HomeMy WebLinkAboutBLD2023-01165 - BLD CD Environmental Health Review - 10/3/2023 s` G'p`�y�w„ MASON COUNTY COMMUNITY SERVICES Permit No: f6��y3-O(j ,�
PERMIT ASSISTANCE CENTER: MM
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films •BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHALMUL `
a 615 W.Alder Street,Shelton,WA 985b4
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f Phone Shelton:(360)427-9670 ext. 352•Fax:(360)-27-77S8Pho0 3 2023 E ��I1�.
Qhho ^4: Belfair.:(360)275-4467•Phone Elma:(360)432-5269RECEIVED �E ttii
BUILDING PERMIT APPLICATION 615 W. Alder Street
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME: Kcv}'I a- �.PV 1V1�' V+ Al{nil NAME:
MAILING DDRESS: 1<K$1l ' —S 1� Q , ,/ MAILING ADDRESS: s
CITY: E44tt( STATE:W O ZIP:�5Zb CITY: STATE: ZIP:
PHON #1: , Q -`�- - IL/�/ PHONE: _CELL:
PHONE#2: 5L.R()- L0-- LAO'5 EMAIL :
EMAIL: hQ�mpkrhn5 a)V\laVZ',ahlj1L CV-4 L&I REG# EXP. / /
PRIMARY ONTACT• OWNER[ , CONTRACTOR❑ OTHER❑
NAME VV( ' VI Wi1AV1 EMAIL h Y17*.Ylo 5ct W' 1V��Li.t0 9...( j
MAILING ADDRESS \ / CITY F Ztt(/ STATE V� ZIP -1 5ZX
PHONE ([ - 2_1 3G4c_ CELL
PARCEL INFORMATION:
PARCEL NUMBER(12 Digit Number)ZZZA Zr l 1 - C U a C i ZONING jlS
LEGAL DESCRIPTION(Abbreviated) FIRE DISTRICT 1
SITE ADDRESS I O Q t. se..\(�u CITY 5 I
DIRECTIONS TO SITE ADDRESS . i j 3 ' ) -)- 9 "it) ' a td clveSS! L
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YESVI NO ❑
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply):
SALTWATER❑ LAKE❑ RIVER/CREEK❑ POND ❑ WETLAND ❑ SEASONAL RUNOFF [1, STREAM❑
TYPE OF WORK: NEW EP, ADDITION ❑ ALTERATION ❑ REPAIR ❑ OTHER ❑
USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Etc)-qa.1 -J 1✓
a IS USE: PRIMARY[it. SEASONAL❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS
HEATED STRUCTURE? YES(Whole Bldg) ] YES (Part[s]of Bldg) NO ❑
DESCRIBE WORK GIC ✓ W Rout5 taw A-Weivt,
SQUARE FOOTAGE: (propose_+existing)
1ST FLOOR•. • sq.ft. (2ND FLOOR U t Z. sq. ft. 3RD FLOOR sq.ft. BASEMENT sq. ft.
i DECK !f} sq.ft. COVERED DECK sq. ft. STORAGE sq.ft. OTHER sq.ft.
GARAGE 1-". Li('' sq. ft. Attached Detached❑ CARPORT sq. ft. Attached❑ Detached❑
MANUFACTURED HOME INFORMATION:Am *4 COPIES OF THE FLOOR PLAN UIRED �.
MAKE MODEL YEAR GTH
W TH BEDROOMS THS SERIAL NUMBER
ENVIRONMENTAL HEALTH: A / i, -2/ .,?,,5SEWAGE/SEWER SOURCE: SEPTIC' SEVER❑ / W EXISTING ❑
PLUMBING IN STRUCTURE? YES 14 NO ❑ If yes, attach completed Water Adequacy Form
° PERIMETER/FOUNDATION D AINS PROPOSED? YES ❑ NO EXISTING SQ.FT.
EXISTING BEDROOMS PROPOSED BEDROOMS TOTAL BEDROOMS pt
OWNER acknowledges that submission of inaccurate information may result in a sto 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
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EH Setbacks ♦
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A.) Drainfield/Reserve requires 10'setback from footing/foundations
B.)Septic tank(s)requires 5'setback from all tooting/foundations
C.)No foundation/Perimeter Drains within 30ft.downgradient of
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Drainfield/Reserve area
D.)No Cut Bank(s)(greater than 5ft and over 45 degrees)within
50t1,down gradient of Draintietd/Reserve area
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PROPOSED EXISTING
EH APPROVED DRAINFIELD ACCESS
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Rhonda Thompson 10/31/2023
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EXPIRES
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INSTALLATION DESIGN ER SIGNOFF/ASBVILT
FEE WILL BE CHARGED AT TIME OF \
INSTALLATION
CUSTOMER: KARR1 HOHMANN SCALE 1:100
PIONEER DIGGING, INC. PARCEL#:22212-11-9009i TEST HOLE I: TEST HOLE 2:
ADDRFSS: 18230 STATE ROUTE 106 0-63 GLS 0-72 GLS
SEPTIC DESIGNS ROOTS-63 ROOTS-72
3083 E MASON BENSON RD. GRAPEVIEW,WA 98546 DESIGNER: ROBERT PAYSSE NO Rif. NO Rol.
OFFICE-360-426-1803 FAX-360-427-2353 DESIGN PAGE OF