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Date By Date By --DECKS >
Walls Date By Cn
FRAMING Data PROPANE TANKS 9
Date BY 8Y --4
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Date BY ato By
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IDRYWALL roe,
D�W.v I Int.Brace Wall Dale By
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C) Interior Date By Interior-Date 10
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FIRE DEPARTMENT
Date 13Y Date By By 0
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z
Date Data By DECKS >
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FRAMING Date By PROPANE TANKS &
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FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO.
PLEASE? N�PES ARD °, -BUILDING edar.PoERMITAPPox 186, oLICA 85ON84 ( t"�
I Shelton (360) 427-9670 • Belfair (360) 275-4467 • Elma (360) 482-5269
1� I \ On the web www.co.mason.wa.us
APPLICANT_INFORMATION CONTRACTOR INFORMATION
Owner. .:7-e7_7 Company Name
Mailing Address =? Mailing Address
City State U1Z_Zip Code ZS!E/D/ City State Zip Code
Phone Other Ph.ds3 Phone Other Ph.
Lien/Title Holder Contractor Re Exp.
E mail address E Mail A ss
Drivers Lic.# DOB Drivers Lic.# DOB
SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic tin Se ti
Connect to Water System Name of Water Systems �`�>L,--Y �P
Well Water System Name of Water System 1Z 5` -
PARCEL INFORMATION - 12 Digit Parcel No. 1_2 6/— -5-r— 36, Fire District 1, _
Legal Description
Site Address (Please include street name, street number anA city) ���-.
Direct' ns to it / W/`, _
Will timber be cut and sold i arcel prepara�-.XXi�s
Is property within 200'of Saltwater (:_Lake_ River/Creek Pond
Wetland Seasonal Runoff Stream Slopes or Bluffs > 15%
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Ye;E777
TYPE OF JOB qLew Add Alt Repair Other PRIMARY RESIDENCE SEASONAL ❑
Use of Building Describe Work
No.of Bedrooms No.of Bathrooms Square Footage- 1 st Floor 2nd Floor
3rd Floor Basement Deck Covered Deck Other Sq.ft.
Garage Attached Detached Carport Attached Detached
MANUFACTURED HOME INFORMATION - Make Model —1"-Sa�3 f--/Years
Length Width.(-2; Serial No. —No.of Bedrooms No.of Bathrooms
Type of Heat Purchase Price $ Replacement Unit? Yes .
Installer Name Certification No.
OWNER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or permit revocation.Acknowledgement of
such is by signature below.I declare that I am the owner,owners legal representative,or the contractor.I further declare that I am entitled to receive this
permit and to do the work as proposed in the application.I declare that I have obtained the permission from all the necessary parties.If permission is
required from any easement holder or any other party in interest regarding this application or the work proposed in the application,I have obtained
permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,represents that the information
provided is accuratAnd grants employ s of Mason County access to the above described property and structure for review and inspection.
PROOF Oger
IN N OF W IS BY MEANS OF A PROGRESS INSPECTION.
Date:
O ners Re r sentat' Contractor indicate which one
FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department ; ,0'SS •0631` ,Lx,r ti ll
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
FEES
Building Permit Fee Site Inspection
Plan Review Fee EH Review Fee
Plumbing & Base Fee Planning Review Fee
Mechanical & Base fee Other
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal
Valuation $ TOTAL FEES
FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO.
PLEASE Es ARD BUILDING PERMIT APPLICATION
426 W. Cedar • P.O. Box 186, Shelton, WA 98584 C)��C�
i Shelton (360) 427-9670 • Belfair (360) 275-4467 • Elma (360) 482-5269
On the web www.co.mason.wa.us
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner. .` _ `1G1,�� Company Name
Mailing Address yf 9 25G,'1e� sT Mailing Address
City _State 44, Zip C, City State Zip Code
Phone <'s3-�'sz/-?ez* Other Ph.d!`3 `33.2 11-7d Phone Other Ph.
Lien/Title Holder Contr�Ass
Exp.
E mail address E Mail
Drivers Lic.# DOB Dr' s Lic.# DOB
SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic stin Se ti
Connect to Water System Name of Water System_�1971--
Well Water System Name of Water System _155— oZ_
PARCEL INFORMATION- 12 Digit Parcel No. .:3� -:5--r-- O00 3 Fire District
Legal Description
Site Address (Please include street name, street number anA city _ 6.;?, ol
Direct' ns to ite > WIV- �--
el
Will timber be cut and sold i arcel para s
rep
Is property within 200'of Saltwater � River/Creek Pond
Wetland Seasonal Runoff Stream Slopes or Bluffs J 15%
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Ye o
TYPE OF JOB < ew Add Alt Repair Other PRIMARY RESIDENCE SEASONAL ❑
Use of Building Describe Work
No.of Bedrooms No.of Bathrooms Square Footage- 1st Floor 2nd Floor
3rd Floor Basement Deck Covered Deck Other Sq.ft.
Garage Attached Detached Carport Attached Detached
MANUFACTURED HOME INFORMATION - Make Model _ �SG'3 ff Year
Length r Width Serial No. Tx9a No.of Bedrooms 2 No.of BathroomsdZ
Type of Heat Purchase Price$ 6U,52 Replacement Unit? Yes
Installer Name /h/5z51 Certification No. 4/
OWNER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or permit revocation.Acknowledgement of
such is by signature below.I declare that I am the owner,owners legal representative,or the contractor.I further declare that I am entitled to receive this
permit and to do the work as proposed in the application.I declare that I have obtained the permission from all the necessary parties.If permission is
required from any easement holder or any other party in interest regarding this application or the work proposed in the application,I have obtained
permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,represents that the information
provided is accuratgand grants employ s of Mason County access to the above described property and structure for review and inspection.
PROOF OF IN N OF W IS BY MEANS OF A PROGRESS INSPECTION.
Date:
Owner/O ners Re r sentat' Contractor indicate which one
FOR OFFICIAL USE BEYOND THIS POINT Accepted by: 1CA_ L Date
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department OO
Planning Department
Environmental Health Departmen
Public Works Department
Fire Marshal
FEES
Building Permit Fee Site Inspection
Plan Review Fee EH Review Fee
Plumbing & Base Fee Planninq Review Fee
Mechanical & Base fee Other
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal
Valuation $ TOTAL FEES
FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO.
PLEASE PF ES ARD BUILDING PERMIT APPLICATION (_
426 W. Cedar• P.O. Box 186, Shelton, WA 98584 C)cc",rvv
i Shelton (360) 427-9670 • Belfair (360) 275-4467 • Elma (360) 482-5269
l , On the web www.co.mason.wa.us (d
APPLICANT_INFORMATION CONTRACTOR INFORMATION
Owner Company Name
Mailing Address 9f 9 Mailing Address
City _State 4'40 Zip Code City State Zip Code
Phones 3-fin/-ir� Other Ph.ds3 Phone Other Ph.
Lien/Title Holder Contractor Re Exp.
E mail address E Mail A ss
Drivers Lic.# DOB Dr' s Lic.# DOB
SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic 'E--x'stinq Septic
Connect to Water System Name of Water System � e!22--i.LrY ��P
Well Water System Name of Water System "Z- `r`
PARCEL INFORMATION - 12 Digit Parcel No. 3� 12 y- '000 a o
Fire District -
Legal Description -
Site Address (Please include street name, street number anj city)--. 5:�-: cf-4zza .
Direct ns to site
Will timber be cut and sold i arcel re ara s
Is property within 200'of Saltwater prep
p ak River/Creek Pond
Wetland Seasonal Runoff Stream Slopes or Bluffs J 15%
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Ye o
TYPE OF JOB New Add Alt Repair Other PRIMARY RESIDENCE SEASONAL ❑
Use of Building Describe Work
No.of Bedrooms No.of Bathrooms Square Footage- 1 st Floor 2nd Floor
3rd Floor Basement Deck Covered Deck Other Sq.ft.
Garage Attached Detached Carport Attached Detached
MANUFACTURED HOME INFORMATION - Make Model Z/ Year
Length Width c-�i Serial No. No.of Bedrooms --:3, No.of Bathrooms�Z
Type of Heat Purchase Price$ Replacement Unit? Yes
Installer Name _ /5p Certification No. 4/
OWNER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or permit revocation.Acknowledgement of
such is by signature below.I declare that I am the owner,owners legal representative,or the contractor.I further declare that I am entitled to receive this
permit and to do the work as proposed in the application.I declare that I have obtained the permission from all the necessary parties.If permission is
required from any easement holder or any other party in interest regarding this application or the work proposed in the application,I have obtained
permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,represents that the information
provided is amurateand grants employ s of Mason County access to the above described property and structure for review and inspection.
PROOF OF IN N OFW9RK IS BY MEANS OF A PROGRESS INSPECTION.
Dates
Owner/O ners Re r sentat' Contractor indicate which one
FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department 00O .66�3k ( �
Planning Department
Environmental Health Departmen
Public Works Department
Fire Marshal
FEES
Building Permit Fee Site Inspection
Plan Review Fee EH Review Fee
Plumbing & Base Fee Planning Review Fee
Mechanical & Base fee Other
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal
Valuation $ TOTAL FEES
FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO.
PLEASE ES ARD B P.O.ILDING PERMIT APPLICATION C l �
uym��" 426 W. Cedar- Box 186, Shelton, WA 98584 CS
�n i Shelton (360) 427-9670 - Belfair (360) 275-4467 - Elma (360) 482-5269
Y 1. 1. \ I On the web www.co.mason.wa.us
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner .�_6�2_7 /_1�,U� Company Name
Mailing Address_A 9 ;F, Mailing Address
City— State 4415ZZip Code J /DL City State Zip Code
Phone �s3-�sz/-Z�+,'i Other Ph.d5�3`33.2 ri��' Phone Other Ph.
Lien/Title Holder Contractor Re Exp.
E mail address E Mail A ss
Drivers Lic.# DOB Dr' s Lic.# DOB
SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic = tin Se pti
Connect to Water System Name of Water SystemP� G�z' �/v
Well Water System Name of Water System - oZ._
PARCEL INFORMATION - 12 Digit Parcel No._,2�_L,2 4/- --Y-r Dom Fire District
Legal Description
Site Address (Please include street name, street number ano city) 6 o
Direct ns to ite
Will timber be cut and sold i arcel prepara s
Is property within 200'of Saltwater LLLake ^ River/Creek Pond
Wetland Seasonal Runoff Stream Slopes or Bluffs J 15%
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Ye o
TYPE OF JOB New Add Alt Repair Other PRIMARY RESIDENCE SEASONAL ❑
Use of Building Describe Work
No.of Bedrooms No.of Bathrooms Square Footage- 1 st Floor 2nd Floor
3rd Floor Basement Deck Covered Deck Other Sq.ft.
Garage Attached Detached Carport Attached Detached
MANUFACTURED HOME INFORMATION - Make S_ /� // !'c' �sT" Model �/S�G'3 zV Year
Length �Width c-2 Serial No. —- a No.of Bedrooms 3 _No.of Bathrooms Z'
Type of Heat Purchase Price$ gE 4U:�2 Replacement Unit? Yes
Installer Name /�l�/5C 1l5 Certification No.
OWNER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or permit revocation.Acknowledgement of
such is by signature below.I declare that I am the owner,owners legal representative,or the contractor.I further declare that I am entitled to receive this
permit and to do the work as proposed in the application.I declare that I have obtained the permission from all the necessary parties.If permission is
required from any easement holder or any other party in interest regarding this application or the work proposed in the application,I have obtained
permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,represents that the information
provided is accurat d grants employ s of Mason County access to the above described property and structure for review and inspection.
PROOF OF IN N OF W IS BY MEANS OF A PROGRESS INSPECTION.
Date_
Owner/O Hers Re r sentaf Contractor indicate which one
FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date
DEPARTMENTAL REVIEW APPROV D DENIED NOTES
Building Department L �d�-O
Planning Department
Environmental Health Department
Public Works Department �, 1
Fire Marshal
FEES
BuildingPermit Fe Site Inspection
Plan Review Fee EH Review Fee
Plumbing& Base Fee Planninq Review Fee
Mechanical & Base fee Other
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal
Valuation $ TOTAL FEES
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NGES FOR L
MUST MEET ALL CURRENT
WASHINGTON STATE CODES
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MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
June 13, 2008 PO BOX 1666 Shelton WA98584
Shelton (360)427-9670
Fax (360)427-8442
SCOTT MUNZ / DONNA SMITH Elma (360)482-5269
909 EAST FILBERT ST Belfair (360)275-4467
KENT WA 98030
Case No.: BLD2008-00665 Parcel No.:321245000036
Dear Applicant:
Your building permit cannot be approved by Mason County Environmental Health until
the following are completed and turned in:
IjReport within the last three years from either a septic tank pumper or an Operation
and Maintenance Specialist.
Please call me at(360)427-9670, ext. 279 if you have any questions.
Sincerely,
Amanda Reynolds
Environmental Health
Mason County Health Services
Comments:
6/13/2008 1 of 1 BLD2008-00665
Mason County Planning Intake Checklist
Owners Name:
Date: �(
Project: Reviewed
Proposed use(s) of structure(s-Commercial Development: YES NOS PLANNER: GBM TSW PB RDH REC JMS
S"te Plan: -
North Arrow o Su y uired /�I�yn�UGA - ❑ AF# ❑ Monuments
Property Dimensions:
Streets and Driveways Shown. Road name• - 41 A
All Existing Structures shown with setbacks and use
, Septic and Drain-field Shown with se ks
-TJ!�-`Identify all surface water(streams, �ponds,shorelin an�Cs,;natural or historic drainage,defined 1 /
drainage ditches) ��� 4�L �.� _- / 1�. �'tit�'
Topography(slopes) C 16\C�,l (C y � � ,��k0
Minimum Structslre Setbacks Tr/TSl:
etback
F• L. / 3c; R: S2:
} Utility and Drainage Easements: Yes No,(if yes enter condition #5022)
Other Easements
cc
essory Appurtenances: Propane / Heatpump�n 1 -
Res site plan show JamdLn l exits. V
Variance applied for( Yes / J- parking�spkes allotted? Yes / No . ,
unty Access Perms (add condition #0010) )2 � - L�)l 3te Access Permit Needed (add condition #0020) }.a
Standard Conditions to be added to all Building permits that planning reviews: #5019 and #0700
Site Access: Are there any impediT ?(d��s/gates)that my restrict access to your site?
Is the site clearly marked? How? Address
❑ l�1Va�n�- �"
Zonin : ❑ Other:
C PI n: I Z i UGA Zoning:
ural \RR 2.5 5 10 20 ❑ RT/RTC ❑ R 5 ❑ HC
0 RAC ❑ RMF 0 Unknown ❑ k4p-�___ ❑ R-10 0.�'"—D VC
0 .Allyn UGA ❑ RC 1 2 3 0 Agricultural. ❑ R-1R g-f�= 0 FR ❑ �HP
❑ Belfair UGA ❑ RI D In-holding ❑ R-2 "b PF 0
0 Shelton UGA ❑ RNR ❑ LTCFL ❑ R 3 ' ❑ POS ❑ GC ❑
❑ Tribal _ �.�.,
❑ GC-CI
Critical Areas: (streams, pond shorelin 'Veti Inds;steep slopes)
Shoreline
Desig-nation: ❑ N/A 01 Urban 0 Rural ❑Conservancy ❑ Natural ❑ Unkown
Water Bode a of water if unnamed):
SEPA: Y No,` Unknown Flood Plain: YES/NO
(Unknown Map#
Aquifer Recharge: YES/NO Unknowh Map#
Tags/Cases:
RLC/SPI Case: �1� 6-Year Dev. Moratorium: YE I NO
Eagle Nest Tag: Y NO Other YES(NO ;
Revised: 02-07-2008 I:\PLANNING\PAC\PLANNING INTAKE
MASON COUNTY af
l DEPARTMENT OF HEALTH SERVICES
Environmental Health - Personal Health
PO BOX 1666 SHELTON,WA 98584
LOCAL(360)427-%70
BELFAIR(360)275-4467
.Application for Determination of Adequacy FAX(360)427-7798
Instructions
G Bart 1 t *` rya rude uia >s i. c
PART 1: Applicant/Parcel Identification
Name of Applicant 560'1T 4k. XA LW7- Date '
CEO- ;j�3- 3 32—lni 70
Mailing Address qCPQ TiL8iM7 V1-e Telephone yfmil-i- 1-53-024 79p+
Assessor's Parcel Number `3 Cam. q- ' 5 d" 020 0
Type of Water System Check One): Reason forA lication Check One):
Public(Community Water System(2 or more Building permit
connections)" ❑ Land use application,if so..
❑ Individual water source(one connection), ❑ Division of land:
if so..
Well #of Parcels? SPL -
Spring/surface water ❑ Boundary line adjustment
❑ Other(explain) ❑ Other(explain)
**If you have more than one residence ❑ Replacement(please indicate name of water system
connected to this well,check the Public box. below if applicable—no signature required)
PART 2: Water System.Information
Complete the section appropriate for the type of water system being evaluated:
Public Water System
Name of Water System kK c'� j '�`` A N" '�c c '-L
JV
Water Facility Inventory(WFI)Number:
(write."none"for two party)
0 I am the manager of this water system.The water system has been approved for services.
There are presently f3-2 connection(s)in use.This.will be the J�_connection,
❑ I am the manager of this system.This connection will be to upgrade or change the use of an
existing connection on this system(ie:recreational to full time).Please indicate on the following
line the nature of this change:
This water system is able and willing to provide water to this(these)connection(s)without
exceeding the limits of the water system or any limits set by state and local regulation.
Signature of Water System Mana ger ate
Update:Apri12006
�—-- �jGl Parcel# C %/�� BLD#
Name,-��C "// / ' /y� ����t"i�� C--� r � ,
Mason County A
Department of Community Development _ g "
Small Parcel.Stormwater Management Application/Worksheet (page I'dZ)
Per Mason County Code,Title 14, Chapter 14.48 a stormwater site plan is required-whenever a building application is
made for residential development,or redevelopment', with more than 2,000 square feet of impervious surface'.
'Redevelopment means,on an already developed site, the creation or addition of impervious surfaces,structural development
including construction,installation or expansion of a building or other structure,and/or replacement of impervious surface that is not
part of a routine maintenance activity,and land disturbing activities associated with structural or impervious redevelopment..
2Connnon impervious surfaces include,but are not limited to,rooftops,walkways, patios,driveways,parking lots or storage areas,
concrete or asphalt paving,gravel roads,packed earthen materials,and oiled,macadam or other surfaces which similarly impede the
natural infiltration of stormwater.Open,uncovered retention/detention facilities shall not be considered as impervious surfaces.
.. ..... ......................................................................................v.:...... ............. ....................... ................ ... .... .. .... Wow
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Surface Type Length X Width = Area *All dimensions in feet
Buildings X _
X = Measurements for buildings are taken at the
perimeter of the farthest projections (example:
X = eaves/gutters)
X =
Driveways X =
G; X = Length of drive begins at the right of way
X =
Parking Areas X =
X = Any paved, gravel or packed area per definition
above table
X =
PatiosMalks X =
X = Any paved, gravel or packed area per definition
above table
X =
Oth
ers
X =
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1t >
X — :«<::' ::'. <:l' 'i' �al £#lil#f:• ''11# SH
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rfar : a
'I*t3tai..im.
If the Total Impervious Surface.Area is LESS THAN 2000 Square Feet, please read, acknowledge and sign below.
Based Upon the information you have provided a Stormwater Site Plan IS NOT required for this development activity.
Owner/Builder/Agent Acknowledges that submission of inaccurate information may result in a stop work order or permit revocation.
Acknowledgement of such is by signature below. I declare that I am the owner,owner's legal representative,or the contractor. I
further acknowled that the ' 'on provided is accurate and employees of Mason County are granted access to the above-
described pro� for reviq� an inspection as y be required. 5�
x' l" Ownei eantractor(circle one)Date:
If the Total Impervious Surface Area is GREATER THAN 2000 Square Feet,please read, acknowledge and sign
the information provided on page 2 of 2.
Page 1 of 2
Name f� Parcel# 7 S% BLD#
Mason County '
Department of Community Development . �, 0V
Small Parcel Stormwater Management Application/Worksheet (paVwj-? f 2)
{
Based Upon the information you have provided a Stormwater Site Plan IS Required for this development activity.
Title 14,Chapter 14.48 of the Mason County Code(MCC)regulates compliance requirements for Stormwater
Management in this jurisdiction. A complete copy of the ordinance can be found on the Mason County website:
http//www co mason wa—us/code/commissioners/index.htm
Please follow the links to "Title 14, Chapter 14.48 Stormwater Management".
Regulated activities shall be conducted only after Mason County Public Works approves a stormwater site plan
(Mason County Code Title 14 Chapter 14.48 section 14.48.70).You will receive a copy of the Public Works document
entitled "Managing Storm Drainage on Small Lots,The Small Parcel Stormwater Site Plan". This document will assist
you in preparing the necessary information and plans for Public Works to review and approve. Per Department of
Public Works this document will constitute an approved plan if all of the relevant details* are to be installed in
their entirety AND no part of the stormwater system adversely affects any septic system (see Environmental Health
information below). If an alternative system is to be used a plan will need to be submitted to Public Works for approval.
A design by a registered professional may required for more complex sites.
*These details are found in the document Managing Storm Drainage on Small Lots, The Small Parcel Stormwater Site Plan
on the pages that begin with"Handout"
PLEASE INITIAL BELOW TO INDICATE THE STORMWATER MANAGEMENT PLAN FOR THIS SITE
A) The relevant details from Managing Storm Drainage on Small Lots, The Small Parcel Stormwater Site Plan will be installed
in their entirety AND the system will be located as not to adversely affect any septic systems on this,or any other,.parcel.
B) An alternative plan and/or professional design will be submitted to the Department of Public Works for approval AND the
system will be located as not to adversely affect any septic systems on this,or any other,parcel
If you have further questions pertaining to parcel drainage and stormwater management Mason County's Public Works
Department can provide additional instructions,guidance and examples. (Section 14.48.130)contact Public works at:
Phone: (360)-427-9670 EXT. 450
Mail: P 0 Box 1850, Shelton WA 98584
Physical: 415 N 6th St, Shelton WA 98584
If this development has, or will have, a septic/drainfield system you may need to contact Mason County Division of
Environmental Health to ensure that the stormwater system will not adversely affect the septic system of this, or
any other,parcel.You may also wish to consult with the septic design professional involved with the project. Mason
County Division of Environmental Health can be reached at:
Phone: (360)-427-9670 EXT. 352
Mail: P 0 Box 1666, Shelton WA 98584
Physical:426 W Cedar St,Shelton WA 98584
A condition will be added to the building permit that states, in part,that all conditions the stormwater site plan will be met
prior to a request for final inspection of the building permit.
Owner/Builder/Agent Acknowledges that submission of inaccurate information may result in a stop work order or permit revocation.
Acknowledgement of such is by signature below.I declare that I am the owner,owner's legal representative, or the contractor. I
further acknowledge that the information provided is accurate and employees of Mason County are granted access to the above-
described property for review and inspection as may be required.
X Owner/Agent/Contractor(circle one)Date:
Page 2 of 2