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Home My WebLink AboutGRD96-00021 - GRD Application - 7/22/1996 GRD MASON COUNTY LAND MODIFICATION PERMIT Grading, Excavation, Fill, Slopes, Drainage 7171, � Department of General Services 426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628 PLEASE PRINT 7 , #1 Owner � `(fC�j� S(��, Phone# � � Fire District# Site Address City St Zip Owner Address /Z70 7l City ` _St zjzeoZip Describe Work #2 Contractor Name J,>✓�fL � C � (', 1A � WA ontractor Reg# Pi9 CC I Z2./A Address O/3Expiration Date 37--S-- Z City f St 4dZPL—Zip Phone#��r #3 Engineer's Name Phone# 2.� �7 Address 6 City ) St 6t/,*- Zip #4 Parcel No.3 2-1 3"( Legal Description 4-- Z 1�1 #5 Number of cubic yards to be excavated: Number of cubic yards to be filled: 2— Number of cubic yards to be graded: #6 Will this be a balanced 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? Does fill contain any potentially hazardous materials? Yes No #7 Will excavated materials be taken off site?Yes No If Yes: Where will excavated materials be taken? #8 Briefly describe existing terrain, vegetation, and improvements on subject site? X/O #9 Total size of area to be cleared C- J acres/sq ft Size of area to be cleared on slopes over 10% r'� AC/SF #10 Has a soils report been completed on the subject site? Q�/L If yes, include copy with application. #11 Is the subject site within 200 feet of a designated shoreline #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 P p 9 p � ! where storm water or groundwater enters or exits the site? 7 #14 Will the proposed land surface modification change the quality, quantity, or velocity of storm water/groundwater? #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? 1*72 D #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? Oti1 #18 Will the land be replanted upon completion? Gam!<l4l-PL If yes, with what types of plants? #19 Will this modification result in slopes steeper than those currently on the site? 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 S� 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 OF THE 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 X BY DATE DATE FOR OFFICIAL USE ONLY:Accepted by: Date: DEPARTMENTAL REVIEW Planning J _ APP COND APP HOLD 5Pt- —Ob s a5hc.�6E Building Environmental Other Special Conditions FEES Grading Permit $ Plan Review Site Inspection Violation Fee Other TOTALFEES $