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HomeMy WebLinkAboutSHX2006-00046 JARPA Dock - SHX Permit / Conditions - 6/12/2006 014.STATE MASON COUNTY BPS C °4a DEPARTMENT OF COMMUNITY DEVELOPMENT o n O N Planning Division r o N z P O Box 279, Shelton,WA 98584 7 N Y ti (360)427-9670 OJ �O 1864 Exemption from Shoreline Management Act Case No.: SHX2006-00046 Substantial Development Permit Requirement The Proposal By: STANLEY JACOBS 501 N MT.VIEW DR TAH UYA,WA 98588 To undertake the following development: Dock Within Wooten Lake and/or its associated wetlands is exempt from the requirement of substantial development because the development is categorized under WAC 173-27-040(2) as being category A-does not exceed $245 �� n Please contact Chuck McCoy at ext 294 if you have any questions. Issued: 6/12/06 dE�� /)` 27r�-4 Expires: 6/12/08 Authorized Local Government Official cc: APPLICANT WDFW USACOE WDOE TRIBAL COUNCIL i ANY WIN 4my Agentfy Fitllrilityfllli *: ©Q(p— 000`-f(, Date Received:_ C lrcttFtl W VM • agency) Q rl Cp Yt. (�MMii• or JOINT AQUATIC RESOURCES PERMIT APPLICATION FORM (JARPA) (for use in Washington State) ;•s•; PLEASE TYPE OR PRINT IN BLACK IN ❑ tam applying for a Fish Habitat Enhancement Project per requirements of RCW 75.20.350. You must submit a ropy 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 days as the instructions provided, I am sending copies of this application to the following: (check al;th ppty) L I Government for shoreline:❑Substantial Development ❑ Conditional Use ❑Variance Exem ti A El Revision ❑Floodplain Management ❑ Critical Areas Ordinance Washington Department of Fish and Wildlife for HPA(Submit 3 Copies tc 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 SECTION A-Use For all permits covered by this oppliesuon. Be sure to ALSO complete Section C(Signature Block)for all permit applications. [1, PPLICANT AILING ADDRESS ;# : ORK PHONE E-MAIL ADDRESS HOME PHONE FA �1 If an agent is acting for tlta appNcant during the permit process, complete 02. --� 2.AUTHORIZED AGENT MA I )DRESS � Q WOR PHO0 O s 7 ZE A.- o' S' HOME PHONE IA n Iasi L.QO 3.RELATIONAX SHIP OF APPLICANT TO PROPERTY:#OWNER 0 PURCHASER 0 LESSEE ❑OTHER: .NAME,ADDRESS,AND PHONE NUMBER OF PROPERTY OWNER(S),IF OTHER THAN APPLICANT: Dr S.LOCATION(STREET ADDRESS,INCLUDING CITY,COUNTY AND ZIP CODE, HE WHERE PROPOSED ACTS IVITY EXISTS OR WILL OCCUR) Sot n S- fY1W&A-kLr\\J1�ew 0 ( 1` KL q`t tF.�J'Q q LOCAL GOVERNMENT WITH JURISDICTION cr Y OR COUi tr-.D ATERBOpYlV] � OF 1h'RIA 1!OSECTION SECTION TDW"HIP RANGE GOVERNMENT LOTESIONATION TITUDE a LONGITUDE IF KNOWN: F I. SIGNATION TAX PARCEL NO: ZU Z^ --31 �C) �ocx)3 STREAM TYPE.IF KNOWN 1 :�: JARPA,Revised 12/98,contact Ecology's Permit Assistance Center for latest version,360/407-7037 Page 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. �-Q 0-f'o-C4 L bv\.- IS THE PROPERTY AGRICULTURAL LAND? ❑YES NO ARE YOU A USDA PROGRAM PARTICIPANT? ❑YES NO 'a. UFSCRIBE THE PROPOSED CONSTRUCTION ANOiOR 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 SWARATE SHEET IF ADDITIONAL SPACE IS NEEDED. Drw-�- Q uV\) rr QA,4-e d Pi (�C d 340 loc �4' D 0 C r- 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 INFLUENCED THE[DESIGN. T, c -- o docL Sup v�l G M- Dock 7c. DESCRIBE THE POTFNTJL 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 MNPACTS,AND PROVIDE PROPER PROTECTION OF FISH AND AQUATIC LIFE ATTACH A SEPARATE:,MEET IF ADDITIONAL SPACE IS NEEDED. PREPARATION OF DRAWINGS: SEE SAMPLE DRAWINGS AND GUIDANCE FOR COMPLETING THE DRAWINGS. ONE SET OF ORIGINAL OR GOOD QUAVry 'I REATTACHED. NOTE APPLICANTS ARE ENCOURAGED TO SUBMIT PHOTOGRAPHS OF THE PROJECT SITE,BUT THESE DO NOT LEDRAYgNOS�j(¢j ENGINEERS AND COAST GUARD REQUIRE[DRAWINGS ON A-1Pl X 11 INCH SHEM' URGER DRAWINGS MAYBE REQUOtED BYO FOR OitAWING9. 1tAE CORPB OF � 8.WILL THE PROJECT BE CONSTRUCTED IN STAGES? ^ PROPOSED STARTING DATE J U h..Q �, S — �U l� 1� - �UC�� BYES t7 NO ESTIMATED DURATION OF ACTIVITY. 9.CjHECK IF ANY STRUCTURES WILL BE PLACED: a WATERWARD OF THE ORDINARY HIGH WATER MARK OR LINE FOR FRESH OR TIDAL WATERS:ANDIOR 3WATERWARD OF MEAN HIGH WATER LINE IN TIDAL WATERS 10.WILL FILL MATERIAL(ROCK,FILL.BULKHEAD,OR OTHER MATERIAL)BE PLACED' /YP ❑YATERWARD OF THE ORDINARY HIGH WATER MARK OR LINE FOR FRESH WATERS? IF YES,VOLUME(CUBIC YARDS) !AREA (ACiRES) ❑WATERWARD OF THE MEAN HIGHER HIGH WATER FOR TIDAL WATERS? IF YES,VOLUME(CUBIC YARDS) AREA (ACRES) 1ARPA, Revised t 2/98,contact Ecology's Permit Assistance Center for latest rersien,360/407-7037 Page 2 of 4 11.WILL MATERIAL BE PLACED IN WETLANDS? ❑YES C AJO IF YES: A. IMPACTED AREA IN ACRES: B. HAS A DELINEATION BEEN COMPLETED? IF YES,PLEASE SUBMIT WITH APPLICATION. ❑YES [3A0 C. HAS A WETLAND REPORT BEEN PREPARED? IF YES,PLEASE SUBMIT WITH APPLICATION. ❑YES ❑40 0. TYPE AND COMPOSITION OF FILL MATERIAL(E.G.,SAND,ETC.): E. MATERIAL SOURCE: F. LIST ALL SOIL SSMS(TYPE OF SOIL)LOCATED AT THE PROJECT SITE.6 INDICATE IF THEY ARE ON THE COUNTY'S LIST OF HYDRiC SCILS SOILS INFORMATION CAN BE OBTAINED FROM THE NATURAL RESOURCES CONSERVATION SERVICE(NRCS): 12.WILL PROPOSED ACTFVRY CAUSE FLOODING OR DRAINING OF WETLANDS? ❑YES rNO IF YES,IMPACTED AREA 0 ACRES. 13.WILL EXCAVATION OR DREDGING BE REQUIRED IN WATER OR WETLANDS? p YES ENO IF YES: A. VOLUME: (CUBIC YARDS)/AREA (ACRES) B. COMPOSITION OF MATERIAL TO BE REMOVED: C. DISPOSAL SITE FOR EXCAVATED MATERIAL: D. MEMO OF ORM OR - 14.HAS THE STATE EMONIIIIIIIIENTAL POLICY ACT(UPIA)WEN COMPLETED? EYES ❑NO SEPA LEAD AGENCM: �K DEONNOW ID 4 M - I D&ADOPTION EXEMPTION DECISION DATE(END OF PERIOD). SUBMIT A COPY OF YOM SWA DOOMS N LETTER TO WDFW AS REQUIRED FOR A COMPLETE APPLICATION 15.LIST OTHER APPLICATIONS,APPROVALS,OR CERTWICATKM FROM OTHER FEDERAL STATE OR LOCAL AGENCIES FOR ANY STRUCTURES,CONSTRUCTION.DISCHARGES,OR OTHER ACTIVITIES DESCROBD IN THE APPLICATION(I.E.,PRELIMINARY PLAT APPROVAL,HEALTH DISTRICT APPROVAL,BUILDING PERMIT,SEPA REVIEW,FEDERAL ENERGY REGULATORY COMMISSION LICENSE(FEW),FOREST PRACTICES APPLICATION,ETC.) ALSO INDICATE WHETHER WORK HAS BEEN COMPLETED AND INDICATE ALL EXISTING WORK ON DRAWINGS. TWE OF WArUING A Y IDENTIFICATION DATE OF APPLICATION DATE APPROVED COMPLETED? NO, 16.HAS ANY AGENCY DPW APPROVAL FOR THE ACTIVITY DESCRIBED'HEREIN OR FOR ANY ACTIVITY DIRECTLY RELATED TO THE ACTIVITY DESCRIBED HEREIN? p YES IF YES,EXPLAIN: SECTION B-Use Ibr morleNne and oI Enpineers permlis tT.TOTAL COST PROJECT. THIS MEANS TILE FAIR MARKET VALUE OF THE PROJECT.INCLUDING MATERIALS,LABOR,MACHINE RENTALS.ETC 3q LH, co 9.LOCAL GOVERNMENT WITH JURISDICTION: IR- OK 9.FOR CORPS,COAST GUARD,AND DNR PERMITS,PROVIDE NAMES,ADDRESSES,AND TELE ONE NUMBERS OF ADJOINING PROPERTY OWNERS.LESSEES.ETC. PLEASE NOTE: SHOAELWE MANAGEMENT COM* AVCE MMY REOU/RE ADD1TlONAL NOTIC -CONSULT YOUR LOCAL GOVERNMENT. NAME ADDRESS PHONE NUMBER JARPA,Revised 12M,contact Ecology's Permit Assistance Center for latest—ion,360/407-7037 Page 3 of 4 I 1 SECTION C- This section MUST be com feted for&ny permit covered by this opplicatfon o APPLICATION IS HEREBY MADE FOR A PERMIT OR PERMITS TO AUT"ORtZE THE ACTIVITIES DESCRIBED HEREIN. I CERTIFY THAT 1 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 CCURATE. I FURTHER CERTIFY THAT I POSSESS THE AUTHORITY TO UNDERTAKE THE PROPOSED ACTIVITIES. I HEREBY GRANT TO THE AGENCIES TO WHICH HIS 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 OF APPLICANT O THORIZ GENT r A �^ Qom. I HEREBY SIGN, �',l �L� TO ACT S MY AGENT MATTERS RELATED TO THIS APPLICATION FOR PERMIT($), I UNDERSTAND THAT IF A FEDERAL PERMIT IS ISSUED, I MUST SIGN THE PERMIT. SIGNATURE OF APPLICANT DATE SIGNATURE OF LANDOWNER(EXCEPT PUBLIC ENTITY LANDOWNERS,E.G.DNR) THIS APPLICATION MUST BE SIGNED BY THE APPLICANT AND THE AGENT,IF AN AUTHORIZED AGENT IS DESIGNATED. IOU S C 61001 provides that: Whoever,in any manner within the jurisdiction of any department or agency of the United States kn material fad or nukes ary false.fictitious,or fraudulent staternents or represerilations or makes or uses any false writing or docur a+nnt����cCnneb,n any carver �'� 'st device a er,Iry,shall be fined not more than S 10,000 or imprisoned not more than 5 years or both. n9 to eon4in any false,fleNtloua,Ix fraudulent statement or A. Nature of the existing shoreline. (Describe NMMWWWPb•.ga plain,floodway, delta;type of beach,sugh as a T.bank, mud, clay, rock, riprap; and extent and pipe of a B. In the event that any of the proposed bUfllidill—:�t v*exceed a he** ; "cd level, indicate the approximate location 4f till ll - existfft ; view: F C. If the application involves a conditional aaa•of:v ,siii►.fof4h in full that the proposed use may be a conditional w$,.p{C;. •'ABM ,f0cmwr These Agencies are Equal Opportunity and Affirrnahis Action errlployers. For special accommodation needs,Please contect the apprvpdate agency in(t Inshuceorls 1ARPA, Revised 12/98,contact Ecology's Permit Assistance Center for latest version,360/407-7037 Page 4 of 4 I