FPA/N #:
Received Date:
WDFW Concurrence Due Date:
WDFW Concurrence Review
Completed:
Comments Due Date:

Forest Practices Application/Notification

Decision Due Date:

Office Checklist Page 1

lo/1 l /1<?

FP Forester:

South Puget Sound Region

Shutdown Zone:
RMAP#:
FPA/N CLASSIFICATION:
Landowner
Name:
WRIA:

0 II

Ill

O

IVG

O IVS

Biomass D FFFPP D 20/ac Exempt D Aerial Spray
Project
Name:

PoPE f<ESOl!l'2CES

KITSAV

WAU:

R\G~LE-TS

0A"1E:OR- H)R 1 GiA M\3LE

WAU:

WRIA:

WAU:

WRIA:
Legal:

24002/.p

-~ 01 '.?I- 2--7- O'ZE

Activity Type(s):
Rock Pit

Harvest
ac

~o

County:
ac

C'z'.

S~oils

i<-ITSAP

S~ray

ac

Construction

ft

Crossing{s)

#

Abandonment

ft

ALTERNATIVE PRESCRIPTIONS
D Alternate Plan D Fixed-Width D Overstocked

• Ten-Year Forest Management Plan

D Habitat Conservation Plan D HCP Crosswalk{s)
D Landowner Option Plan for Northern Spotted Owl

D Columbia River Gorge National Scenic Area
D Watershed Analysis:._ _ _ _ _ _ _ __

D Cooperative Habitat Enhancement Agreement

RESOURCE REVIEW
D Potentially Unstable Slopes
0 Soils Map O Highly Erodible O Highly Unstable
SLPSTAB
0 LHZ O HighNery High O Moderate O Low
D Landslide Inventory Polygon
D Rain-on-Snow D Outside Approved WA
0 Hydric Soils
D Wetland D Forested D AD B
0 In WMZ of O A O B Wetland
0 In RMZ/ELZ of Type O S O F O Np
Water Verification
WAI/SS

D
D
D
D
D

Bull Trout Overlay D HCP Bull Trout Population
Arsenic Plume 40.1 + D WNHP Rare Species
Bald Eagle nest or roost within 660 feet
Group A or B Water Supply
Hatchery I Name:_ _ _ _ _ _ _ _ _ _ __

D
D
D
D
D
D

Even-Aged Harvest greater than 120 Acres
Ground-based Equipment on Slopes greater than 40%
Road Construction on Slopes greater than 65%
Saltwater Islands D Long Term Commitment Area
In or Over Typed Water D S D F D Np D Ns
Volume greater than 5 mbf per acre

ASSOCIATED NON-SCANNED DOCUMENTS - On file with the FPA/N at the Region office.

181 Large Landowner RMAP

D SEPA ChecklisUDocuments

ASSOCIATED SCANNED DOCUMENTS

0

COHP O SEPA DNS/MDNS O LGE Permit(s)/lnfo
FPHP Plans & Specifications
Qualified Expert Report I Type:_ _ _ _ _ _ __
Natural Regeneration Plan
Shoreline Permit
6a Marbled Murrelet Form
0 FPBM or FPA Appendix(s) _ _ _ _ _ _ _ __
0 SFLO RMAP Checklist
D CMZ Assessment Form

D
D
D
D

EARR Tax Credit ~ Yes O No
ADDITIONAL COMMENTS:

0

ICN

O SWO O

NTC #_ _ _ __

D Hardwood Conversion Form
D Wetland Mitigation Plan
D Water Protocol Surveys
0 New O Old I WTMF # _ _ _ _ _ _ _ _ _ _ __
D Water Classification Worksheet
D Shade Documentation {Stream Shade Assessment Worksheet)
D Watershed Analysis Worksheet
D DFC Printout
D Slope Stability Informational Form
WDFW BIOLOGIST:_ S_ l _lA
_ _ _ _ _ _ _ _ __

D Previous FPA #_ _ __ __

Form completed by

MD

 For DNR Region Office Use Only
FPA/N # :
Region :
Received Date:

Forest Practices Application/Notification
Project Name: _R_ic_k_le
_t_s_ _ _ _ _ _ _ _ __

Western Washington

PLEASE USE THE INSTRUCTIONS TO COMPLETE THIS APPLICATION.
1.

Landowner, Timber Owner and Operator
Legal Name of TIMBER OWNER
Same as Landowner

Legal Name of OPERATOR
Same as Landowner

Mailing Address:

Mailing Address:

City, State, Zip:

City, State, Zip:

Phone: (360) 394-0537

Phone:

Phone:

Email: sgreif@orminc.com

Email:

Email:

Legal Name of LANDOWNER
Pope Resources

Mailing Address:
19950 7th Ave NE, Suite 200
City, State, Zip:
Poulsbo, Wa 98370

2.

Contact Person
Contact Person:

Phone: (360) 440-481 1

Sean Greif
3.

Are you converting the land to non-forestry use within 3 years of harvest?

[i]No

4.

Email: sgreif@orminc.com

• Yes

If yes, include your SEPA checklist and SEPA determination (if applicable) and county clearing and
grading permit (if applicable).

If you are harvesting timber, enter the Forest Tax Number of the Timber Owner:
800-007 -969

Eligible for EARR Tax Credit

• No

[i]Yes

Contact the Department of Revenue at 1-800-548-8829 for tax reporting information or to obtain a number.
5. Are you a small forest landowner per RCW 76.09.450? See instructions

[i]No

• Yes
D

If yes, Check all that apply. If no, skip to Question 6.
My entire proposed harvest area is on a single contiguous ownership consisting of one or more

parcels.

10/1/2018

Page 1 of 9

Western Washington

 6.

D

My proposed forest practices activities is within an area covered by an approved Forest
Stewardship Plan or Forest Management Plan developed in cooperation with DNR.

D

I received technical assistance from a DNR small forest landowner Stewardship and Technical
Assistance Forester in preparing this FPN N.

D

I have participated in a Washington State University Extension Service and/or DN R-sponsored
Forest Stewardship Coached Planning course.

D

I have attended a Washington State University Extension Service and/or DNR-sponsored Family
Forest Owner Field Day.

Are you substituting prescriptions from an approved state or federal conservation agreement or Watershed
Analysis?

li]No

• Yes

Write 'HCP' or 'Using Prescriptions' in tables that apply. Attach or reference prescriptions
and/or crosswalks for approved state or federal conservation agreements or Watershed Analysis
on file at the Region office.

7. What is the legal description of your forest practices?

8.

Section

Township

Range

E/W

Tax Parcel Number

County

30

27

2

E

forest land

Kitsap

31

27

2

E

forest land

Kitsap

Have you reviewed this forest practices activity area to determine whether it may involve historic sites and/or
Native American cultural resources? Read the instructions before answering this question.

li]No
9.

• Yes

If you made any contacts, please provide information in Question 28.

Do you have a DNR approved Road Maintenance and Abandonment Plan (RMAP)?
a.

• No

b.

[i]No

c.

[i]No

[j]Yes

• Yes
• Yes

Enter the RMAP number: ..;.R..::2=--4'--'0'-"0-=2..:.6_-1'---_ _ _ If yes, continue to b. If no, skip to c.
Is this Forest Practices Application/Notification for work that is included in this approved RMAP?
Is a Checklist RMAP required (see instructions)?

10. Are there potentially unstable slopes or landforms in or around the area of your forest practices activity?
[i]N o

• Yes

If yes, attach Appendix D. Slope Stability Informational Form and map of areas reviewed for and
locations of unstable slopes and landforms found. If applicable, attach a geotechnical letter,
memo, or report, Watershed Analysis prescriptions, and/or a SEPA Environmental Checklist.

11. Is this Forest Practices Application/Notification (answer every question):
[i]No

• Yes

b. [i]No

• Yes

a.

10/1/2018

A request for a multi-year permit? If yes, length requested: D 4 years or D 5 years.
Not everyone qualifies for a multi-year permit. See instructions for details.
An Alternate Plan? If yes, include a template or detailed plan. See instructions for details.

Page 2 of 9

Western Washington

 d. i ]No

• Yes
• Yes

e.

i ]No

• Yes

f.

~ No

C.

li]No

g. ~No

• Yes
• Yes

h.

li]No

• Yes

i.

0No li]Yes

j.

li]No

• Yes

For a funded Forest Family Fish Passage Program project?
Within an urban growth area? If yes, see instructions for add itional required documents.
Within a public park? If yes, include SEPA Environmental Checklist or SEPA Determination,
except for harvesUsalvage of less than 5,000 board feet within a developed public park.
Park name:
Within 500 feet of a public park? Park name:
In an approved Conversion Option Harvest Plan (COHP) from the local government? If yes,
include a copy. This only applies to proposals within urban growth areas.
Within 200 feet of the Ordinary High Water Mark (OHWM) or floodway of Type S Water?
If yes, check with the county or city to determine whether a substantial development permit
is required under the local shorelines master plan .
Within 50 miles of saltwater AND do you own more than 500 acres of forest land in Washington
State? If yes, include Marbled Murrelet Form or attach/reference HCP prescriptions.
In or directly adjacent to a potential Channel Migration Zone (CMZ)? If yes, include CMZ
Assessment Form. Attach/reference applicable HCP and/or Watershed Analysis prescriptions.

You are required to verify all waters within 200 feet of your proposed forest practices activities prior to
submitting a Forest Practices Application / Notification. Use the Water Type Classification Worksheet and/or a
Water Type Modification form to explain how you verified water types. See Water Typing Requirements in the
instructions.

* * * * * If not working in or over typed Waters, skip to Question 16 * * * * *
Prior to answering Questions 12-15 in this section please refer to the Forest Practices Application Instructions
and Forest Practices Board Manual Section 5.
12. Are you proposing any of the following projects NOT permitted by current HP As from WDFW?

[j] No

O Yes

Installing, replacing, or repa iring a culvert at or below the bankfull width of Type Sor F
Water(s) that exceeds a five percent gradient?

b. Ii] No

O Yes

Constructing, replacing, or repairing a bridge at or below the bankfull width of unconfined
streams in Type S or F Water(s)?

c. [j] No

O Yes

Placing fill material with in the 100-year flood level of unconfined streams in Type Sor F
Water(s)?

a.

13. Have you consulted with DNR and/or WDFW about the proposed hydraulic project(s ) in or over Type Sor F
Water? [j] No

O Yes

14. If installing , replacing , removing, o r maintaining structures in or over any typed Water, complete th e table
below. Provide crossing locations and identifiers on your Activity Map. Provide plan details in Question 28 or attach
plan to the FPA/N. Type S and F Waters require detailed plan information. Complex hydraulic projects in Type N
Waters may also be required per WAC 222-24-042(2). See instructions for detailed plan requirements.

10/1/2018

Page 3 of 9

Western Washington

 ...

Q)'

Cl)

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..

C: .Q
0

<l)

...a.

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Q.

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Cl)

3:!

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Cl

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)( co

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<
-.. ;.

C: I...'
<l)
.....,
Ill.....,

· Ill
-

a.. .!

e~

:I:

0

Cl:I

C

Planned
Activity
(install,
replace,
remove,
temporary,
structure
maintenance)

Structure
(bridge,
ford/equipment
crossing**
puncheon/fill,
arch, pipe arch,
round culvert,
other)

Proposed
Size
(width x
length)
(inches x
feet)

c~

Culvert Design
Method
(no-slope,
stream-sim,
hydraulic,
other)
(F and S only)

Cl)

·-

C:

-g Cl)0

... -0
(!) C:

E co
Cl:I

Li..

Cl) ----

._ -..,_

U) ~

.!!!

*Existing HPAs issued by WDFW will be complied and enforced by W DFW until expiration. Plan details are not
required for hydraulic projects permitted with an existing HPA (see instructions).
**Fords and/or equipment crossings on Type Sand F Waters may result in an unauthorized incidental take of certain
threatened or endangered fish species. For more information, see 'Background for the State's Incidental Take Permits
for certain threatened and endangered fish species' following Question 22 of the FPA/N Instructions.

15. If conducting any of the following activities in or over typed Water(s), complete the table below. Some
activities will require identifiers on the Activity Map and/or more information in Question 28. See instructions.
*Activity

Type S Water

Type F Water

Type Np Water

Type Ns Water

PROVIDE DETAILS IN QUESTION 14

Equipment Crossing**
Suspending Cables
Cable Yarding
LW D Placement/Removal
Beaver Dam Removal
Felling and Bucking
Other (describe in Question 28)

*Existing HPAs issued by WDFW will be complied and enforced by WDFW until expiration . Plan details are not
required for hydraulic projects permitted with an existing HPA (see instructions).
•• Fords and/or equipment crossings on Type Sand F Waters must be identified in Question 14.
16. If constructing o r abando ning forest roads, complet e th e table below. Show th e road locatio ns and identifiers
on the Activity Map. Include abando nment plans for all t emporary roads and abandonment projects.
Road Identifier
(name, number)

Road Construction
Length
(feet)

Steepest
Side-slope (%)

Road Abandonment
Length
(feet)

Abandonment Date
(MMIYYYY)

-

10/1/2018

Page 4 of 9

Western Washington

 17. If depositing spoils and/or expanding or developing a rock pit for forestry use, complete the table below.
Show locations and identifiers on the Activity Map.
Spoil Area
Identifier
(letter, number)

Acres of
Existing Rock
Pit Expanded

Acres of New
Rock Pit
Developed

Rock Pit Identifier
(name, number
or letter)

Amount of Spoils
Deposited
(cubic yards)

-

18. If operating within 200 feet of a wetland not associated Type F Water, complete the table below. Welands
associated with Type S or F w ater should be listed in Question 25. Show the boundaries of each w etland,
along w ith its identifier, and Wetland Management Zones on the Activity Map. See instructions for
information .
Wetland
Identifier
(letter,
number)

Wetland
Type
(A, B,
Forested)

Planned
Activities in
Maximum
Width WMZ

Planned
Activities in
Wetland

How
many
Acres
will be
filled?

How
many
Acres
will be
drained?

Total
Wetland
Acres

-

* * * * * If not harvesting or salvaging timber, skip to Question 27 * * * * *
19. If harvesting or salvaging timber, complete the table below. Show all harvest areas and unit numbers on the
Activity Map. For even-aged harvest units, also show surrounding stand information on the Activity Map.

...
G)

.c
E
:::,

z

t:

::,

1

10/1/2018

~II)
G)

Harvest Type
(Even-aged,
Uneven-aged,
Salvage,
Right-of-Way)

even aged

c::

~ ;?

:I: ...
II) 0
II) >-

E

0

in
y

Harvest Method
(rubber tired skidder, tracked
skidder, dozer, shovel, full
suspension cable, leading end
suspension cable, helicopter, cable
assist/tethered logging, animal,
chipper, forwarder, slash bundler)
skidder/shovel

Page 5 of 9

G)

.c

"'C
G)

0 -

II)

...
QI

II)
G)

c::

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80

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G)

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(1)

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0

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o '--':::, QI

>~
:I:
1620

0

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.c
0-c
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0

:I: :::::..

800

.:! c::
0

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99

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0 ·--

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en
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II)

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30

Western Washington

 20. Reforestation. Check all that apply:

Planting. Tree Species: _c_o_n_ife_r_ _ _ _ _ _ __

D
D

Natural. Include a Natural Regeneration Plan
Not required because of one or more of the following:

D

I am converting some or all of this land to non-forest land in the next 3 years or lands are exempted under
WAC 222-34-050.

D
D

Individual dead, dying, down, or wind-thrown trees will be salvaged.

D
D
D

Trees are removed under a thinning program reasonably expected to maximize the long-term productivity of
commercial timber.
I am leaving at least 100 vigorous, undamaged, and well-distributed saplings or merchantable trees per acre.
An average of 190 tree seedlings per acre are established on the harvest area and my harvest will not
damage them.
Road right-of-way or rock pit development harvest only.

* * Do you own MORE than 80 acres of forest land in Washington? If yes, skip to Question 25 * *
21. Are you using the exempt 20-acre parcel riparian management zone (RMZ) rule (WAC 222-30-023) on type S,
F, or Np Waters?

•

No

Skip to Question 25.

D

Yes

Continue to Question 22. See instructions for qualifications and information.

22. Choose the answer below that best fits your situation. Show all RMZs on the Activity Map.

D

a. ALL of the following apply to me and my land: (If no, answer b.)
• Between June 5, 2006 and today's date I have always owned less than 80 acres of forest land in
Washington .
• Between June 5, 2006 and today's date this parcel has always been 20 acres or less of contiguous
ownership. See RCW 76.09.020 for definition of 'contiguous'.
• Between June 5, 2006 and today's date this parcel has always been owned by me or someone else that
has owned less than 80 acres of forest land in Washington.
b. ONE OR MORE of the following apply to me and/or my land (check all that apply):
If any of the statements below apply AND you use the exempt 20-acre parcel RMZ rule, you are NOT
authorized under the State's Incidental Take Permits (see explanation in FPA instructions under
Question 22).

10/1/2018

D

Between June 5, 2006 and tod ay's date I have owned more than 80 acres of forest land in
Washington.

D

Between June 5, 2006 and today's date this parcel has been a part of more than 20 acres of
contiguous ownership. See RCW 76.09.020 for definition of 'contiguous'.

D

Between June 5, 2006 and today's date this parcel has been owned by someone that has owned
more than 80 forested acres in Washington.

Page 6 of 9

Western Washington

 23. If harvesting within 115 feet of a Type S or F Water on an exempt 20-acre parcel, complete the table below.
Show RMZs and stream segment identifiers on the Activity Map. If you are harvesting within 75 feet or within the
maximum RMZ (whichever is less), stream shade must be assessed and met following harvest. Describe in Question
28 how stream shade was determined to be met, using the 'Appendix F. Stream Shade Assessment Worksheet' if
necessary.
Stream
Segment
Identifier
(letter)

Water Type
(S, F)

Segment Length
(feet)

Bankfull Width
(feet)

Are you harvesting
within the
maximum RMZ?
(Yor N)

RMZ
Maximum
Width
(feet)

24. Are you harvesting within 29 feet of a Type Np Water on an exempt 20-acre parcel?

D No
D Yes

Skip to Question 27.
See instructions and describe leave tree strategy in Question 28. Then skip to Question 27.

25. If harvesting within 200 feet of any Type Sor F Water or periodically inundated areas of their associated
wetlands, complete the table below. Include Desired Future Condition (DFC) for all inner zone harvests
unless you have an HCP prescription. Show RMZs, CMZs, and stream segment identifiers on the Activity
Map. If you are harvesting within 75 feet or within the maximum RMZ, whichever is less, stream shade must be
assessed and met following harvest. Describe in Question 28 how stream shade was determined to be met or use
the 'Appendix F. Stream Shade Assessment Worksheet' if necessary.
Stream
Segment
Identifier
(letter)

Water
Type
(S, F)

Site
Class
(I - V)

Stream Width
(feet)

Is there
aCMZ?
(YorN)

RMZ Harvest
Code(s)
(see instructions)

DFC Run
Number

Total
width of
RMZ
(feet)

-

26. If harvesting within 50 feet of Type Np Water, complete the table(s) below. Show RMZs and stream segment
identifiers on the Activity Map.
Stream
Segment
Identifier
(letter)

Total Stream
Length in
Harvest Unit
(feet)

Length of No-Harvest,
50-foot Buffers in
Harvest Unit
(feet)

Stream
Segment
Identifier
(letter)

Total Stream
Length in
Harvest Unit
(feet)

Length of No-Harvest,
50-foot Buffers in
Harvest Unit
(feet)

-

10/ 1/2018

Page 7 of 9

Western Washington

 27. How are the following currently marked on the ground? (Flagging color, paint color, road, fence, etc.) Harvest/
Salvage Boundaries:

Orange flashers, Orange ribbon, type change

Clumped Wildlife Reserve Trees/Green Recruitment Trees: Single tree is Band of orange paint.
Right-of-Way Limits/Road Centerlines: _n_a_ _ _ __ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ __
Stream Crossing Work: _n_a_ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ __ _ _ _ __ _ _ __
Riparian Management Zone Boundaries and Leave/Take Trees: same es t:lariest bc;n,mdar:y

S9

CJ/ j 2- / l<i?

Channel Migration Zone: _n_a_ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ __ _ _ _ _ _ __
Wetland Management Zone Boundaries and Leave/Take Trees: _n_a_ _ _ _ _ _ _ _ _ _ _ _ _ _ __
28. Additional Information (attach additional pages if necessary): For hydraulic projects in or over Type S, F, or
complex N Water(s) see instructions for requ ired plan information. If applicable, document the mitigation measures
you will be implementing from a geotechnical memo, letter, or report.
Proposal Name: Ricklets
*please reference unit name on all correspondence
There is no typed water associated with this FPA.

Notice: Any agency, person or persons desiring to conduct a field review of this FPA must contact ORM's Poulsbo
office for gate, access, and traffic information. Such access will be granted to those having a legitimate, specific
interest in reviewing th is FPA during a specific time frame. This extra control is needed for the safety and protection
of our tree farm visitors as well as the people who work on the tree farm. Thank you for your cooperation.

10/1/2018

Page 8 of 9

Western Washington

 29. We acknowledge the following :
•

The information on this application/notification is true.

•

We understand this proposed forest practice is subject to:
o The Forest Practices Act and Rules AND
o All other federal , state or local regulations.

•

Compliance with the Forest Practices Act and Rules does not ensure compliance with the Endangered Species Act
or other federal, state or local laws.

•

If we said that we would not convert the land to non-forestry use, the county or city may deny development permits
on this parcel for the next 6 years.

•

The following may result in an unauthorized incidental take of certain endangered or threatened fish species:
o Conversion of land to non-forestry use.
o Harvesting within the maximum RMZ on a 20-acre exempt parcel that was acquired after June 5, 2006.
o Equipment Crossings/Fords in or over Type S and F Waters.
Inadvertent Discovery - Chapters 27.44, 27.53, 68.50 and 68.60 RCW
o If you find or suspect you have found an archaeological object or Native American cairn, grave, or glyptic
record, immediately cease disturbance activity, protect the area and promptly contact the Department of
Archaeology and Historic Preservation at 360 586-3077.
o If you find or suspect you have found human skeletal rema ins, immediately cease disturbance activity,
protect the area, and contact the County Coroner or Medical Examiner and local law enforcement as soon as
possible. Failure to report human remains is a misdemeanor.

The landowner understands that by signing and submitting this FPA, he/she is authorizing the Department of
Natural Resources to enter the property in order to review the proposal, inspect harvest operations, and monitor
compliance for up to three years after its expiration date. RCW 76.09.1 50
Signature of Legal TIMBER OWNER*
(If different than landowner)

Signature of Legal OPERATOR
(If different than landowner)

Print Name: Sean Greif

Print Name:

Print Name:

Date: 9/7/18

Date:

Date:

Signature of Legal LANDOWNER

-6§;;

¼,

OLM

* NOTE: If you are a "Perpetual Timber Rights Owner," and are submitting this without the Landowner's Signature, provide
written evidence the landowner has been notified.

Please make a copy of this FPAIN for your records. If this FPA/N contains a hydraulic project requiring WDFW
concurrence review, it will not be available online for public review until after the WDFW concurrence review
period.

10/1/2018

Page 9 of 9

Western Washington

 Acres: 80

(

Contract# _ __
Exhibit: A-1
0 erator Ma

TRS: Sec30/31 T27N R2E
Lat/Lon : -122.59 47.80

, _ J rall

,

-

-

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I
\

/
/

\

I

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,.

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:

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/

N

1910248

EE

il

..
t:
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1 inch = 500 feet

Fish
Nonfish

Olympic Resource Management

...... Even-aged
t..,. .J Forestry

r.-7 Leave Tree
Doesn't Exist l:.___jJ Area

0

270

r - 7 Managed
l.-.J Ti mberlands
Timber
Reserve

Contractor Instructions:
Unit boundary marked with orange ribbon and orange "Timber Harvest Boundary" tags, And timber type change.
Spec and Info:
Shovel logging landings my be located anywhere within 50 ft of any/all
roads that are located within or along the harvest boundary.
Company Rep. :_ _ _ _ _ _ _ __ __

Contractor: _ _ _ _ _ __ __ __

 Marbled Murrelet Form
Western Washington Forest Practices Application/Notification
Complete this form only if you are harvesting timber (including salvage) or constructing roads.
Do not complete this form if you have an HCP for marbled murrelets.
Answer every question.

1. [8] No

D Yes

For this FPA/N, has a protocol survey(s) been completed that includes:
Harvest units (and within 300 ft on your ownership), or
Salvage units (and within 300 ft on your ownership), or
Any area of proposed road construction (and within 300 ft on your ownership)?
If 'Yes', fill out the table and check the appropriate findings below.

Survey ID

Township,
Range, &
Section

(Name or
Unit#)

Survey was
approved by
WDFW
(Attach approval
letter from W DFW)

Survey was
disapproved by
WDFWand is
being
resubmitted with
this FPA/N
(Explain below)

• Occupancy D Occupancy
• Presence
D Presence
D No Detections D No Detections
• occupancy • occupancy
D Presence
• Presence
D No Detections D No Detections
• Occupancy • Occupancy
D Presence
• Presence
D No Detections

D No Detections

Survey is complete
but has not yet
been submitted to
WDFW
(Submit survey
with FPA/N)

Survey has been
submitted to
WDFWand
survey approval is
unknown
(Explai n below)

• occupancy
• Presence
D No Detections
• Occupancy
• Presence
D No Detections
• occupancy
• Presence
D No Detections

• occupancy
• Presence
D No Detections
• Occupancy
• Presence
D No Detections
• occupancy
• Presence
D No Detections

Explanation:

2.

[8] No

D Yes D Unknown

Will you harvest, salvage, or construct roads within 0.25 miles of an
occupied site?

3.

[8] No

D Yes D Unknown

Will you fly helicopter(s) over or within 0.25 miles of an occupied site?

4.

[8] No

D Yes

Will you harvest live trees in a buffer of an occupied site?
If Yes, describe the leave trees and buffer widths you will leave.
NO TE: If you leave less than required in WA C 222-16-080( 1) (h) (v) this
is a Class IV-Special and an Environmental Checklist is required

Description of managed buffers:

Appendix J - 6/1/2016

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 5. [8] No

D Yes

Are there nesting platforms within any harvest unit (including salvage and road
construction) that are within 300 feet that:
Are not located within a surveyed area , and;
Have a minimum of 2 platforms per acre, and ;
Are located within 7 or more acres of contiguous habitat, and;
Have a least 40% (number not volume) of the dominant and co-dominant
trees made up of Douglas-fir, western hemlock, western red cedar, or Sitka
spruce?

If "Yes", complete the table below for those areas.
Name or# (as
shown on map) of
delineated stands
of contiguous
habitat

6. [8] No

D Yes

Delineated
stand acres

Nesting
platforms
per acre

Number of
trees 32 inches
dbh or greater
with platforms

Platform Assessment Method
Field Sampling Method, Sample Plot
Method, 100% Cruise Method, Inventory
Model Method, or Other

Are there areas within this forest practice or within 300 feet that:
Are not surveyed, and;
Are not listed in question 5, and;
Have trees that are at least 32 inches dbh

If "Yes", list the forest practice unit numbers from your activity map. Provide brief description of current
stand cond itions. Such as tree species composition , stand age (if known), and maximum tree size (dbh).
Harvest Unit #(s)_ __ __ __,.__, Within the Unit

• Within 300 feet of the Unit

Description:

Harvest Unit #(s)_ __ _ _-L_JW ithin the Unit

D Within 300 feet of the Unit

Description:

Harvest Unit #(s)_ _ _ _ ___,.__, Within the Unit

D Within 300 feet of the Unit

Description:

7.

If you answered yes to question 1, 4, or 5, include a map (separate from your map that shows your
harvest units and/or road construction) See the instructions for the information required on each map.

Appendix J - 6/1/2016

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