HomeMy WebLinkAboutGRD2021-00010 - GRD Application - 7/28/2021 0Nrc0c, MASON COUNTY PERMIT NO.0 ri 202,1 -
DEPARTMENT OF COMMUNITY DEVELOPMENT 00010
BUILDING•PLANNING.FIRE MARSHAL
www.CO.MASON.WA.US (360)427-9 � E D
Mason County Bldg. 8, (360)275-4 it
1854 615 W.Alder Street, Shelton,WA 98584 (360)482-5269 Elma ext. 352
LA MODIFICATION PERMIT (Grading Permit)' �G 5 2021
OWNER INFO CONTRACTOR INF6 I,6Jqer Street
NAME: - .� NAME: F
MAIL RESS: MAILING ADDRESS: -T-A AA S--
CITY:getFy /g- STATE:/ZIP: o CITY: STATE: ZIP:
PHONE:��7�oaQ.j�ELL: PHONE: CELL:
EMAIL: ��o• �, �, �� �7r._7-c .c v��r EMAIL :
L&I REG# EXP.
PARCEL INFORMATION:
PARCEL NUMBER(12 DIGIT NUMBER) , 3 2:7 Zit G ZQ FIRE DISTRICT�i9/,.F'.,
LEGAL DESCRIPTION(ABBREVIATED): Ar,a y
SITE ADDRESS L ft5 iV<— ST_ �'$ T �Zp CITY y'LF /R 51- X �i�/ ,y
DIRECTIONS TO SITE ADDRESS
IS PROPERTY WITHIN 200 FT:—!�-/!10
SALTWATER❑ LAKE ❑ RIVER/CREEK❑ POND ❑ WETLAND ❑ SEASONAL RUNOFF ❑ STREAM ❑
DOES PROPERTY HAVE SLOPE(S)WITHIN 300 FT OF THE PROJECT-GREATER THAN 14% YES El NO2
WILL TIMBER BE CUT AND SOLD IN PARCEL PREPARATION? YES ❑ NO; (
TYPE OF JOB: EXCAVATION ❑ FILLING g GRADING X CUTTING ❑ OTHER ❑
TOTAL SIZE OF PARCEL , L ACRES/SQ FT SIZE OF AREA TO BE EFFECTED '7_ ,757 AC SQ FT
ESTIMATED AMOUNTY OF CUBIC YARDS��tS
DOES THE SITE HAVE SLOPES 14%OR GREATER YES❑ NOS'
DESCRIB SC PE OF WORK A LX S r,T )
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WILL FILL BE BROUGHT ON SITE? IF YES,SITE ADDRESS:
WILL EXCAVATED MATERIAL BE TAKEN OFF SITE?IF YES,SITE ADDRESS: Alp
DOES FILL CONTAIN POTENTIAL HAZARDOUS MATERIALS? YES ❑ N07
HAS A SOILS REPORT BEEN COMPLETED ON SITE?IF YES,INCLUDE A COPY. YES 6g'NO❑
WILL PROPSAL RESULT IN REDIRECTION OF ANY SURFACE W WATER RUNOFF? YES ❑ NO/
WILL WORK ALTER WHERE STORMWATER OF GROUND WATER ENTERS OR EXISTS THE SITE? YES ❑ NO B
WILL QUALITY,QUANTITY OR VELOCITY OF STORM/GROUND WATER BE ALTERED? YES ❑ NOZ
WILL THE RUNOFF BE COLLETED/CONTROLLED BY INTERCEPTORS,CURTAIN DRAINS OR OTVFR DEVICES>YES NO ❑
WILL THE LAND BE REPLANTED UPON COMPLETION? L--�/ —'-"1I`?- YES NO JZ
WILL THE PROPOSAL RESULT IN SLOPES STEEPER THAN THOSE CURRENTLY ON SITE? YES ❑ NO is
IS THE SITE WITHIN 200 FT OF A DESIGNATED SHORELINE OR A WETLAND? YES ❑ NO
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. I 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 permit/application b comes null&void if work or authorized construction is not commenced within 180
days or if construction work is suspe for period of 180 days. PROOF OF CONTINUATION OF WORK IS BY MEANS OF
INSP N.INACTIVITY OFT R T APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION.
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nature of Applicant
X WNER/ EPRESENTATIVE/CONTRACTOR
Print Name (CIRCLE TO INDICATE)
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ECEIVEL,
AUG 0 5 2021
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PLANNING
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PLANNING:
_ ALL.SETBACKS ARE MEASURED
` RROM THE FURTHEST
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