HomeMy WebLinkAboutExempt - GRD Application - 3/29/1994 -V vi t
GRID
MASON COUNTY
LAND MODIFICATION PERMIT
Grading, Excavation, Fill, Slopes, Drainage
Department of General Services
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628
PLEASE PRINT
#1 OwnerToH.-,l 1 i Tru 5 Phone# 2-06/73S-33SC) Fire District#
Site Address Gc/SZD RjJ Cit St /4/i4 Zip 98S'S
Owner Address /6OZ S: Nd,/ City 1+o13uA^1 St 15/,4-- Zip 9$�/
Describe Work C.,,,., 5 TA tic C-i S, DOCK 5� S;eZ c, AS A-t)D 1
TO ,e-xi S i/ 30 , 000 �o/L T�'yi=
STo/1A-G E O/' A1PZ C/2.47=T
Pb E Co.v/ s7a t PO 13ox 89-/ A--au,2,v V,,q f*07/ /00FG0I' Z'f 7 Q E
#2 Contractor Name R+S C.►f,'2 Co/d's 7-4 K G i/D Contractor Reg#?It 5 C H j�C 16 it NZ
Address l' O /3&x /8/9 Expiration Date 3 -s's5—
City Sff,ECToy St Zip 98 Phone# yLG-9,--02-
#3 Engineer's Name /44-11-N IOoE POE 6NG Phone#
Address 6/0 1,-/, Si, Su „E /0/ City K6n/r St k1A Zip !Z$03 Z
/,V A/ZOO 2 7S (90 o L o
5Wy200 L7S- 1oa /o
#4 Parcel No.5,C H Zoo -z,)5— - 900 0
Legal Description TRl-cr Z- $3 ol-- Sukagj!/ Ab" Z-Yo-s,/ /Lor,S / 19Z ar 5P /V /-8
#5 Number of cubic yards to be excavated: #oo0
Number of cubic yards to be filled: No,/,c
INumber of cubic yards to be graded: 1/0.•/"a
#6 Will this be a balanced cut and fill entirely within the site?
Yes X No
If No: Will fill be brought on site? Yes No
Where does imported fill originate from?Does fill fill contain any potentially hazardous materials?
Yes No
#7 Will excavated materials be taken off site?Yes No X
If Yes: Where will excavated materials be taken?
#8 Briefly describe existing terrain, vegetation, and improvements on subject site? /Mo57 4x LBJEL w.;y
S�9.f�L /�/SC or f}-��PRox y'S i=T �T i3�c.c o F coi %ors so/c ova
Pi N/c 7oe4i S o/' NO CvH hd G L ✓k G.U 30,000 sk
—S S .
#9 Total size of area to be cleared 4??,eox 3 4c e4 r acres/sq ft
Size of area to be cleared on slopes over 10% /V AC/SF
#10 Has a soils report been completed on the subject site? 14s
If yes, include copy with application.
#11 Is the subject site within 200 feet of a designated shoreline A/o
#12 Does the subject site contain any of the following features?
River Lake Wetlands Saltwater
Slope greater than 15% Soft compressible soils
Seasonal Runoff None
#13 Will the proposed land surface modification change the points
where storm water or groundwater enters or exits the site? /K/o
#14 Will the proposed land surface modification change the quality,
quantity, or velocity of storm water/groundwater? Qp_+:5.5 L,A/46 sw.Fe-Es 7-o c oA+ ,-2oc. SuoeF•rc-�F-
I,c A-77"
#15 What methods, if any, will be utilized to minimize erosion and
possible sedimentation into nearby waters during and after
construction? CR'+Ss L/N/E/> 5..y/tc.,o—, S
#16 Will this land modification result in the redirection of any surface
water runoff onto adjacent properties? A/c,
#17 Will surface or subsurface runoff be collected or controlled by
interceptors, curtain drains, or other water collection devices
once this land modification has been completed? I/, s G a 4-s s e- 1v As
#18 Will the land be replanted upon completion? x-5
If yes,with what types of plants? 2 f fi S A-eo u/vd .C;z-Z 4 i? ni k.7• •—�f LOG/} c_
ScR k 13S
#19 Will this modification result in slopes steeper than those currently
on the site? /4o If so, how steep?
Show following on the site plan
Lot Dimensions Flood Zones
Existing Structures Fences
Structure Setbacks Driveways
Water Lines Shorelines
Drainage Plan Topography
Septic Systems Wells
Proposed Improvements Easements Indicate Directional by (N, S, E, W)
Name of Flanking Street in relation to plot plan
Name of Fronting Street
APPLICANT TO DRAW SITE PLAN BELOW
APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW
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 OFTHE ORDINANCE REQUIREMENTS REGU-
ORDINANCE REQUIREMENTS FOR WHICH THIS PER- LATING THE WORK FOR WHICH THE PERMIT IS ISSUED
MIT IS ISSUED AND THAT ALL WORK DONE WILL BE IN AND ALL WORK DONE WILL BE IN CONFORMANCE
CONFORMANCE THEREWITH.NO CHANGES SHALL BE THEREWITH. NO CHANGES SHALL BE MADE WITHOUT
MADE WITHOUT FIRST OBTAINING APPROVAL FROM FIRST OBTAINING APPROVAL FROM THE BUILDING
THE BUILDING DEPARTMENT. DEPARTMENT.
X OWNER XS`—� Tones 27rw s X BY
DATE �z S 5 S! DATE
FOR OFFICIAL USE ONLY:Accepted by: Date:
DEPARTMENTAL REVIEW
Planning APP COND APP HOLD
Building
Environmental
Other
Sp I Conditions _ FEES
Grading Permit $
2 `7 O
® Plan Review
+7,0r6, 1 Oct Site Inspection
Violation Fee
Other
TOTALFEES $ 7