2010; 44470-EA.pdf�
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Date Received
AGENCY WILL ASSIGN NUIviBER AGENCY WILLASSIGN fBE .
Watenva triventoi No. Ure on De a�tnient of State Lauds A licatiou No. �•
SEND COMPL�TE AND SIGNED APPLICATION TO;
{�'Vest of tlie C�sende Grest) (East of tiie C:�scade Crest)
V4'�STEItI�i It�GION �r�ST�RN I2�GION
Departuient of State L1nds Department of State Zands
775 St�miuer Street NE, Su3fe 100 WW`V .ore�onst�tel�nds .l�� 1645 NE Forbes Road, Suite 112
3aletu, QR 97301-1279 Send, OR 97701
503-98b-5200 541-338-6112
FAX: 503-378-4844 FA3X: 541388-6�80
1-1�PPI,I��T II1��C)I��IV1[A.TIOI�
Applicant is: U Private Facility oveimnent Eiitity O PUC Regulated Ufility O Parson
A��lieant's Name and Addres. : r � Business I'hone; ;U'� �S`t'L- ?_�-�-1 �,
�,��s � t�. _n�Y-t. l-:s� c� i� � t�L l 1�.� 1�-e Hotne Phone:
f f �10�� �`���:;-k... �1. vc� `=� � _ Fax: S v��. ��lZ. � �'S�''�� �;
�` �� ��'�^r��� ��-- ��� ��"�'�t� email Address; �c�.F,�e.� � `�1ryt�l�,v��uS
Co-�1�plieant's Nanie and Address: Busiiiess Phone:
Hattae Pho�te;
.�'' flY:
email Acielress:
Autliorized Agent Name and Adclress: I3usiiiess Phoiie:
IIome Phone:
rax:
einail Acldress:
Ri�ai•iau Property Ownei Naiiie ancl A�i�iress: Busuiess Phone: �5 U3 9!� 6~'� z-DU
(vested title); if different th n applicant � Home PIione:
�.��:i-� ��\ t�v.����.z �c��, �s�.
Faa:
.��-ti ` . ' - wntiw�cr- S�, Sv��•� l �(�
etilail Adclress:
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2 - PR:OJ��'T I.,O�A'�'IO�I
Street, Road or other descri tive location Legal.Descri tion
� � Totivi�ship Range Sectioii Qut�rter
� i�tz. .�►� � �,,.,.�� = �; �; 2�.. 0 - � - , �-��
In or Ne r (City or To�vn) Coun Tax Ivlap t� Tax Lot #
�t��..�,�-�-... -�� 1 �w,Uv1L. � v �L.� � ti t�.
W tivay River Iviile Couiity Properiy Tax Elccount Number
rl, 6L. �.i (��"� ti l�
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Activity Type (Check all that apply):
a) O Water O Stonn water O Se�ver O Gas O Electricity
O Combined Water Pipeline & Assaciated Fixture O Cornbined Sewer/Storm water
O Communication Cable O Pressure Se�ver Line O Effluent Outfall and Diffuser
Area request (length x width)
b) O Di#ches O Iirigatian O Mining O Drainage
O Other
Area request {length x width)
c} O Raih•oad O Road, trail O Bridge
Area z�equest (lengtli x width)
d) O Surfaee O Subsurfaee O Overhead
e) (�}}ther: Describe: ���i� 2�-�. �n, ��►�4 olt-rnA,�-�c_
v
fl Eaclx crossing requires a separate easement. Total number of crossings requested:
a} Are there any State, Fedaral listed, or Candidate Endangered Species {iucluding (�Yes O Na O Unknown
plants, fish or wildlife} on the project site?
b) Are there any Cultural Resources on or near the project site? O Yes O Na (�Unknown
c) Is the project site near a State Scenic Vdaterway? 4 Yes �"No t� Unkno�vn
If yes, please expiain in the project description (Section 4)
d) If you are applying for a special use easement for �vater pipeline and associated fixture, do you l�ave a pending or
valid Deuartment of Water Resources application to appropriate water? O Yes O No O Unknotivn
4 - P'I�C.�JECT P�PC�SE � DESCRIl'T'I�I�I
o EX�St��
Project Purpase and Need:
S�ee. 1"7 S�--. ��-�^�-�- �� I��- t3 � C�l�
Project Description: (include altez•native sites considered)
� e.�... ��u�
EsTimated Start Date�'Y! ��L� 7 Estiinated
-2-
5 - .��ITI�l�� �FC) TI�N
Name, address and phone number for all adjouung property owners
S�. `l� SL �-�-�- � �l ( � ��--
Have yau applied for Corps o£ Engineeis or Departrnenf of State Lands permits for this project? �j�..Yes O No
If yes, what identification number{s} were assignec� by the respective agencies:
Co s# �� t� ZOl (� � State af C}re on # C r�--
6- CI'I'Y/CO�`I'�.' P'LAN�II�TG IDEP�.�.'1VIEI�FT AI'�IDAV�'T
to be com leted b local lanning official
O This project is not regulated by the local compreliensive plan and zoning ordinance.
�This project has been revieeved and as consistent �vith the local comprehensive plan and zoning ordinance.
O This project bas been reviewed and is nat consistent with the local coinprehensive plan and zone ordinance.
O Consistency of tlus project with the lacal planning ordinance cannot be determined until the following local
approval{s) are obtained: �,,
O Conditional Use Approval O Devetopinent Permit �(����� �'
C) Plan Amendment O Zane Change �..e,J""`�``"
O Other S�' ��
An applieation O O has not been made for loeal approvals checked above.
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Si �ature of loc lanni.ng afficial Title Cit Coun Date
7 - ��7SIi�S� II�IFO�21.`V�.TIOl�T
LYNT�T�lD LIABILITY COMPAN�Y: Cam late the following
a) Do you have autharity from the �regon Secretary of State to do business in the State of Oregon? O Yes O No
b} Is the LLC presently in gaod standing with the Oregon Secretaiy of State? C) Yes O Na
c) In tivhat state is the LLC pruna��ily domiciled?
d) Is tl�e LLC name and tlie Oregon business address the salne as stated in this appIieation? O Yes O Na
If no, state the legal Name:
Address:
5tzeet or Bax Nu�nber Ci State 7i Code
Addirionally, a LIMITED LIABILITY COMPANY must submit the fallowing with the application:
a) A certified copy of the company's Ai•ticles of Urganization
b A co of the eom an 's a eratiti a�•eetxieixt
CORPORATIt�I�T: Com lete the fallawing:
a) Da you have autharity from the C)regon Secretary of State to do business in the State af Oregan? O Yes C� No
b) Is the corporation presently in good standing �vith t2�e Oregon Secrefary of State? C) Yes O Na
c) In �vhat state are you incotporated?
d) Is the legal eorporation name and �regan business address the same as stated in this applicatzan? O Yes O No
If no, state the legal Corparate Name:
Address:
Street or Bax Number City State Zip Code
-3-
�ARTI�tERSI3IP �?R JOINT VE1�ITURE: Com lete the followin
NAME BUSINESS ADDRESS %SHARE DIVISIC3N
TRUST: Com lete the fallowin for each beneficia of the Trust:
NAME BUSINESS ADDRESS
tJeR identify tl�e Trust document b ti#le, doeument number, and coun where dacument is recarded:
TITLE DOCUIVIENT TtUM7BER COUNTY
A resalutian that the individual designt�ted to sign tLe lease is authorized ta act on behalf of ti�e company iu this
mattet�.
g - 1���1��;� �� �� � I'���� ��-:
INCOM�'L�TE AP'PLICATIONS WII,L B� R:CTCJBN�D
a) A street or higliway location map with road directions to the site from tlse nearest main higlaway or road.
b) Assessor map that co�itai►ts the riparian uplands. Do not mark an this map.
c) A copy af t1�e current year's property tax statet2�ent which identi�es the present owner's name(s), land vaiues, land size and tax
account numbers of the riparian uplands.
d) A legal description of the requested easement area �vitli an accurate delineatioti of ttie area reiative to tlie tax Iot boundaries of the
upland parcei, (Tlie department n�ay require a survey for this purpose).
e) A separate drawasg ta a scale a£ 1 inch = 100 feet of all existing and proposed struch3res fox the Iease area. Labsl eaa}i separate
activity type stated in Section 3 and sho�v the dimensio�}s of each area by lengdi and �vidtti, as stated in Section 3.
fl Non-refundable application fee of $125.00 for �vater pipeline and associated fixtures or $750.00 for atl other easement requesfs.
Mail a ent ta: DEPAl2T1VI�NT OF STAT� Y,ANDS, UNIT 18 PO B4X 4395 PORTLAND, OR 97208-4395
9 - A�'PLI� �1'I' SIGl�TA'�'�J
I hareb re uest a state authorization for number ears. The maacimum easement tern� is for 30 ears.
Application is liereby made for tfie activities described herein. I certify tl�at I atn familiar �vid� the u�#'onnation contained in tiie application,
and, to the best of nry knowledge and belief, this infonnation is true, complete, and accurate. I further certify that I pass$ss the autliority to
undertake the proposed activities. I understand diat the grantuig of other pern�sts by Iocal, county, state or federal agencies does not release
me from the rec�uirement of abta'vung tl�e authorization requested Uefare coirunenev�g die project. I understand that payment of the requu•ed
state applicatio�i fee d s not guaraiitee authorization.
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Applicaxit Sig�iature Title
L/-2.(-,-- 2olU
nate
I�ppaint ttie person na►ned belo�v to act as my duly authorized agent.
Print/Type Name Title
A licant Si nature Date
-4-
Updated 191d7
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