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US Army Corps <br />Of Engineers (Portland District) <br />Joint Permit <br />Application Form <br />~ i <br />i <br />DATE STAMP <br />1 <br />I <br />i <br />i i <br />AGENCIES WILL ASSIGN NUMBERS, ° <br />Corps Action ID Number Oregon Department of State Lands No <br />Corps PCN for NWP 36 <br />SEND ONE SIGNED COPY OF YOUR APPLICATION TO EACH AGENCY <br />US Army Corns of E t ioeers: DSL - West of the Cascades: DSL - East of the Cascades: Send DSL Application Fees to: <br />District Engineer State of Oregon State of Oregon State of Oregon <br />ATTN: CENWP-OD-GPPO A <br />Department of State Lands <br />Department of State Lands <br />Department of State Lands <br />OR <br />ND <br />AND <br />Box 2946 775 Summer Street, Suite 100 1645 NE Forbes Road, Suite 112 PO Box 4395, Unit 18 <br />Portland, OR 97208-2946 Salem, OR 97301-1279 Bend, Oregon 97701 Portland, OR 97208-4395 <br />503-808-4373 503-378-3805 541-388-6112 (Attach a copy of the first page of the application) <br />(1) APPLICANT INFORMATION <br />Name and Address City of Eugene Parks and Open Space Business Phone # 541-6824842 <br />Division: ATTN. Eric Wold Home Phone # <br />1820 Roosevelt Blvd. Fax # 541-682-4882 <br />Eugene, OR 97402 Email eric.n.wold@ci.eugene.or.us <br />Authorized Agent Nancy Holzhauser Business Phone # 541-822-1090 <br />Name and Address Environmental Solutions LLC Home Phone # <br />Check one 55646 Drury Drive Fax # 541-822-1053 <br />Consultant X Blue River, OR 97413 Email nholz@envsol.net <br />Contractor <br />Property Owner Business Phone # <br />Name and Address Home Phone # <br />lfdifferent from above' Fax # <br />Email <br />(2) PROJECT LOCATION <br />Street, Road or Other Descriptive Location <br />Legal Description (attach'ta.T lot nran*) <br />Park at Checketmallow Access lot (marked) on south side of <br />Township <br />Range <br />Section <br />Quarter/Quarter <br />Royal Ave. (1/3 mile east from intersection with Greenhill and <br />Royal), follow levee east and south, project is 1220' along north <br />17S <br />4W <br />29 <br />13 <br />and east side of levee <br />In or near (City or Town) <br />County <br />Tax Map # <br />Tax Lot # <br />Eugene <br />Lane <br />17-04-29-00 detail map 1 and 17- <br />1506(17-04-29-00) and 101(17- <br />04-29-13 <br />04-29-13) <br />Wetland/Waterway (pick one) <br />River Mile (if known) <br />Latitude (in DD.DDDD format) <br />Longitude f in DD.DDDD fortnat) <br />none <br />NA <br />44.0694-44.0640° N <br />123.2098-123.1998° W <br />-Directions to the site <br />Interstate 5, west on Beltline Road to Roosevelt Blvd., turn right (west) on Roosevelt Blvd., to the roundabout at Terry St., <br />turn right (north) on Terry St. to Royal Ave., turn left (west on Royal and travel west to entrance of Checkermallow Access <br />parking lot. <br />If applicant is not the property owner, permission to conduct the work must be attached. <br />Attach a copy of all tax maps with the project area highlighted. <br />