CULTURAL RESOURCES MANAGEMENT PERMIT APP

Community and Ecosystems

Kathleen Sloan
Program Director
ksloan@yuroktribe.nsn.us
(707) 482-1822 ext. 1009
Cell: (541) 251-3159

Joe Hostler
Specialist
Air Quality jhostler@yuroktribe.nsn.us
(707) 499-3811 cell
(707) 482-1822 x 1010 office

Suzanne Fluharty
Specialist
Pesticides & Environmental Health sfluharty@yuroktribe.nsn.us (707) 954-9290 cell
(707) 482-1822 x 1013 office

Robin Blythe
Specialist
NEPA & CEQA Compliance/Environmental Education, Tribal Ordinances rblythe@yuroktribe.nsn.us
(707) 954-3342 cell
(707) 482-1822 x 1014 office

Rosie Clayburn
Specialist
Cultural Resources - NHPA rclayburn@yuroktribe.nsn.us
(707) 954-2075 cell
(707) 482-1350 ext. 309 office



Yurok Tribe
Klamath Office
15900 Hwy 101 N
PO Box 1027
Klamath, CA 95548


Cultural Resources Management Permit Application


border

Please fill out form below and submit for approval.

Instructions: Complete and return this application form and necessary supporting documentation to the Yurok Tribal Office in Klamath. All information requested must be completed before the application will be considered. Use separate pages if more space is needed to complete a section and attach.


Applicant Name (Yurok Tribal Department, Corporation, Lead Agency, Individual, or Other Entity)

Mailing Address

Email Phone

Fax

LOCATION OF PROPOSED WORK: Description of lands involved using the best available location information (complete all boxes possible).

i. Latitude and Longitude

ii. UTM Coordinates

iv. APN (parcel) Number

v. Assignment/ allotment

vi. Physical Address

b. Attach a map and other relevant supporting documentation identifying the location of proposed work, defined as the Area of Potential Effect, which should include all areas proposed for use in the project, such as staging, implementation, cleanup, or otherwise included in the Proposed Work described below. Location should preferably be mapped on a 1:24,000, 7.5-Minute Series U.S. Geological Survey (USGS) Topographic Quadrangle map. Additional supporting Documentation that may be attached could include photos, parcel maps, site plans, surveys, and engineer drawings.


7. Nature of Proposed Work: a. Please check all that apply:
trenching road construction boring drilling plowing
excavation road grading digging tunneling
topsoil stripping auguring backfilling blasting land leveling
install utility pole quarrying ground clearing grating
vegetation removal other (explain below)

2 b. Please describe in detail the proposed work, particularly as related to ground-disturbing activities, including the depth and width of each activity as checked in 7a.


8. Date of Proposed Work: From:To:

9. Time of Proposed Work: a.m. TO p.m.

10. Permit Applicant Contact Information:


a. Name:

b. Title:

c. Organization:

d. Telephone number(s):

e. Email Address:

f. Mailing Address:


11. Landowner(s) Contact Information:

a. Name(s):

b. Telephone number(s):

c. Email Address(es):

d. Mailing Address(es):

12. Project Manager:

a. Name:

b. Title:

c. Organization:

d. Telephone number(s):

e. Email Address:

f. Mailing Address:


13. Project Contractor:

a. Name:

b. Title:

c. Organization:

d. Telephone number(s):

e. Email Address:

f. Mailing Address:
14. Project Inspector:

a. Name:

b. Title:

c. Organization:

d. Telephone number(s):

e. Email Address:

f. Mailing Address:


15. Project Subcontractor:

a. Name:

b. Title:

c. Organization:

d. Telephone number(s):

e. Email Address:

f. Mailing Address:


16. Does this proposed project involve Federal funds, proposed to occur on federal lands, or could otherwise be defined as an “undertaking” according to Section 301 (7) of the National Historic Preservation Act of 1966 as amended through 2006?

Check applicable: Yes No


17. To your knowledge, is the proposed project in an area that likely contains cultural resources?

Check applicable: Yes No

Certification

I, certify that I have read the Cultural Resources (Permit Applicant) Protection Ordinance, understand work may not begin until the proposed project is permitted, and agree to the terms and conditions that may be applied to the permit, and have the full consent of all pertaining landowners to conduct the proposed work. (Initial) I certify and declare under penalty of perjury that I have read and understand all items on this application and have had the opportunity to consult legal counsel in regard to this Permit. I further declare under penalty of perjury that all information contained herein is true and correct to the best of my knowledge and belief and agree to submit to the jurisdiction of the Yurok Tribal Court for all actions arising out of, or related to, the project associated with this Permit. (Initial)


Signature of Permit Administrator
Date



border
border

line

RESOURCES