HomeMy WebLinkAboutRLC94-0663 - RLC Application - 4/4/1994 MASON COUNTY
15EPARTMENT OF COMMUNITY DEVELOPMENT
G` RESOURCE LANDS AND CRITICAL AREAS C► HECKLIST
=ewageSite
The followin c e Js designed to assist an applicant for a Building Permit, On-Site
Evaluation a al Permit, Access Permit, Land Modification Permit, Boundary Line Adjustments, Land
Segregations rdous Waste Permit, or Shoreline Permit in determining whether their property is affected by
regulations under the Mason County Interim Resource Ordinance (77-931*. This checklist is an important
opportunity for identifying early in the permit process whether there will be any environmental regulations affecting
the proposed development.
Owner 1- Phone #( )
Site Address_,&F4 s-t'c f old; +o N C Al w s S a d City Zip 4 8Sz 8'
Owner Address CitYLas llgco5 State w1✓ Zip 22 //
Tax Parcel No. (Confirm with Assessors Office) 12 .3 33 / -�_- pd o 6 o Legal Description_
GCO 40T 6 � A1010110X 39 /o 'q 0.^ es' Sc'C 31 TWiy 23 N {� /
Project Description S' P r, 7q--ci � 5 �, ,, �, a ( , a ,¢ , I,•ca f-,'
Directions to site (Please attach map)
Please provide or attach a vicinity map which includes cross streets, major roads, creeks, etc.
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
we only Department.
Do any of the following exist on this property or within 200 feet of this property?
County Yea No
❑ ❑ 1. Saltwater shoreline or a lake 20 acres or larger?
❑ ❑ 2. Rivers, streams, or creeks with year-round flow?
❑ ❑ x❑ 3. Rivers, streams or creeks with intermittent flow but are within a clearly defined channel?
❑ ❑ [21 4. Lakes or ponds less than 20 acres in size?
❑ ® ❑ 5. Wetlands: Areas that are inundated or saturated by surface water that under normal circumstances
support vegetation adapted for life in such conditions; such as marshes, bogs, and swamps. (See County
Maps for guidance.)
❑ ❑ 6. Slopes greater than 15% (8.5 degrees)? (See the County Landslide and Erosion Hazard Maps for
guidance.)
❑ ® ❑ 7. Floodplains? (See County Federal Emergency Management Maps and County Seismic Hazard Map
for guidance.)
❑ ❑ [0 8. Seismic Hazard Areas? (See County Federal Emergency Management Maps and County Seismic
Hazard Map for guidance.)
You may be provided nuisance protections by the County for certain resource activities. If you are enrolled in any
of the following programs:
County Yes No
❑ ❑ 2 1. Agricultural Open Space Taxation Program, RCW 84.33
❑ ❑ ® 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 Development for $5.00 each.
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,drainfields, wells &driveways. ► Project description
Scale 1"_
North Arrow
state that I have answered the above truthfully to the best of my knowledge.
Applicant/Owner .-IZ4Z9 Date
FOR OFFICIAL USE ONLY
Adjacent property.
Uslnc4uffy R0tsroe Lrld MapsR' Xht pirgptary iy dEySigtgr;tt�.d a:SR
+ntirl t� rf14 casrurrl ir�;ie: f f�rrf��f _:4 ;i t�rf�iiri� R/las�c�r Eyre grIm<
7. it)
hc,Irling 1.arI(I , . » ....�... 1�, C. 0C, r�c�t apply
.. , .:.. . . ..3. Mi1 era{ Resourrla Land
There is a $40.00 application fee for the Resource Land & Critical Areas Checklist. Make checks payable to the Mason
County Treasurer.
When completed, this form becomes part of the permit application.
-M_
PLEASE PRINT ' I C'� SQ z �W� 4 S
1 . Owner: Applicant: /'S,o vi J er, se, 7
Site Address: F*P71-o 7t' 1�7E J�J /1 Nfi3�oo Applicant Address: E'ost-
Owner Address: 6s s/ Co City: St
_yA Zip
City: Ago, ✓e$ a s St V ✓ Zip 89 i/ 9 Phone: ( ) 2 7 5=4-4 77
Phone: ( )
2. Parcel No. Legal Description: C, v ao f
LPOroX 39. /G �c� Ps StC 31_
7: 'cWA/ 3N WO /
3. Purpose of Pre-Inspection: 1 Q-a f' � .v o s s �. �, /- �, a m e
_S 1 �P $ O Yl .✓N O i� U �V b N eA
- 4., Use of Building:
5. Is there any type of water on or adjacent to property?: saltwater des lake
river Oe,o pond wetland 7tze- seasonal runoff other
Directions to Site: 300 o .S o 7L
0
If the information is incomplete, then Mason County must disclaim any errors resulting from
deficiencies in the original application. Pre-inspection reports remain valid only until
development changes occur in the vicinity which affect the lot evaluated in this inspection.
Applicant Signature: 2 - Date: ?
Return application to: Department of Community Development,Planning Division
426 W. Cedar/P.O. Box 578
Shelton, WA 98584
(206) 427-9670/1-800-562-5628
Please include a $40.00 check or money order payable to Mason County Treasurer
FOR OFFICE USE ONLY: Accepted by: Date:
:p
Departmental Review
(For Office Use Only)
Planning Department Findings:
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