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CONV NTIONAL ,SYSTEM DESIGN FORM — PAGE TWO nwis.a 09/OS/92
32 �32. --23 - g000z
• PLOT PLAIT
PL. � : . . . . . . . .
- � FROM
. . . . . . . . . . . .1�.
. . . . . . . . . . - K'•
-� 1
_ _ . . . . . . . . .
. . . . frfOpv 6 Gov q QE p D5 xQ ; . : : AP. . PROVED:
.
'tip MASON CUUV I_Y DCD PLANNING
SITE RLAN REQIA�' ED TO BE ON SATE-
• - - - - - - - J'• GHANG&S S __ ;T TO- APPROVAL
- - - - - - - - E3XAZI
� .—
. . . . . . . . . . . ---�►-
l�S=� p �' . . . . . . . . . . . _ . . . .
-: . Marott t:uJr;;y
A
�� �� - .• _ -- , - Initials -
.. _ _ _ . . . - - Date.
- . . . . . . . . . - - . `---
,/
G 6 +C •�-6
DaSIGPER PLOT PLIST L E ve L
AN F
Scaled plot plan if lot is under j acres Location and dimensions of reserve area
El/ Existing and proposed wells, including 1:1Buildings, roadways, easements, parking
wells within 100 ft of property lines
j---J� Property lines
E3Topographical features, cute, banks
ElDirection and percent of slops
Location and orientation of curtain
drain & all absorption area components 0 Building stub-out
Name KOPLAL-rS Parcel# 3 2 1 32-23 —lD OoZBLD# 201 l0 - 0 1 1-1 Cp
Mason County
Department of Community Development
Small Parcel Stormwater Management Application/Worksheet(page 1 of 2)
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.
'Common 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.
To Calculate Impervious Surfaces Please Complete-This Table
Surface Type Length X Width = Area 'All dimensions in feet
Buildings lE3 X 32 = 57(�
X = Measurements for buildings are taken at the
perimeter of the farthest projections(example:
X = eaves/gutters)
X =
Driveways X =
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 =
Patios/1Nalks X =
X = Any paved, gravel or packed area per definition
above table
X =
Others X =
X = If the total impervious area of the proposed site
X = development_is greater than 2000 square feet a
Small Parcel Stormwater Site Plan is Required
Total Impervious Surface Area (sum of all areas) j7b
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 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 Owne<E3 ontractor(circle one)Date:
If the Total Impervious urface 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 Parcel# BLD#
Mason County
Department of Community Development
Small Parcel Stormwater Management Application/Worksheet (page 2 of 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 be 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 e)d 450
100 W.Public Works Dr
Shelton.WA 99584
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 400
415 N. Gth St— Bldg #8 lower level
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
ors .co r MASON COUNTY COMMUNITY SERVICES
PERMIT A SSIS TA NCE CENTER: Permit No: .1 0 '901 Le -6 1 17l D
?` BUILDING• PLANNING• FIRE MARSHAL Received b .
615 W. Alder St - Shelton, WA 98584
Phone Shelton:(360)427-9670 ext 352 Fax:(360)427-7798
Rs1'' Phone Belfa'r• _1 . 360 275-4467 Phone Elma: 360 482 5
BUILDING PERMIT APPLICATION AlderF'!5
PARCEL OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME: AIL Ab4 V_R ,NE, H,p1e4t-1F S NAME: SczW MxA(L!fy
MAILING ADDRESS: 221 E SfoHG6rt cv pL MAILING ADDRESS: SK Vit, .
CITY: 150- Ei t STATE: WA ZIP: 9 Zsy CITY: !E>kaL6,, STATE:(,Jk0, ZI : 98�
PHONE#1: PHONE: q2 7--G72 3 CELL: 3(,p 22 q-9313
PHONE#2: EMAIL oK . Ce
EMAIL: L&I REG# " EXP.�/� / 7
CONTACT PERSON : PARCEL OWNER ❑ CONTRACTORS *OTHER/See Below ❑
NAME;: S co MAILING ADDRESS: leoo 1,30e, s/CV j
CI l'Y:_-Sk_1�vh STATE: Li PHONE: 3(e0-q27'(v723ELL:340-Z29-43)3
L'MAIL:�cto-
PARCEL INFORMATION: PLANNER r-
PARCEL NUMBER(12 Digit Number) 3 Z / 3 2 - Z 3 '9 O O O Z ZONING_ _ l�
LEGAL DESCRIPTION(Abbreviated)SW N W L o T. Z OF Sp -4* FIRE DISTRICT `$
SITE ADDRESS 2 Z/ iiF_ STaiiiIF 6pl&wPL CITY S HOL LZv h/
DIRECTIONS TO SITE ADDRESS 7,,,,,, dw}a -Y� a( / va [c.J Sofa S> ,e�ria�
4"a Z,�kccS'C iJ off . ) 0 ve Ck/,WleseL C
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES[] NC I["YES",GCOTEC11 maybe req'd)
IS PROPERTY WITHIN 200 FT: (Check all rhal apply):
SALTWATER❑ LAKE ❑ RIVER/CREEK❑ POND ❑ WETLAND ❑ SEASONAL RUNOFF ❑ STREAM ❑
TYPE OF WORK: NEW ❑ ADDITION 7-\ALTERATIO//N ❑ REPAIR❑ OTHER ❑
USE OF STRUCTURE(Residence,Gw-age.Commercial Bldg,EI.c.) /??S i C.P--
IS USE: PRIMARY SEASONAL ❑ NUMBER OF BEDROOMS .3 NUMBER OF BATHROOMS 3
HEATED STRUCTURE? YES (11'hole Bleb ❑ YES ("Part[,] ❑ NO
DESCRIBE WORK E�00/N G— A C��pr��.� ,D GLC OFF "7ht1EtuE-
(Valuation/Project Bid Amount: $ )
SQUARE FOOTAGE:
1 st FLOOR sq. ft. 2nd FLOOR sq. ft. 3rd FLOOR sq. ft. BASEMENT sq. ft.
DECK sq. ft. COVERED DECK sq. ft. STORAGE sq. ft. OTHER sq. ft.
GARAGE sq. ft. Attached❑ Detached❑ CARPORT sq. ft. Attached❑ Detached❑
MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED*
MAKE MODEL YEAR LENGTH
W TH BEDROOMS BATHS SERIAL NU
PARCEL OWNER 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 or owner's legal
representative. I further declare that I am entitled to receive this permit and to do the work as proposed. I have obtained
permission from all the necessary parties, including any easement holder or parties of interest regarding this project.
The owner or legal representative, represents that the information provided is accurate and grants employees of Mason
County access to the above described property and structure(s) for review and inspection. This permit/application
becomes null & void if work or authorized construction is not commenced within 180 days or if construction work is
suspended for a period of 180 days.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF INSPECTION. INACTIVITY OF THIS PERMIT
APPLICATION OF 180 DAYS WILL CAUSE THE APPLICATION TO BE EXPIRED. (MASON COUNTY CODE 14.08.42)
x
Signature of PARCEL OWNEIC Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL,
PERMIT SPECIALISTS Intake: Approved&Ready for Pick-Up:
Visit us on-line: http://www.co.mason.wa.us/community_dev/ Rev. 1013112016 byJBN