HomeMy WebLinkAboutMEP2016-00039 - MEP Application - 10/20/2016 T0, &L&I LO CSC`
Ce MASON ENVIRON ENTAL PERMIT($630 or$380 w/other permit) Mason County Permit Center Use:
❑ CONDITIONAL US ($1520) MEP 0 - QM39
HABITAT MANAGEMENT PLAN REVIEW($445) _
Date Rev a "
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MASON COUNTY 4b Alder Street
DEPARTMENT OF COMMUNITY DEVELOPMENT
Mason County Resource Ordinance(Chapter 17.01 MCC)
ENVIRONMENTAL PERMIT APPLICATION
The purpose of the Resource Ordinance is to protect Mason County's natural resource lands and critical areas and is
under the authority of Chapters 36.32, 36.70A, 39.34, 58.17, 76.09, 84.33, 84.34 and 90.58 RCW,
PLEASE PRINT
1. PROPERTY OWNER
Name: J
Mailing Address: fl S I S NW
Work Phone: 25� �9 38 Email Address: J eGS P�(�Q(ulS,�Duti
Home/Cell Phone: 389 p Fax#: Z53 gS8 I�
If an agent is acting for the property owner during the permit process, complete#2.
2. AUTHORIZED AGENT
Name:
Mailing Address:
Work Phone: s:
Home Ce11 Phone: Fax#
3. PROJECT SITE
Site Address:
Parcel#: a��j . oZ.b a 3 Lega escription:
Directions to Site: I
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Attach a site plan showing the following: Lot Dimensions,Flood Zones,Existing Structures,Fences,
Water Lines,Driveways,Drainage Plans, Shorelines,Septic System,Topography,Proposed
Improvements,Easements,North Arrow,and Scale. Also draw a separate topography diagram.
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4. State which section requires permit:
❑ Long Term Commercial Forest, Chapter 17.10.060 ❑ Frequently Flooded Areas,Chapter 17.01.090
❑ Mineral Resource Lands; Chapter 17.01.066 ❑ Landslide Hazard Area, Chapter 17.0 L I00
❑ Aquifer Recharge Area,Chapter 17.01.080 ❑ Seismic Hazard Areas, Chapter 17.01.102
❑ Erosion Hazard Area,Chapter 17.01.104 Fish&Wildlife Habitat Conservation Areas, Chapter
❑ In-Holding Lands,Chapter 17.01.062 17.01.110
❑ Wetlands, Chapter 17.01.070
5. Identify current use of the property with existing improvements:
6. Identify and describe the proposed project, including the type of materials to be used, construction methods,
principle dimensions, and other pertinent information (attach additional sheets, if needed):
7. Describe why the action requiring this permit cannot be avoided.
8. Will there be an alteration of a wetland and/or wetland vegetation area(circle one)? Yes No
9. Identify any surface water on or adjacent to property(circle one):
Saltwater Lake Stream Pond Wetland Drainage Ditch
10. Identify existing septic/sewer connection(circle one): If septic is located on project site, include records.
Connected to Septic Connected to Community Septic
11. Identify existing water supply(circle one): Public Water Supply Well
y 4
11. Type of Job (circle one):
New Add Alteration Repair Demolition Other:
Print Name Signature Date
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