NE Belfair Tahuya Rd. Turn L onto Tahuya River Road. Turn L and park on WDFW property. Walk downstream along river to trap site. If you require this document in another format,contact The Governor's Office of Regulatory Assistance(ORA). People with hearing loss can call 711 for Washington Relay Service. People with a speech disability can call(877)833-6341. ORA publication number: ENV-021-09 JARPA 2009 Attachment B:Additional project locations(see JARPA Part 5)_v1 04/07/2010 Page 3 of 3