HomeMy WebLinkAboutBLD2023-00120 - BLD CD Environmental Health Review - 1/30/2023 /''''°6 i' ate, MASON COUNTY COMMUNITY SERVICES Permit No: ' ' 'v� 'L '
PERMIT ASSISTANCE CENTER: (� v L V L.V
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615 W.Alder Street,Shelton,WA 98584
,r' :f' S Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Phone ti I U J A N 3 0 2023
v2,* `:.� Belfair.:(360)275-4467.Phone Elma:(360)482-5269
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BUILDING PERMIT APPLICATION 615 W. Alder Street
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME: 7lhSrn+ISA 12(I I( Eryy le r NAME: Flan\�LTAt2 £ y'S
MAILING ADDRESS: 1st a CIrg 00 ;di a Rd MAILING ADDRESS.Qb 2Ox 1
CITY:Un;O h .jj4 STATE: i ZIP!SS9 2 CITY: �,t STATE:W ZIP:�gspq
PHONE#1:3 Go 119 0 1753 PHONE. 75(L q4;d►CELL:
PHONE#2:907 qg7 5157 EMAIL:.Frc,,,V..L „f4 LA.C. C vt► CO14
EMAIL: i 54 a ri t e r�t19 nut;J• C O Wl L&I REG I1�1 GA ,C(g7)A,e EXP. /Z/Z1
PRIMARY CONTA T: OWNER❑ CONTRACTOR OTHER❑ .J
NAME'7(704*s I e4Ltt.4 EMAIL ' e JIB Q
MAILING ADDRESS PC) 30zr 39CD CITY/ 4c 4 Y STATE ZIP 'C__ 1.7..
PHONE 34.,o•-7.(7- qu 3-e CELL Z
PARCEL INFORMATION: U.1 =
PARCEL NUMBER(12 Digit Number) .3Z j O 7 5 q 01(,0 t ZONING '2 H
LEGAL DESCRIPTION(Abbreviated) n FIRE DISTRICT Z Q
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SITE ADDRESS (et t LA n't tb. IA -k1 Er. 4-r) CITYuv»cr•7 ow
DIRECTIONS TO SITE ADDRESS /hCztG.V� LEA L,�t 0" +.�ti(v.� (li O6r a
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IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES❑ NO NOW LOAD:30 psf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply): W
SALTWATER 0 LAKE❑ RIVER/CREEK❑ POND❑ WETLAND❑ SEASONAL RUNOFF 0 STREAM❑
TYPE OF WORK: NEW ADDITION 0 ALTERATION 0 REPAIR 0 OTHER ❑
USE OF STRUCTURE(Re'ence.Garage.Commercial Bldg.Etc.)
IS USE: PRIMARY SEASONAL 0 z NUMBER OF BEDROOMS NUMBER OF BATHROOMS
HEATED STRUCTURED] YES(Whole Bldg)Nil YES(Pan(s)of Bldg)0 NO❑
DESCRIBE WORK /V a.,.., At H
SOUARE FOOTAGE:(proposed)
1ST FLOOR(51Z—sq.ft. 2ND FLOOR sq.ft. 3RD FLOOR sq.ft. BASEMENT sq.ft.
DECK 3 Z sq.ft. COVERED DECK sq.ft. STORAGE sq.ft. OTHER sq.ft.
GARAGE sq.ft. Attached❑ Detached❑ CARPORT sq.ft. Attached 0 Detached❑
MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED*
MAKE 66. A t bait MODEL CQ 91irZ F YEAR 7_02_3 LENGTH SU
WIDTH al BEDROOMS S BATHS Z SERIAL NUMBER . I gi2 ,
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC(� SEWER 0 / NEW EXISTING 0 .
PLUMBING IN STRUCTURE? YES 0.3r. NO❑ If yes,attach completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? YES 0 NOISY.-- EXISTING SQ.FT.
EXISTING BEDROOMS PROPOSED BEDROOMS S TOTAL BEDROOMS 3
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 and 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 ON THIS PERMIT IS BY MEANS OF INSPECTION. INACTIVITY OF THIS
PERMIT APPLICATION OF 180 DAYS OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED.(MASON
COUNTY CODE 14.08.42)
X �?!t I-5-202�
Signature of OWN (Must be signed by the OWNER) Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL jJ
PUBLIC HEALTH . /i 21 ^��.ki3 fit fol4 WO) C('Ildi 1013
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2" L S -t m Ott Se.syre k, EH APPROVEI
u 7 _~ �� / D.Anderson 02,'24/20;
Somas. roat5 +0 — ?� /
tt EH SETBACKS
A)Drainfreld/Reserve requires 10'setback from footing/foundations
6)Septic tank(s)requires 5'setback from all footing/foundations
C)No oundation/perimeter drains within 30'down-gradient of drainfir
rese e
area
D) cut(s),bank(s)(greater than 5'&over 45 degrees)within 50'
i— �{ 55 C) do n-gradient of drainfield/reserve area
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sew.•
5' min
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r9R4J Z~-o o / O Cleanout
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_0. Pro-rod' 8R — _ . _`o. 60. 31200 Galion_Septic'rank
/ PQ r 2-Compartment with .
6' '1fligf - Effluent Filter
>;k;S+. Z0. ( 1 QC Gallon Pump Chamte
44,
- O Valve Control Box
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RECEIVED
JAN 30 2023
615 W. Alder Street
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