HomeMy WebLinkAboutGRD95-0041 Cancelled - GRD Permit / Conditions - 9/21/1995 ol�
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GRD 00"'Ott I
MASON COUNTY
LAND MODIFICATION PERMIT
Grading, Excavation, Fill, Slopes, Drainage
Department of General Services
426 W. dar/P.O. Box 186, Shelton, WA 584 427-9670/1-80 -56 -5628 i
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#1 Owner 9 Phone# 5l Fire District#
Site Address f`C City St Zip
Owner Address ° City _ St Zip
Describe Work
#2 Contractor me ✓�G � � �f' � � e,Contractor Reg #
Address rL'�9 O Expiration Date
7
City r St Zip �� Phone# off
#3 Engineer's Name Phone#
Address City St Zip
#4 Parcel No.
Legal Description C',VV\
C), (�-a .G, v\ n 1(--�5 a� TV/
#5 Number of cubic yards to be excavated:
Number of cubic yards to be filled:
Number of cubic yards to be graded: /
#6 Will this be a balanced cut and fill entirely within the site?
Yes No
If No: Will fill be brought on site? Yes No
Where does imported fill originate from? O✓1 S4�. .
Does fill contain any potentially hazardous materials?
Yes No
#7 Will excavated materials be taken off site?Yes No t r�
If Yes: Where will excavated materials be taken? , ��( �,[—�sCV1S I
#8 Briefly describe existing terrain, vegetation, and improvements on subject site?
fte avte brJJtX 4r jJl s yes acrfsjej + ° '"' 4;t{3h,
Size of area to be cleared on slopes aver 10% AC/SF
#10 Has a soils report been completed on the subject site?
If yes, include copy with application.
#11 Is the subject site within 200 feet of a designated shoreline
#12 Does the subject site contain any of the following features?
River Lake Wetlands Saltwater
Slope greater than 15% Soft compressible soils
Seasonal Runoff None—x_
#13 Will the proposed land surface modification change the points
where storm water or groundwater enters or exits the site?
#14 Will the proposed land surface modification change the quality,
quantity, or velocity of storm water/groundwater? �
#15 What methods, if any, will be utilized to minimize erosion and
possible sedimentati into nearby waters during and after
construction? 14� %�
#16 Will this land modification result in the redirection of any surface
water runoff onto adjacent properties? ///G)
#17 Will surface or subsurface runoff be collected or controlled by
interceptors, curtain drains, or other water collection devices
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once this land modification has been completed? kll� —
#18 Will the land be replanted upon completion? /V
If yes, with what types of plants? _
#19 Will this modification result in slopes steeper than those currently
on the site?- 1/ C; If so, how steep?
NOTICE:THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED
WITHIN 180 DAYS OR IF CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT
ANYTIME AFTER WORK IS COMMENCED. PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS IN-
SPECTION.
OWNERS AFFIDAVIT CONTRACTORS AFFIDAVIT
I CERTIFY THAT I AM EXEMPT FROM THE REQUIRE- I CERTIFY THAT I AM A CURRENTLY REGISTERED
MENTS OF THE CONTRACTORS REGISTRATION LAW CONTRACTOR IN THE STATE OF WASHINGTON AND I
RCW 18.27, AND AM AWARE OF THE MASON COUNTY AM AWARE OF THE ORDINANCE REQUIREMENTS REGU-
ORDINANCE REQUIREMENTS FOR WHICH THIS PER- LATING THE WORK FOR WHICH THE PERMIT IS ISSUED
MIT IS ISSUED AND THAT ALL WORK DONE WILL BE IN AND ALL WORK DONE WILL BE IN CONFORMANCE
CONFORMANCE THEREWITH.NO CHANGES SHALL BE THEREWITH. NO CHANGES SHALL BE MADE WITHOUT
MADE WITHOUT FIRST OBTAINING APPROVAL FROM FIRST OBTAINING APPROVAL FROM THE BUILDING
THE BUILDING DEPARTMENT. DEPARTNJEn
J
X OWNER X BY
DATE DATE
FOR OFFICIAL USE ONLY:Accepted by: Date;
DEPARTMENTAL REVIEW
Planningomm-tAPP COND APP HOLD
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Building
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Environmental
Other
Special Conditions FEES
Grading Permit $ v
Plan Review
ZTi tSi
Site Inspection
Violation Fee
Other
S o
TOTAL FEES $