HomeMy WebLinkAboutJARPA - SHX Application - 10/1/2008 AGENCY USE ONLY
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JOINT AQUATIC RESOURCES PERMIT APPLICATION FORM (JARPA)
(for use in Washington State)
PLEASE TYPE OR PRINT IN BLACK INK.
TO FILL IN ELECTRONICALLY,USE F11 TO MOVE THROUGH THE FORM
❑ Application for a Fish Habitat Enhancement Project per requirements of RCW 77.55.290. You must submit a copy 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.
Based on the instructions provided, I am sending copies of this application to the following: (check all that apply)
Local Government for shoreline: ❑Substantial Development ❑Conditional Use []Variance ❑Exemption []Revision
❑Floodplain Management MCritical Areas Ordinance
❑ Washington Department of Fish and Wildlife for HPA(Submit 3 copies to WDFW Region)
❑ Washington Department of Ecology for 401 Water Quality Certification(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: ❑ General Bridge Act Permit ❑ Private Aids to Navigation (for non-bridge projects)
❑ For Department of Transportation projects only: This project will be designed to meet conditions of the most current
Ecology/Department of Transportation Water Quality Implementing Agreement
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
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MAILING ADDRESS
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WORK PHONE E- AIL ADDRESS HOME PHONE FAX#
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If an agent is acting for the applicant during the permit process,complete#2. Be sure agent signs Section C(Signature Block)
for all permit applications
2.AUTHORIZED AGENT
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MAILING PQDRESS
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WORK PHONE E-MAIL ADDRESS HOME PHONE FAX#
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3. Relationship of applicant to property: ❑ OWNER ❑ PURCHASER ❑ LESSEE 0).inE_
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)
Local government with jurisdiction(city or county)
Waterbody you are working in TW(Y) M6 Tributary of WRIA#
Is this waterbody on the 303(d)List" YES NO
If YES,what parameter(s)?
`*For 303d List, Shoreline designation
htti)://www.ecy.wa.gov/pro-grams/wQ/303d/index.html
Zoning designation CJr'flt i? M0fJ-CArrw7- ieN6C FO
'/,Section Section Township Range Government Lot
DNR stream type if known Lkr tf �O X)
Latitude and Longitude: Tax Parcel Number 22 31 r7J y(P Do00
ECY 070-15(Rev. 11/04) JARPA Contact the State of Washington Office of Regulatory Assistance for latest version or call 360/407-7037 or 800/917-0043
1
6. Describe the current use of the property,and structures existing on the property. Have you completed any portion of the proposed
activity on this property? N YES ❑ NO
For any portion of the proposed activity already completed on this property,indicate month and year of completion.
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Is the property agricultural land? ❑ YES NO Are you a USDA program participant? ❑ YES NO
7a. Describe the proposed work that needs aquatic permits: Complete plans and specifications should be provided for all work waterward j
of the ordinary high water mark or line,including types of equipment to be used. If applying for a shoreline permit,describe all work
within and beyond 200 feet of the ordinary high water mark. If you have provided attached materials to describe your project,you still
must summarize the proposed work here. Attach a separate sheet if additional space is needed.
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PREPARATION OF DRAWINGS: See sample drawings and guidance 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 drawings. THE CORPS
OF ENGINEERS AND COAST GUARD REQUIRE DRA WINGS ON 8-112 X 11 INCH SHEETS. LARGER DRAWINGS MAYBE REQUIRED BY OTHER AGENCIES.
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.
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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 of fish and aquatic life. Identify which guidance documents you have used. Attach a separate sheet if additional
space is needed.
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7d.For in water construction work,will your project be in compliance with the State of Washington water quality standards for turbidity
WAC 173.201A-110? YES 0 NO (See USEFUL DEFINITIONS AND INSTRUCTIONS)
8. Will the project be constructed in stages? YES N NO ❑
Proposed starting date: Novel nbi r 0008
Estimated duration of activity:
9. Check if any temporary or permanent structures will be placed:
❑ Waterward of the ordinary high water mark or line for fresh or tidal waters AND/OR
❑ Waterward of the mean higher high water for tidal waters?
10.Will fill material(rock,fill, bulkhead,or other material)be placed: i\J 0
❑ 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)
ECY 070-15(Rev. 11/04) JARPA Contact the State of Washington Office of Regulatory Assistance for latest version or call 360/407-7037 or 800/917-0043
2
r �11. Will material be placed in wetlands? ❑ YES NO
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,and indicate if they are on the county's list of hydric soils. Soils informatiol
can be obtained from the natural Resources Conservation Service(NRCS).
G. WILL PROPOSED ACTIVITY CAUSE FLOODING OR DRAINING OF WETLANDS? ❑ YES ❑ NO
If YES, IMPACTED AREA IS ACRES OF DRAINED WETLANDS.
NOTE:If your project will impact greater than X of an acre of wetland,submit a mitigation plan to the Corps and Ecology for approval along with the JARPA form.
NOTE:A 401 water quality certification will be required from Ecology in addition to an approved mitigation plan if your project impacts wetlands that are: a)greater than Y.acre in size,
orb)tidal wetlands or wetlands adjacent to tidal water. Please submit the JARPA form and mitigation plan to Ecology for an individual 401 certification Ka)orb)applies.
12. Stormwater Compliance for Nationwide Permits Only: This project is(or will be)designed to meet 13cology's most current
stormwater manual,or an Ecology approved local stormwater manual. ❑ YES ❑ NO
If YES—Which manual will your project be designed to meet?
If NO—For clean water act Section 401 and 404 permits only—Please submit to Ecology for approval, along with this JARPA
application,documentation that demonstrates the stormwater runoff from your project or activity will comply with the water quality
standards,WAC 173.201(A)
13.Will excavation or dredging be required In water or wetlands? ❑ ,YES NO
If YES:
A. Volume: (cubic yards)/area (acre)
B. Composition of material to be removed:
C. Disposal site for excavated material:
D. Method of dredging:
14. Has the State Environmental Policy Act(SEPA)been completed 0 YES ❑ NO
SEPA Lead Agency:
SEPA Decision: DNS, MDNS, EIS,Adoption,Exemption Decision Date(end of comment period)
SUBMIT A COPY OF YOUR SEPA DECISION LETTER TO WDFW AS REQUIRED FOR A COMPLETE APPLICATION
15. 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(i.e.preliminary plat approval, health district approval,building permit,SEPA review,
federal energy regulatory commission license(FERC),Forest practices application,etc.). Also,indicate whether work has been
completed and indicate all existing work on drawings. NOTE:For use with Corps Nationwide Permits,identify whether your project ha:
or will need anNPDES permit for discharging Wastewater and/or stormwater.
TYPE OF APPROVAL ISSUING AGENCY IDENTIFICATION DATE OF APPLICATION DATE APPROVED COMPLETED
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16. Has any agency denied approval for the activity you're applying for or for any activity directly related to the activity described herein?
❑ YES N NO
If YES, explain:
ECY 070-15(Rev. 11/04) JARPA Contact the State of Washington Office of Regulatory Assistance for latest version or call 360/407-7037 or 800/917-0043
SECTION B - Use for Shoreline and Corps of Engineers permits only:
17a:Total cost of project. This means the fair market value of the project,including materials,labor,machine rentals,etc.
17b. If a project or any portion of a project receives funding from a federal agency,that agency is responsible for ESA consultation. Please
ndicate if you will receive federal funds and what federal agency is providing those funds. See instructions for information on ESA.'
FEDERAL FUNDING ❑ YES ❑ NO If YES, please list the federal agency.
18.Local government with jurisdiction:
19. 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
SECTION C- This section MUST be completed for any permit covered by this application
0. 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.
agree to start work ONLY after all necessary permits have been received.
DATE /
SIGNAT F I&LIQAT
DATE
SIGNATURE OF AUTHORIZED AGENT
I HEREBY DESIGNATE TO ACT AS MY AGENT IN MATTERS RELATED TO THIS APPLICATION FOR
PERMIT(S). 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.
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.
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F �n e'Clerit f}1it al�.y of theial £bpildlhgs or sfixIGtures Will i;xceed ta,het hl df:thtrty fve feet above die avian grade level;
ht®ic; a �xi'M6fe Io13tiiS f'd'ti t r tlCt`ti�bt t�f tes delitlai lthit :e is lit f Ceiltlal,ihat will havb�n d �ck�+ V,
If#h it�pj3ho ticn i6.lNbs a-apHp "b'611U8e:br variartoe, set fdrth m tJll that portion,'d the mastbr grar I+i j1)bh prowldes4thatithe
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These Agencies are Equal Opportunity and Affirmative Action employers.
For special accommodation needs,please contact the appropriate agency in the instructions
ECY 070-15(Rev. 11/04) JARPA Contact the State of Washington Office of Regulatory Assistance for latest version or call 360/407-7037 or 800/917-0043
4
Pa e 3 of 3
Show the following on the site plan
r
Lot Dimensions Flood Zones
Existing Structures Fences
Water Lines Driveways
Drainage Plans Shorelines
Septic System Topography Indicate Directional by(N,S,E,W,etc.)
Proposed Improvements Easements In relation to plot plan
Name if Flanking Street
APPLICANT TO DRAW SITE PLAN BELOW:
(Pei-
too (n
2-0 i
APPLICANT TO DRAW TOPOGRAPHY BELOW:
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(12/4/2008) Grace Miller - SEP2008-00154 4-H Dock Replace.-Cornments.cloc- Page -1
Skokomish Indian Tribe
Natural Resources Department (360) 877-5213
N. 541 Tribal Center Road Fax(360) 877-5148 Skokomish Nation,WA 98584
November 26,2008
Environmental Review Application No.: SEP2008-00154
Project Name:4-H Camp Dock Replacement
Description of Proposal: Replace existing 4-H camp dock by replacing pier and dock
with floating materials and removing existing platform docks
Location: 6430 NE Tahuya-Blacksmith Rd.Belfair,WA.
Proponent: Kitsap County 4-H
Dear Ms.Miller,
It has been determined that the above project will not have any negative
environmental impacts to the Skokomish Tribe or their resources. As such we agree with
your determination of nonsignificance. Thank you for including the Skokomish Tribe in
the planning process,if you have any questions about the comments provided herein
please contact Randy N.Lumper(Aquatic Resources Enhancement Biologist)at 1-360-
877-5213 ext#508 or email them to rlumper@skokomish.org.
Sincerely,
Joseph Pavel
Director
Skokomish Natural Resources Department
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DEC n 5 2000
F WASHINGTON (.4? r C:U. F�r, •E.itU CErT.
P � R T OF ECOLOGY
PO 7 • , Was ington 98504-7775 • (360) 407-6300
December 4,2008
Y
Ms. Grace Miller rc►�' Your address
Mason County is in the
Department of Community Development Kitssp
Planning Division watershed
PO Box 279
Shelton,WA 98584
Dear Ms.Miller:
Thank you for the opportunity to comment on the mitigated determination of nonsignificance for the
Kitsap County 4-H Dock Replacement project(SEP2008-00154)located at 6430 Northeast Tahuya-
OBlacksmith Road in Belfair as proposed by Kelly Fisk,WSU Extension-Kitsap County 4-H. The
Department of Ecology(Ecology)reviewed the environmental checklist and has the following
comment(s):
SOLID WASTE&FINANCIAL ASSISTANCE: Al Salvi(360)407-6287
We encourage the applicant to reuse or recycle all possible leftover construction materials and reduce
waste generated. Recycling construction debris is often less expensive than landfill disposal.
The applicant proposes to remove a structure(s)that may contain treated wood. Please refer to
Ecology's publication"Focus on Treated Wood Exclusion," available at:
hM://www.egy.wa.goy/pubs/0304038.pdf,for suggested best management practices and disposal
requirements for treated wood. For additional information or clarification,please contact Dee
Williams with Ecology's Hazardous Waste and Toxics Reduction program,at(360)407-6348.
Ecology's comments are based upon information provided by the lead agency. As such,they do not
constitute an exhaustive list of the various authorizations that must be obtained or legal requirements that
must be fulfilled in order to carry out the proposed action.
If you have any questions or would like to respond to these comments please contact the appropriate
reviewing staff listed above.
Department of Ecology
Southwest Regional Office
(SM: 08-8604)
cc: Al Salvi, SW&FAP
Kelly Fisk,WSU Extension-Kitsap County 4-H(Applicant/Contact)
i~�
KITSAP COUNTY 4-H EXTENSION PROGRAM
PIER/FLOAT REPAIR/REPLACEMENT ON SPIDER/TWIN LAKES
(WETLANDS)
Because the two lakes are less than 20 acres they are considered a wetland and not a lake
under MCRO 17.01.070. Therefore they are subject to the requirements of the Wetland
Ordinance.
Permits required for the repair/replacement of the pier/floats on Spider/Twin Lakes due to
the damaged incurred during the December 2007 storm.
BUILDING PERMIT-YES if replacement dock will be attached to land.
MASON ENVIRONMENTAL PERMIT (MEP)-YES
SEPA (MASON COUNTY ENVIRONMENTAL CHECKLIST) YES
(3) Repair, remodeling and maintenance activities. The following activities shall be
categorically exempt: The repair, remodeling, maintenance, or minor alteration of
existing private or public structures, facilities or equipment, including utilities, involving
no material expansions or changes in use beyond that previously existing; except that,
where undertaken wholly or in part on lands covered by water, only minor repair or
replacement of structures may be exempt (examples include repair or replacement
of piling, ramps, floats, or mooring buoys, or minor repair, alteration, or
maintenance of docks). Talk with Gloria
HYDRAULIC PROJECT APPROVAL- (HPA) Talk with Gloria YES
WA DEPT OF FISH AND WILDLIFE
CZ-52i—�
GORST TO CAMP 01� d-(—k
17.1 MILES .,.go
1. From South Kitsap, at Gorst, take HIWAY 3 South overpass. Go straight
at light on SAM CHRISTOPHERSON RD, for 0.3 mi.
2. From North, take HIWAY 3 at Gorst, turn RIGHT on SAM
CHRISTOPHERSON RD, go for 0.3 mi.
3. Turn LEFT onto BELFAIR VALLEY RD.
Road name changes to OLD BELFAIR HIWAY go for 6.2 mi.
4. Turn RIGHT onto BEAR CREEK DEWATTO RD go for 8.4 mi.
5. DONOT TURN ON BLACKSMITH ROAD
6. Bear LEFT on to TAHUYA BLACKSMITH RD go for 1.6 mi.
7. Bear LEFT at 4 H CAMP sign go on one lane dirt road for 1.4 mi.
At Camp
Address 6430 TAHUYA BLACKSMITH RD
Phone 360 7 - `tee
3 2 27�5
6orst to camp
Mountain
Bremerton Bremerton
Junction
L�L V I
ryj
7 merton slope
Twin Lakes 4H - l a{
rt
Camp 4
1.41 mi
f 3_( {
4
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Conadian authorities C l991-2002 Government d Cer�ei7a(Statistics Canadaantlfor Geornetica C 10 01"!an rights reserved.