HomeMy WebLinkAboutGRD2019-00004 - GRD Application - 5/13/2019 - --
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�Tr MASON COUNTY PERMIT NO. o(9'000o4
DEPARTMENT OF COMMUNITY DEVELOPMENT
BUILDING WWW NONMAGO WA-USIRE MARSHAL (360)427-9670 Shelton ext.3RECEIVED
Mason County Bldg.8, (360)275-4467 Belfair ext.352
rasa 615 W.Alder Street,Shelton,WA 98584 (360)482-5269 Elma ext.352 MAY 13 2019
LAND MODIFICATION PERMIT (Grading Permit) 615 W. Alder Street '
OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME: A-lee 5 o ti Co u V•D /1D• 3 NAME:
MAILING ADDRESS:6 Z2 E To44s MAILING ADDRESS:
CITY:gt5 Toy STATE: \,\1.4 ZIP: 795K S' CITY: STATE: ZIP:
PHONE: YZ 6- 9'ZS3' CELL: PHONE: CELL:
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EMAIL: :_► :/le S C EMAIL:
L&I REG# EXP. / !
PARCEL INFORMATION: u
PARCEL NUMBER(]2 DIGIT NUMBER) 3 1 qo F3 3 `� - d O U 4 d FIRE DISTRICT 7
LEGAL DESCRIPTION(ABBREVIATED):
SITE ADDRESS 2 U CO -SE Lam,•h r 13 a CITY eI-1-'o k,
DIRECTIONS TO SITE ADDRESS
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IS PROPERTY WITHIN 200 FT:
SALTWATER❑ LAKE ❑ RIVER/CREEK❑ POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM❑
DOES PROPERTY HAVE SLOPE(S)WITHIN 300 FT OF THE PROJECT-GREATER THAN 14% YES❑ NO
WILL TIMBER BE CUT AND SOLD IN PARCEL PREPARATION? YES ❑ NO X
TYPE OF JOB: EXCAVATION ❑ FILLING Ix GRADINGX' CUTTING JX OTHER ❑
TOTAL SIZE OF PARCEL ?. Q C F-e S ACRES/SQ FT SIZE OF AREA TO BE EFFECTED I-6 CRES SQ FT
i ESTIMATED AMOUNTY OF CUBIC YARDS 'l, S.S0
DOES THE SITE HAVE SLOPES 14%QR GREATER YES❑ NO� -
DESCRIBE SCOPE OF WORK ill, T� VC/%o h
WILL FILL BE BROUGHT ON SITE? IF YES,SITE ADDRESS:
WILL EXCAVATED MATERIAL BE TAKEN OFF SITE?IF YES, SITE ADDRESS:
DOES FILL CONTAIN POTENTIAL HAZARDOUS MATERIALS? YES ❑ NON
HAS A SOILS REPORT BEEN COMPLETED ON SITE?IF YES, INCLUDE A COPY. YES t' NO❑
WILL PROPSAL RESULT IN REDIRECTION OF ANY SURFACE WWATER RUNOFF? YES ❑ NO;,
WILL WORK ALTER WHERE STORMWATER OF GROUND WATER ENTERS OR EXISTS THE SITE? YES ❑ NO X
WILL QUALITY,QUANTITY OR VELOCITY OF STORM/GROUND WATER BE ALTERED? YES ❑ N0,X
WILL THE RUNOFF BE COLLETED/CONTROLLED BY INTERCEPTORS,CURTAIN DRAINS OR OTHER DEVICES? YES NO❑
WILL THE LAND BE REPLANTED UPON COMPLETION? YES ❑ NOW
WILL THE PROPOSAL RESULT IN SLOPES STEEPER THAN THOSE CURRENTLY ON SITE? YES ❑ NO X
IS THE SITE WITHIN 200 FT OF A DESIGNATED SHORELINE OR A WETLAND? YES ❑ NO g
OWNER/BUILDER acknowledges 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, owners legal representative,or contractor. I further
declare that I am entitled to receive this permit and to do the work as proposed. 1 have obtained permission from all the necessary
parties, including any easement holder or parties of interest regarding this project.The owner or authorized agent 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 permittapplication 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 IS BY MEANS OF
INSPECTION. IAC OF—THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION.
X
Signature of Applicant D
X PRESENTATIVE/CONTRACTOR
Print Name (CIRCLE TO INDICATE)