HomeMy WebLinkAboutJARPA- - SHX Application - 6/10/2003 i1GENCY 11SE:IDNL .;
Agency Reference
Date Receiare
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JOINT AQUATIC RESOURCES PERMIT APPLICATION FORM (DARPA)
(for use in Washington State)
PLEASE TYPE OR PRINT IN BLACK INK
❑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 ❑ Critical 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
❑ 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
EJDIW I N - " s GoRD h- U ANE1V
MAILING ADDRESS
:fHOLjHVEWORKPHONE E-MAILADDRESS M4
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 ADDRESS
mq I TV L-V,^d 5 F_rl D WA 7 63& S
WORK PHON E-MAIL AbDRESS
I ., H ME PH NE FAX#Q -
60 3E35- U
3.RELATIONSHIP OF APPLICANT TO PROPERTY: O(OWNER ❑PURCHA R ❑LESSEE ❑OTHER:
4.NAME,ADDRESS,AND PHONE NUMBER OF PROPERTY OWNER(S),IF OTHER THAN APPLICANT:
S.LOCATION(STREET ADDRESS INCLUDING�CJ�u;UNTY AND ZIP CODE,WHERE/PROPOSED ACTIVITY EXISTS OR WILL OCCUR)
fi'Gl �i l �. Ulul dIV t W� l�✓ /
LOCAL GOVERNMENT WITH JURISDICTION(CITY OR COUNTY) M/I SC7 iJ CtOUN t
WATERBODY YOU ARE WORKING IN HOOD
CA
�1`+A L TRIBUTARY OF /_ \ WRIA#
IS THIS WATERBODY ON THE 303(c1 LIST?YES❑ NO I LT I 561 L i A)1J
IF YES,WHAT PARAMETER(S)?
ttp:/huw"A ecy wa gov/PTograms/wq/links/impaired Al htnil WEBSITE FOR 303d
LIST
V,SECTION SECTION TOWNSHIP RANGE GOVERNMENT LOT SHORELINE DESIGNATION
d 5 da1\1 0 r'�3 or LOT Lr T. L.
LATITUDE&LONGITUDE: ZONING DESIGNATION
Lam&� iaa . 99 39� Igo
TAX PARCEL NO: 5 1 tf-- 000 3 0 DNR STREAM TYPE,IF KNOWN
3a a
I TARPA Rr�ncPrf 7/m(nntact the QtatP.nfWachinatnn Clf irr nfPPrmit AccictanrP fnr latPet vrrcinn 7F,n/an7_7m7 nr Rnn/Q17_nnAi
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6.
DESCRIBE TFE CURRENT USE OF THE PROPERTY,AND STRUCTURES EXISTING ON THE PROPERTY. HAVE YOU COMPLETED ANY PORTION OF THE PROPOSED ACTIVITY ON THIS
PROPERTY? 0 YES %NO FOR ANY PORTION OF THE PROPOSED ACTIVITY ALREADY COMPLETED ON THIS PROPERTY,INDICATE MONTH AND YEAR OF COMPLETION.
S NG1.E FAAAI Ly RE-5t` DG-/vCE, w;i/f R-o' FLO Orr. ' -
IS THE PROPERTY AGRICULTURAL LAND? ❑YES A NO ARE YOU A USDA PROGRAM PARTICIPANT? ❑YES*0
78. DESCRIBE THE PROPOSED WORK 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 AL LL 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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Con+'c RC-c-; 1z00-,7;vCs {LA-f-E7 A3ov E -ntE AAEAN #lct4 WATEk br f-
?wo P' l.i rq&S Wl u- BE- iZE-NIAV E�\-> AND i wo wt-L 3�,: 9EPL <-Eb WiTH
/}t��• i t�E t.11t l.l� +3 E S�►�Ei�l 1\4eAV Pt L r NC-5 r-vop I-E Pl�,r,, 2AMp
PREPARATION OF DRAWINGS: SEE SAMPLE DRAWINGS AND GUIDANCE FOR COMPLETING THE DR
MUSTBEATTACHED. NOTE;APP AWINGS. ONE SET OFORlGfNAL OR GOOD QUALITY RFPRODUCIBLEDRAWIIVG$
LICANTS ARE ENCOURAGED TO SUBMIT PHOTOGRAPHS OF THE PROJECT SITE,BUT TI ESE DO NOT SUBSTITUTE FOR DRAWINGS. THECOR!'S OF
ENGINEERS AND COAST GUARD REQUREE DRA WINGS ON&1/2 X 11 fNCH 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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70. 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 OFFISH AND
AQUATIC LIFE. IDENTIFY WHICH GUIDANCE DOCUMENTS YOU HAVE USED.ATTACHA SEPARATE SHEET IF ADDITIONAL SPACE IS NEEDED.
NO AbVEZ5E.A-FFEC-1-5 TO W)4-)'P-g Z30bY4N7'lChPF}TEZ�)•
d. FOR IN WATER CONSTRUCTION WORK,WILL YOUR PROJECT BE IN COMPLIANCE WITH THE STATE OF WASHINGTON WATER QUALITY STANDARDS FOR TURBIDITY
WAC 173.201A-1107 AYES ❑NO (SEE USEFUL DEFINITIONS AND INSTRUCTIONS)
8.WILL THE PROJECT BE CONSTRUCTED IN STAGES?
❑YES NC
PROPOSED STARTING DATE: A5 --ooN h{ 7.^jem IT ARE.
�rE. 1-2514E-D/ wrTt*.,JColvV-RttCTio��!
ESTIMATED DURATION OF ACTIVITY: `TN/0 W F EKS
CHECK IF ANY TEMPORARY OR PERMANENT STRUCTURES WILL BE PLACED:
1;WATERWARD OF THE ORDINARY HIGH WATER MARK OR LINE FOR FRESH OR TIDAL WATERS;AND/OR
WATERWARD OF MEAN HIGHER HIGH WATER LINE IN TIDAL WATERS
10.WILL FILL MATERIAL(ROCK,FILL,BULKHEAD,OR OTHER MATERIAL)BE PLACED: NO
❑WATERWARD OF THE ORDINARY HIGH WATER MARK OR LINE FOR FRESH WATERS? IF YES,VOLUME(CUBIC YARDS)
/AREA (ACRE
❑WATERWARD OF THE MEAN HIGHER HIGH WATER FOR TIDAL WATERS? IF YES,VOLUME(CUBIC YARDS) AREA (ACRES)
TARPA R (nntar t the-Ctate-of Wac1linotnn(NT'r.P of Permit A ccictbnrp fnr late-ct trPrcinn ';Fin/An7_7nl7 nr R110/917_nnQ: 7
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11.WILL MATERIAL BE PLACED IN WETLANDS?IF YES: ❑YES K NO
A. IMPACTIED AREA INACRES:
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(MRCS):
G. WILL PROPOSED ACTIVITY CAUSE FLOODING OR DRAINING OF WETLANDS? ❑YES ❑NO
IF YES,IMPACTED AREA IS_ACRES OFDRAINED WETLANDS.
NOTE: If your project will impact greater than%of an acre of wetland,submit a mitigation plan to the Corps and Ecology for approval along with the JARPA form
.NOTE-a 401 wafer quadty certdjicabbn WArbe required from Ecohgyin addibion to an approved mitigation plan if yourpro/ect impacts wetlands that are: a)greater then 34 acre in size,or
b)tidal wetlands or wetlands adjacent to hda/Hater. Please submit the JARPA form and mitigation plan to Ecology for an indrvidue/401 certification if a)or b)appbes,
12. STORMWATER COMPLIANCE FOR NATIONWIDE PERMITS ONLY:
THfS PROJECT IS(OR WILL BE)DESIGNED TO MEET ECOLOGYS MOST CURRENT STORMWATER MANUAL,OR AN ECOLO GY APPRO VED LOCAL STORMWATER MANUAL ❑YES ❑NO
IF YES—WHI CH MANUAL WILL YOUR PROJECT BE DESIGNED TO MEET
f NO—FOR CLEAN WATER ACT SECTION 401 AND 404 PERMITS ONLY—PLEASE SUBMITTO 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 (ACRES)
B. COMPOSITION OF MATERIAL TO BE REMOVED:
C. DISPOSAL SITE FOR EXCAVATED MATERIAL:
D. METHOD OF DREDGING:
14.HAS THE STATE ENVIRQQ N ENTAL Oj fCY ACT SEPA)BEEN COMPLETED? YES �{NO
SEPA LEAD AGENCY: �� (_C��{n/}L l SEPA DECISION: DNS,MONS,EIS,ADOPTION,EXEMPTION DECISION DATE(END OF COMMENT PERIOD):
SUBMIT A COPY OF YOUR&EPA DECISION LETTER TO WDFW AS REQUIRED FOR A COMPLETE APPLICATION
IS.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 HAS OR WILL NEED AN NPDES PERMIT FOR DISCHARGING WASTEWATER AND/OR STORMWATER.
TYPE OF APPROVAL ISSUING AGENCY IDENTIFICATION DATE OF APPLICATION DATE APPROVED COMPLETED?
NO.
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ECT 0 i.C
Wr
CIM C Do
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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 ANO IF YES,EXPLAIN:
TA RP Revised 7/f)7('_fn t the.<`tate of Wachinotnn OffirP nfPPrmit Accictanr.r fnr latest vercintt ;F(1/A()7_7(},7 nr ROO/017-MA I j
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,ET 3 rj/OC i
17b. IF A PF:OJECT OR ANY PORTION OF A PROJECT RECEIVES FUNDING FROM A FEDERAL AGENCY,THAT AGENCY IS RESPONSIBLE FOR ESA CONSULTATION. PLEASE INDICATE IF YOU
ILL RECEIVE FEDERAL FUNDS AND WHAT FEDERAL AGENCY IS PROVIDING THOSE FUNDS. SEE INSTRUCTIONS FOR INFORMATION ON
ESA—
RAL FUNDINIG E2 YES )jN0 IF YES,PLEASE LIST THE FEDERAL AGENCY
18.LOCAL GOVERNMENT WITH JURISDICTION:
o\j C0Lkr_(;
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
,�i -;-n l� .]/,,I" 1 ADDRESS PHONE NUMBER
yVl LL) 1N('V D Sox of rWA '
6l. rev 5 O
RISTINF- c,• W1CKLuN41101 . 70*AVE7 NE, KEHMORE98026
SECTION C-This section MUST be compfeted for any permit covered by this application
0.APPLICATION IS HEREBY MADE FOR A PERMIT OR PERMITS TO AUTHORIZE THE ACTIVITIES DESCRIBED HEREIN. I CERTIFYTHAT I AM FAMILIAR WITH THE
INFORMATION CONTAINED IN THIS APPLICATION,AND THATTO THE BEST OF MY KNOWLEDGE AND BELIEF,SUCH INFORMATION IS TRUE,COMPLETE,AND
CCURATE. I FURTHER CERTIFY THAT 1 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
ATE
SIGNATURE OR AUTHORIZEDA` NT ATEl0 03
- d3
1 HEREBY DESIGNATE DATE
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�SIG THE PERMIT.
C/I�/�B /Q� /J I/!/.l�I
NATURE OF APPLICANT DATE
SIGNATURE OF LANDOWNER(EXCEPT PUBLIC ENTITY LANDOWNERS,E.G.DNR) v
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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uf• l.-r.]�the ap�►catoota�,:�v�l�res,��tx�:dr��rna}Juse:�r•:: - - _ ,.�.,,��y r.,v,:. -�'
� :.v;anane,� se�fortft�3''`�': Y�•..,:rt titF;.. a 'ori:ti--= �'� '• � �,pa1tl ��he master�rtagram uv}uc�•'._tri�,V�.�. ---'',`'
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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.
TARP A RavicPrl 7/fl')(�nntartt the.Qtatr of Wachino'fnn (lffica of Permit k ccictanrP for latest cArc,nrr ;F,F}/d!}7_7f1�7 nr Rf3f1lQ17_flfllq Q