HomeMy WebLinkAboutGRD92-0016 - GRD Permit / Conditions - 7/9/1992 _ � e
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MASON COU= j
LAND MODIFICATION PERMI
Department of General Services
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-80 -562-5628
PLEASE PRINT
#1 Owner S If" Phon # 2 6 " f. 4
Si to Address i4ol Ci t Ship
Owner Address , ofo st' City'' S ti AZipj4 '
Describe Work
04 l`'
#2 Contractor Name ` �Y�t Contract Reg#
Address Expiration date
City StE ip Phone
#3 Engineer's Name Phone#
Address Ci ty St Zip
#4 Parcel
Legal Description 2 2c "�
#5 Number of cubic yards to be excavated:
Number of cubic yards to be filled: Cyy
Number of cubic yards to be graded:
#6 Will this be a balanced cut and fill entirely within the site?
Yes —_ No
If No: Will fill be brought on site? Yes No
Where does imported fill originate from?
Does fill contain any potentially hazardous materials?
Yes No --K
#7 Will excavated materials be taken off site? Yes No _
If Yes: Where will excavated materials be taken?
#8 Briefly describe exiting ter ain, vegetation, and improvements on
subject site?
#9 Has a soils report been completed on the subject site?
If yes, include copy with application.
#10 Does the subject site contain any of the following features?
River Lake We t1 ands . Sal twa ter
Slope greater than 15� Soft c mpres-sible soils
Seasonal Runoff None
#11 Will the proposed land surface modifica ion change the points
where storm water or groundwater enters or exits the site? tv
#12 Will the proposed land surface modification change the quality,
quantity, or velocity of storm water/gr 'undwater? i—
#13 Is the subject site within 200 feet of a designated shoreline?
#14 What methods, if any, will be utilized to minimize erosion and
possible sedimentation into nearby waters?
#15 Will this land modification result in the redirection of any surf�ce
water runoff onto adjacent properties?
#16 Will surface or subsurface runoff be collected or controlled by
interceptors, curtain drains, or other water collection device
once this land modification has been completed? t �fi
#17 Will the land be replanted upon completion? Jz_.)
If yes, with what types of plants? R..&C'LL,6
#18 What are the lengths and heights of slopes currently existing on
the si te? r7 t4,
a
#19 Will this modification result in slopes steeper than those currently
on the site? _ If so, how steep? t
Show following on the site plan Directions to job site
Lot Dimensions Flood Zones
Existing Structures Fences
Structure Setbacks Driveways
Water Lines Shorelines
Drainage Plan Topography
Septic Systems Wells
Proposed Improvements Easements
Name of Flanking Street
Name of Fronting Street
Scale:
Date:
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NOTICE: THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION
AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS, OR IF CONSTRUCTION OR WORK
IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANYTIME AFTER WORK
IS COMMENCED
OWNERS AFFIDAVIT CONTRACTORS AFFIDAVIT
I CERTIFY THAT I AM EXEMPT FROM THE REQUIREMENTS OF THE I CERTIFY THAT I AM A CURRENTLY REGISTERED CONTRA&OR
CONTRACTORS REGISTRATION LAW RCW 18.27 , AND AM AWARE IN THE STATE OF WASHINGTON AND I AM AWARE OF THE
OF THE MASON COUNTY ORDINANCE REQUIREMENTS FOR WHICH ORDINANCE REQUIREMENTS REGULATING THE WORK FOR WHICH
THIS PERMIT IS ISSUED AND THAT ALL WORK DONE WILL BE IN THE PERMIT IS ISSUED AND ALL WORK DONE WILL BE IN
CONFORMANCE THEREWITH. NO CHANGES SHALL BE MADE CONFORMANCE THEREWITH. NO CHANGES SHALL BE MADE
WITHOUT FIRST OBTAINING APPROVAL FROM THE BUILDING WITHOUT FIRST OBTAINING APPROVAL FROM THE BUILDING
DEPARTMENT. DEPARTMENT. i
y.
X OWNER Se. X BY
DATE DATE
Return permit to: Department of General Services
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628
FOR OFFICIAL USE ONLY Accepted by: ` Date: _
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
Approved Cond Maid
Approvat
Planning:
Environmental Health: a
i
9
Building Plan Review: JABLj� i3O 7a-8 t;
Fire Marshall :
Other:
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Washington State
Department of Transportation QUANTITY CALCULATIONS
Project
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Shaft of
November 24, 1992
Sam Tsai
626 W. Pine St.
Shelton, Wa. 98584
Re: Grading permit #92-0016, 3500 cubic yards fill, and road
construction.
Dear Mr. Tsai:
Your permit application is still on hold pending submission of an
environmental checklist. Please advise us at your convenience
whether or not you will be proceeding with, this application.
If you have any questions regarding filling out the checklist,
Planning staff would be happy to assist Xou. Please be advised
that no grading work should occur until the environmental review
process has been completed and the grading permit issued.
Thank you.
Respectfully,
Don Brush, Planner
Department of Community Development