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US Army Corps <br />of Engineers <br />Portland District <br /> <br /> JOINT <br />PERMIT APPLICATION FORM <br /> <br />THIS APPUCATION WILL MEET THE REQ~JIREMENTS OF 8OTH AGENCIEE <br /> <br />Corps Action ID Number <br /> <br />Oregon Division of State Lands Number <br /> <br />SEND ONE SIGNED COPY OF YOUR APPLICATION TO EACH AGENCY <br /> <br /> DislTict Engineer <br /> AI'rN: CENPP-OP-GP <br /> P O Box 2946 <br />Portland, OR 97208-2946 <br />503-326-7730 <br /> <br />State of Oregon <br />Division of State Lands <br />775 Summer Street NE <br />Salem OR 97310 <br />503-378-3805 <br /> <br />(D ApplicantName ~ ~-~""[-- ~' ' '~'/ <br />and Address ~. ~-~ o 7 ~- /~ u Tl"'~ i ~.-~: <br /> Ct?ooz_ <br /> <br />business phone # <br /> home phone # (~5--0 5 ) ~ 7 ~ - I / Z. I <br /> <br />O Co-Applicant <br />O Authorized Agent <br />O Contractor <br />Name and Address <br /> <br />Property Owner <br /> <br />PROJECT LOCATION <br /> <br />business phone # <br />home phone # <br />FAX# <br />bus[ness phone # <br />home phone # <br />FAX # <br /> <br />Street, Road or other descriptive location <br /> <br />Legal Description <br /> <br />Section Township <br /> <br /> Range <br /> <br />In or Near (City or Town) County Tax Map # Tax Lot # <br /> <br />Waterway Latitude Longitude <br /> ~ I L../.. ~"¢'t4 ~-IT'f,~.'~ /~ ~ t,/~'~..- River Mile/.//~ <br /> <br />Is consentto enter property granted to the CorDs and the Division of State Lands? 0 Yes 0 No <br /> PROPOSED PROJECT INFORMATION <br />Activity Type: ~1 Fill O Excavation (removal) 0 In-Water Structure 0 Maintain/Repair an Existing Struclure <br />BriefDescdption: ~o,~J~I""F--~C'('1o~'1 0~' t2'c~/'A~"lt,~L' 1~4,.~.. T'o ~l'-~r-~lc.l~z~ ~'~,~p~/~ <br />Fill wtll Involve "" cubic yards annually and/or ~ a o - 7 o o cubic yards for the total project <br /> ~-~:~o cubic yards in a wetland or below the ordinary high water or high fide line <br />Fill will be O R/prop ~ Rock ~ Gravel ~ Sand O Silt O Clay O Organics O Other <br />Fill lmpact Area is , D~ Acres; c~O length; /0- ~..o width; /¢-I"Z.- depth <br />Removal will involve /~ t ~ - ' cubic yards annually and/or -' ' ~u~i~yards for the total project <br /> cubic yards below the ordinary high water or high tide line <br />Removal will be O Rlprap O Rack OGravel OSand Osllt OClay O Organics Pother , <br />Removal Impact Area is Acres; length; w/c/th; depth <br /> <br />Is the Disposal areal: Upland? O Yes O No Wetland / Waterway? O Yes O No <br /> <br />Are you aware of any Endangered Species on the project site? 0 Yes ~ No <br />Are you aware of any Cultural Resources on the project site? 0 Yes 0 No <br />Is the project'site near a Wild and Scenic River? O Yes ~ No <br /> <br />If Yes, please explain in the project <br />description (on Page 2, block 4). <br /> <br /> <br />