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RLC94-1177 - RLC Application - 5/27/1994
:; Date Received: 7 ( ` MASON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT FEE WA�vED RESOURCE LANDS AND CRITICAL AREAS CHECKLIST rwLr The following checklist is designed to assist an applicant for a Building Permit, On-Site Sewage System Site Evaluation and Disposal Permit, Access Permit, Land Modification Permit, Boundary Line Adjustments, Lana Segregations, Hazardous Waste Permit, or Shoreline Permit in determining whether their property is affected by regulations under the Mason County Interim Resource Ordinance (77-93)*. This checklist is an important opportunity foridentifying earlyin the permit process whether there willbe any environmental regulations affecting the proposed development. Owner_ a �[1Saa/ Phone #( .Z6 ) 275-Z3,bX Site Address City 6c1'e'- :'- Zip 9-k 577ZY Owner Address ✓K City State Zip Tax Parcel No. (Confirm with Assessors Office) i�530 Legal Description_ © t ea. Project Description e Directions to site (Please attach map) w t CcA-1 �Go� Please provide or attach a v' inity nYap which includ s cross streets, majorfroads, creeks, etc. A .PA /5 /`A ,r O 1 �jj- tj' $ga,d k, APY14 Gvet�z 1Oe��f-o Answer the following to the best of your knowledge. County-wide maps showing general locations of critical areas Official and resource lands are available for review at Mason County Department of Community Development, Planning Use only Department. Do any of the following exist on this property or within 200 feet of this property? Coy Yes No ❑ [ 1. Saltwater shoreline or a lake 20 acres or larger? VW ❑ E] 2. Rivers, streams, or creeks with year-round flow? " (� ❑ 2� 3. Rivers, streams or creeks with intermittent flow but are within a clearly defined channel? ❑ 0-" 4. Lakes or ponds less than 20 acres in size? k ❑ [3� 5. Wetlands: Areas that are inundated or saturated by surface water that under normal circumstances support vegetation adapte for life in such conditions; such as marshes, bogs, and swamps. (See County Maps for guidance.) ❑ 6. Slopes greater than 15fp (8.5 degrees)? (See the County Landslide and Erosion Hazard Maps for guidance.) I .� :20)b I) WW /P' ❑ [fr 7. Floodplains? (See County Federal Emergency Management Maps and County Seismic Hazard Map for guidance.) a ❑ .0' 8. Seismic Hazard Areas? (See County Federal Emergency Management Maps and County Seismic Hazard Map for guidance.) ',/�_o You may be provided nuisance protections by the County for certain resource activities. If you are enrolled in any of the following programs: Co ntYes No [] ,. 1. Agricultural Open Space Taxation Program, RCW 84.33 Q� ❑ E 2. Open Space Timber Taxation Program, RCW 84.33, or Designated Forest or Classified Forest, / RCW 84.34 ' Copies are available at Mason County Department of Community Developmont for $5.00 each. i►LJUUf1VG LPAIYLJJ LX %.*nI 1 IIiHL Hit1CA0 SITE PLAN PLEASE SHOW THE FOLLOWING INFORMATION OR PROVIDE SURVEY MAP IF POSSIBLE: ► Location &dimensions of existing &proposed property boundaries. ► Approximate slope of land (grade &direction), topography. ► Identify legal access Including,width of all road right-of-ways&easements. ► Location of significant natural features(water bodies, rivers). ► Locate all existing &proposed structures,drainflelds, wells &driveways. ► Project description Scale 1"= / North Arrow V (4X-J� 0q gil-2- el T70a f I state that I have answered the above truthfully to the best of my knowledge. Applicant/Owner A_d- E� Date FOR OFFICIAL USE ONLY Adjacent property. ...............:.:::..�::::::..:........................................::::. :................................:..::::::::.....�......a.....�r......::::.��� ... .ray.�.$,.:�:::............................:.::::..:::....... __.. g... ><:<:;<:<:::<:�<..:�.- :>:::::::::>'::;::>:•;<. hareltn�;;:M�s��r..:p.r� r.�rn :,_ :> <�:><::<:>:::,;:•:.:>::;::.:>:>:;>•::>:;.;:>:. eral:>R .f;.o:urcer:Land.............. .......:.;. 9...... ........ There is a $40.00 application fee for the Resource Land & Critical Areas Checklist. Make checks payable to the Mason County Treasurer. When completed, this form becomes part of the permit application.