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HomeMy WebLinkAboutGRD - GRD Application - 12/6/1993 t,In-,i GRID MASON COUNTY �'� D LAND MODIFICATION PERMIT �s Grading, Excavation, Fill, Slopes, Drainage DEC 0 6 1993 Department of General Services � c;�;:j ec_; ;:: , ; UK 426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628 PLEASE PRINT #1 Owner �, �� /c, ��1��� Phone# Fire District# Site Address zgaity St Zip Owner Address 44w City St Zip Describe Work #2 Contractor Name 10/%.6 /V6-t Contractor Reg# Address /e, GK,---7 Expiration Date city St Zip Phone# a27S- o275 �6 #3 Engineer's Name �y /���/� Phone# Address jiQ/''d'[ /-!6� i0v4tJ5 City St Zip #4 Parcel No. Legal Description %tz . z or- Sri I`FZ #5 Number of cubic yards to be excavated: 0 Number of cubic yards to be filled: '700 Number of cubic yards to be graded: AZZ #6 Will this be a bala ced 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? �� o/ Does fill contain any potentially hazardous materi ? Yes No #7 Will excavated materials be taken off site?Yes No I� If Yes: Where will excavated materials be taken? #8 Briefly describe a .sting terrain, vegetation, and improvements on subject site? #9 Total size of area to be cleared acres/sq ft Size of area to be cleared on slopes over 10% AC/SF #10 Has a soils report been completed on the subject site? ©� If yes, include copy with application. #11 Is the subject site within 200 feet of a designated shoreline PE) #12 Does the subject site contain any of the following features? River ND Lake Ak> Wetlands AV Saltwater AIV Slope greater than 15% Soft compressible soils Seasonal Runoff None .e—, #13 Will the proposed land surface modification change the points where storm water or groundwater enters or exits the site? �S #14 Will the proposed land surface modification change the quality, quantity, or velocity of storm water/groundwater? AID #15 What methods, if any, will be utilized to minimize erosion and possible sedimentation into nearby waters during and after construction? #16 Will this land modification result in the redirection of any surface water runoff onto adjacent properties? #17 Will surface or subsurface runoff be collected or controlled by interceptors, curtain drains, or other water collection device s��C) once this land modification has been completed? #18 Will the land be replanted upon completion? J If yes,with what types of plants? #19 Will this modification result in slopes steeper than those currently on the site? A-) If so, how steep? Show following on the site plan Lot Dimensions Flood Zones Existing Structures Fences Structure Setbacks Driveways VII Water Line Shorelines Drainage Pla Topography Septic Systems Wells uu 11 Proposed Improv ent Easements Indicate Directional'by (N, S, E, W) Name of Flanking S eet in relation to plot plan Name of Fronting Stre APPLICANT TO DRAW SI E P N BELOW kk, � � a i J APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW a � v 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. PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS IN- SPECTION. OWNERS AFFIDAVIT CONTRACTORS AFFIDAVIT I CERTIFY THAT I AM EXEMPT FROM THE REQUIRE- I CERTIFY THAT I AM A CURRENTLY REGISTERED MENTS OF THE CONTRACTORS REGISTRATION LAW CONTRACTOR IN THE STATE OF WASHINGTON AND I RCW 18.27, AND AM AWARE OF THE MASON COUNTY AM AWARE OF THE ORDINANCE REQUIREMENTS REGU- ORDINANCE REQUIREMENTS FO WHI H THIS PER- LATING THE WORK FOR WHICH THE PERMIT IS ISSUED MIT IS ISSUED AND THAT ALL WO O E WILL BE IN AND ALL WORK DONE WILL BE IN CONFORMANCE CONFORMANCE THEREWITH. NO N ES SHALL BE THEREWITH. NO CHANGES SHALL BE MADE WITHOUT MADE WITHOUT FIRST OBTAINI G P OVAL FROM FIRST OBTAINING APPROVAL FROM THE BUILDING THE BUILD DEPARTMENT. DEPARTMENT. 7X OWNER X BY DATE ��� DATE FOR OFFICIAL USE ONLY:Accepted by: Date: DEPARTMENTAL REVIEW Planning APP COND APP HOLD Building Environmental Other Special Conditions FEES Grading Permit $ Plan Review Site Inspection Violation Fee Other TOTAL FEES $