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Fail Date Date Done 8y Comments o 0 v C Vl O n O 7 d O 7 O S N fD 3 v cn rD cn O h Cn FORM MUST BE COMPLETED IN INK PLEASE PRESS HARD PERMIT NO.: GRMASON COUNTY LAND MODIFICATION PERMIT APPLICATION 426 W.Cedar/P.O.Box 186,Shelton,WA 98594 Shelton 360 279670 Belfair 360 276.4467 Elms 60 2-6269 Seattle 206 6"968 APPLICANT INFOISMATI N ONTRACTOR INF RMATION Owner o AG. Contractor Name 70 Re fl!/-�TGp Mailing Add rss le Mailing Address City State Lf-470p Code L City State Zip Code Phone(jLO)01 T-3S7SOther Ph,Cn T Ph.( Other Ph.( Lien/Title Holder Contractor Reg.# Address lExpiration ENGINEER INFORMATIO Name Ct ��a7 h e 275— s� Address State Zip Code Z PARCEL INFORMATION-12 di it ax P rce No. / -gCQ1 !3©b Z<P Fire District Legal Description t Site Address(include street name and cit mQ Directions to site: D i Will timber be cut and sold in parcel preparation?(Yes/No)/ ,/ Is your property within 200'of the following:Body of Water(Name) h''D� Gt/!Q. Saltwater_Y Lake River/Creek Pond Wetland Seasonal Runoff Stream­V_Slopes or Bluffs Soft compressible soils a TYPE OF JOB-Excavation�Filling Grading Total size of area G �i Size of area to be cleared on lopes ver 1 % Estimated amount of cubic yards Describe Work �c/ LAND MODIFICATION INFORMATION �^ YES NO Will fill be brought on site? If yes,source �c'X�O y /[�,o J OJ/ W- 0 Will excavated materials be taken off site? If yes,destination_ ;fic- O' Does fill contain potential hazardous materials? O 1 Has a soils report been completed on site? If yes,include copy. Will proposal result in redirection of any surface water runoff onto adjacent properties? E3 1� Will proposed work alter where storm water or ground water enters or exits the site? Will quality,quantity or velocity of storm/ground water be altered? 13 Will runoff be collected/controlled by interceptors,curtain drains or other collection devices? 0 Will the land be replanted upon completion? 0 Will the proposal result in slopes steeper than those currently on site? 3 5CL Is the site within 200'of a designated shoreline? A 0 NOTICE: THIS PERMIT BECOMES NULL 3 VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 190 DAYS OR IF CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED. PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the ` information provided is accurate and grants employees of Mason County access to the above described property and structures for review and fPrT°pl N inspection of this project.Acknowledgment of such is by signature below: O .•� �' OWNER AFFIDAVIT-I certify that I am exempt from the requirements of CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a u W M the Contractor Registration Law RCW 18.27 and am aware of the contractor in the State of Washington and that I am aware of the ordinance requirements for which this permit is issued and that all work ordinance requirements regulating the work for which this permit is issued N V, will be done in conformance t t No changes shall be made without and all work shall be done in conformance therewith. No changes shall first o n ppr be made without first obtaining approval: p WDate ` � — Date FOR OFFICIAL USE BEYOND THIS POINT Accepted by Date Submittal Amount Due Receipt No. DEPARTMENTAL REVIEW APPROVED DENIED CONDITION CODES r ng Departmenting Department Public Works Department Fire Marshal FEES Grading Permit Fee /O/(p. Site Inspection Plan Review Fee aa'� -7 J Other Public Works Fee Pre-Paid at Submittal oZ y 7 ( ) Violation Fee TOTAL FEES