HomeMy WebLinkAboutBLD2023-00065 - BLD CD Environmental Health Review - 3/7/2023 Nib
• '•; MASON COUNTY COMMUNITY SERVICES Permit No:
ID Zon -ao0 b 5
,, PERMIT ASSISTANCE CENTER:
;i •BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL
/, r j)- I • 615 W.Alder Street,Shelton,WA 98584
'. ., Phone Shelton:(360)427-9670 exf.352•Fax'(360)427-7798 Phone ��
Bellair(360)2754467•Phone Elma:(360)482-5269
BUILDING PERMIT APPLICATION MAR�/j�/-ti?
t A
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATIO": NEp I-i `ik'nf rq
NAME: Law.r to V,nd e:ri;Co o. NAME: `7y L
MAILING ADDRESS:y;2,-t:;j$A Alt.t IG.0 E6• MAILING ADDRESS:
CITY: a u u 03,. STATE: H I ZIP:cf G 1('j CITY: STATE: ZIP:
PHONE#1: S""II' 25'3 9314E PHONE: CELL:
PHONE#2: ;Ce1 ti 3 C nC -i 2 EMAIL:
EMAIL:jayrra/u net ttrvobc:ti 41` , c0-,e ) L&I REG# EXP._/_/
PRIMARY CONTACT: OWNERS CONTRACTOR 0 OTHER 0
NAME L0.uYrt•rt WI er-j9 CCist EMAIL
MAILING ADDRESS 5 j-L P.s pr fr1 a Ki C 2.41 • CITY 1-ti s.kii I(. STATE 1-4j ZIP (r 1 1
PHONE $t1 jS 66' CI'3�{( CELL /1
,,
PARCEL INFORMATION: i^
PARCEL NUMBER(12 Digit Number) 4-2_1 11 -15 - ci b l ap ZONING 14 , `0LEGAL DESCRIPTION(Abbreviated)FT � -r 21 0p'I,F.,S i 3 , 1 t. 4L) FIRE'DISTRICT 6 1
SITE ADDRESS 3(a( c 5�41.sel- (Z2 rlcr- T2rt CITY vtlti6Y1 ,� • A J 2022
DIRECTIONS TO SITE ADDRESS I Qf,
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES NO aSNOW LOAD:_psf Street
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply):
SALTWATER❑ LAKE❑ RIVER/CREEK❑ POND❑ WETLAND 0 SEASONAL RUNOFF❑ STREAM❑ .
TYPE OF WORK: NEW$ ADDITION❑ ALTERATION❑ REPAIR❑ OTHER 0
USE OF STRUCTURE(Residence,Garage.Commercial Bldg,Etc.) 2 i rl&v1C.
IS USE: PRIMARY V SEASONAL❑ NUMBER OF BEDROOMS 3 NUMBER OF BATHROOMS 2.5
HEATED STRUCTURE? YES(Whole Bldg)4 YES(Parr(s]oJBldg)❑ NO❑
DESCRIBE WORK :na 1.; ci. ��5Av vC-E``con „r c c tZ-
SQUARE FOOTAGE:(proposed)
1ST FLOOR Rt{3 sq.ft. 2ND FLOOR (,P., sq.ft. 3RD FLOOR sq.ft. BASEMENT _ sq.ft.
DECK sq.ft. COVERED DECK Z7 Lis sq.ft. STORAGE sq.ft. OTHER sq.ft.
GARAGE sq.ft. Attached 0 Detached❑ CARPORT sq.ft. Attached 0 Detached 0
MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED*
MAKE MODEL YEAR LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC Igt SEWER❑ / NEW,® EXISTING❑
PLUMBING IN STRUCTURE? YES.j NO❑ If yes,attach completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? YES 1 NOD EXISTING SQ.FT.
EXISTING BEDROOMS PROPOSED BEDROOMS 3 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 0 ONTINUATION OF W ON)HIS PERMIT IS BY MEANS OF INSPECTION. INACTIVITY OF THIS
PE A TCATION OF 1 AYS OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED.(MASON
COUNTY CODE 14.08.42)
�� 0 r-0 — Z3
tI nature of OW R(Mus s q erl"d by the OWNER) Date
DEPARTMENTAL REVIEW .APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL !,� C
PUBLIC HEALTH F`-A 1 ( r J? c.t/ J.? J czd
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415 N.6th Street
MASON COUNTY Shelton.WA 98584
riCill7 =' COMMUNITY SERVICES Shelton.360-427-9670,Ext.400
r 3. Belfair.360-275-4467,Ext.400
Budding,Planning,Environmental Health,Community Health Elma:360-482-5269,Ext.400
Application for Determination of Water Adequac 11 T sT
Instructions ill( MAY 0 4 2023
1. Complete Part 1. No determination can be made until Part 1 is fully completed. I
2. Complete only the portion of Part 2 applying to the type of water connection utilized.
3. Submit completed application, with any required attachments for review.
4. An approved building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: Laurren Underwood Date: 05/04/2023
Mailing Address: 4760 W Skokomish Valley Rd,Shelton,WA 98584 Phone: 360-490-1206 _
Parcel Number: 421137590100
i
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more GY Building permit
connections) 0 Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water
❑ Other(explain) ❑ Other(explain)
0 Replacement or Remodel (please indicate name
If you have more than one residence connected of water system below if applicable— no
to this well, check the Public/Community Water signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: Webb Hill
Water Facility Inventory (WFI) Number: 057384 (write"none"for two-party)
• am the manager of this water system. The water system has been approved for 29 services. There
are presently 13 connection(s) in use. This will be the 14th connection.
O I am the manager of this system. This connection will be to upgrade or change the use of an existing
connection on this system (i.e.: recreational to full time). Please indicate on the following line the nature of
this change:
This water system is able and willing to provide water to this (these) connection(s)without exceeding the
limits of the water system or any limits set by state and local regulation.
Print Name of Water System Manager Melissa Cox on behalf of NWS Phone 360-876-0958
Signature of Water System Manager • i////-:•;ir ?:,e-.r on Behalf of NWS Date 05/04/2023
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EH Forms\Drinking Water Revised 4/27/2021
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Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) gpm _ gpd.
The well driller often performs well capacity tests at the time the well is constructed. Results from
these tests are noted on the water well report. Results from these tests will be accepted. If the water
well report cannot be located by the applicant or if the water well report does not have a capacity test,
a well capacity test, which provides stabilization of draw-down and recovery data, must be performed
by a licensed contractor.
❑ Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://ais.co.mason.wa.us/planninq 14_ 15_ 16 22_
Water use or limitation recorded N/A Yes
Well Drilled Date
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ I have reason to believe that this water source can provide at least 800 gallons per day; and/or
provides water at a rate of 2 gallons per minute based on the following observations.
Author of Statement Date
Relationship to Applicant
• •
Part 3: Mason County Community Services Evaluation (staff use only)
Satisfactory Determination:
This determination does not address adequacy of the distribution system, guarantee an adequate supply of
water indefinitely in the future, or guarantee compliance with all applicable WDOE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,Title 6, Chapter 6.68.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
H Unsatisfactory Determination:
Applicants water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures:
Environ. Health: U Date S/
This form may be scanned and available for public view at www.co.mason.wa.us.
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