HomeMy WebLinkAboutBLD8983 SFR - BLD Application - 3/16/1975 BUILDING PERMIT APPLICATION
MASON COUNTY
P. 0. Box 400 Shelton, Washinqton 98584
DATE ISSUED
PERMIT NO.
-----__T_ L MAI ADDRESS --_---_—_ --ZIP --_.�-- PHONE
OWNER; Ld:., - Sox _�_ �`il,:.����sr �- - -7 f
DIRECTIONS
.TO JOB SITE�-Fvrv► VrtZSt $t sdl.'CL �s�.ea ���► {��rP,r �roC�Q1 � v �dS
MAIL ADDRESS ZI3P
C]!f[ATTACHED SH[[T)
DESCR. N 1%4
MAIL ADDRESS PHONE
CONTRACTOR
e
USE OF ( MAIL ADDRESS PHONE LICENSE NO.
BUILDING �QS, C 2
Class of work: N NEW ❑ADDITION ❑ALTERATION '❑ REPAIR Cl MOVE ❑ REMOVE
Describe work: t
Valuation of work: $ PLAN CHECK FEE .`'a'�. PERMIT FEE
s
SPECIAL CONDITIONS:
APPLICATION ACCEPTED By PLANS CHECKED BY APPROVED FOR ISSUANCE BY
Type of Occupancy
f Const. Group Division
Size of Bldg. �No.of f Max.
(Total)Sq. Ft./yc)! Stories L Occ. Load
CONTRACTOR AFFIDAVIT Special Approvals Required Received Not Require
I Certify that I am a currently registered contractor in the State NING . y
of Washington and the County of Mason and I am aware cf the PEAC'F DEPT. ✓ # ��/�
ordinance rcquircments regulating the wcrk fcr which the permit ORKB
is issued and all work done wi,l be in conformance therewith. AZ5A15 bivar
Firm
By
Lic. No. Date
OWNERS AFFIDAVIT
I certify that I am exempt from the requirements of the contract-
or registration law RCW 18.27, and am aware of the Mason N 0 T I C E
County ordinance requirements for which this permit is issued
and that all work done will be in conformance therewith. SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING,
HEATING. VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION
I TON AUTHORIZED
WORK IS NOT SUOMMENCED SPENDED ORITHIN 120 ABANDONEDSFOR A PEE CO
NSTRUC-
TION OD F
Owner 0,),j� Date 120 DAYS AT ANY TIME AFTER WORK IS COMMENCED.
PLAN CHECK VALIDATION cK. M.O. CASH PERMIT VALIDATION CK.J M.O. CASH
1 �,HCLTON Pi21NTING CO.
PLOT PLAN
ADDRESS PERMIT NO. , o 0
f o
z
LEGAL n
DESCRIPTION LOT BLK ADDITION N
SITE AREA Sq. Ft. AREA OF SITE OCCUPIED BY BUILDINGS _.._Sq. Ft.
INSTRUCTIONS TO APPLICANT
THIS FORM NEED NOT BE USED WHEN PLOT PLANS DRAWN TO SCALE OF NOT LESS THAN 1"=20' ARE
FILED WITH PERMIT APPLICATION. (EACH BUILC•:NG SITE MUST HAVE A SEPARATE PLOT PLAN.)
FOR NEW BUILDINGS PROVIDE THE FOLLOWING INFORMATION IN THE SPACE BELOW: LOCATION OF
PROPOSED CONSTRUCTION AND EXISTING IMPROVEMENTS.SHOW BUILDING,SITE,AND SETBACK DIMEN-
SIONS. SHOW EASEMENTS, FINISH CONTOURS OR DRAINAGE, FIRST FLOUR ELEVATION, STREET ELEVA-
TION Al"D SEWER SERVICE ELEVATION. SHOW LOCATION OF WATER, SEWER, GAS AND ELECTRICAL
SERVICE LINES.SHOW LOCATION OF SURVEY PINS.SPECIFY THE USE OF EACH BUILDING AND MAJOR POR-
TION THEREOF.
0 INDICATE NORTH IN CIRCLE GRAPH SQUARES ARE 5' X 5' OR 1"=20'
a�
�a Sk
'4
I/We certify that the proposed construction will conform to the dimensions and uses shown above and that no changes will be made without
first obtaining approval.
NAME(S) OF OWNER(S) OF SITE 9 STRUCTURE(S) (PRINT) SIGNATURE OF OWNER(S) OR AUTHORIZED REPRESENTATIVE
DO NOT WRITE BELOW THIS LINE
APPROVED C;
DISTRICT AS NOTED (f .� /�ti, :Y :. DATE /Z�
GNEL�ON PFt'NT^,
i +.
SITE NO. PARCEL NO.
` fiHURSTON-MASON HEALTH DISTRICT DATE BASIS FOR FEE AMOUNT NRECEIPT
UMBER
DIVISION OF ENVIRONMENTAL HEALTH
529 WEST FOURTH 110 W.K ST P.O.BOX 746
PHONE 753-8073 PHONE 426-4407
OLYMPIA, WA 98501 SHELTON, WA 98584
OWNER
P.O. PHONE DIRECTIONS TO SITE: TOTAL
FEES
SEWAGE
CONTRACTOR
ADDRESS OR
LOCATION
NAME OF PLAT LOT
NO. SOIL TYPE
TOWNSHIP RANGE SEC.
DEPTH TO WATER TABLE FT.
WATER ❑ PUBLIC ❑ PRIVATE
SOURCE PERC. TESTS: INCHES PER HOUR
TYPE OF LOT BY: DATE
BUILDING BASEMENT SIZE X
NO.OF NO.OF GARBAGE PRIMARY SECONDARY
BEDROOMS BATHS DISPOSAL SEPTIC TANK lSl GAL. AERATION GAL.
SPACE RESERVED FOR DISTRIBUTION TILE TOTAL FEET
REPLACEMENTS DISTRIBUTION FIELD SQ FT.
NORTH - SITE PLAN AND SPECIAL STIPULATIONS: TRENCH BOTTOM AREA SQ. FEET
QUANTITY OF
APPROVED STONE CU. YD. SAND CU. YD.
FILL REQUIRED CU. YDS.
THE ELEVATION OF THE BUILDING SEWER SHALL BE SUCH THAT
THE MAXIMUM DEPTH OF THE DISTRIBUTION TILE SHALL BE BE-
TWEEN 12 INCHES AND 36 INCHES FROM FINISHED GRADE TO
TOP OF TILE UNLESS OTHERWISE STIPULATED BY THE HEALTH
OFFICER. IF THE ELEVATION OF THE BUILDING SEWER IS TOO
LOW TO MEET THESE ELEVATIONS, A SEWAGE EJECTOR MAY BE
REQUIRED.
ISOLATION STANDARDS FOR PRIVATE WATER SUPPLIES:
BETWEEN WELL AND TANK OR ANY PART OF THE TILE FIELD,
100 FEET FOR SINGLE RESIDENCE, MOBILE HOMES, DUPLEXES
AND MULTIPLE DWELLINGS. NO DRAINFIELD WITHIN 100 FEET
OF ANY WELL, FRESH WATER LAKE OR STREAM)00 FEET FROM
ANY SALT WATER BODY.
NOTE: "FOOTING DRAINAGE, DOWNSPOUTS, WATER SOFTENER AND ANY
OTHER WASTE WATER NOT DEFINED AS SEWAGE SHALL NOT BE CONNECTED
TO OR DISCHARGED INTO THE SEPTIC TANK SYSTEM OR THE SEWAGE DISPOSAL
AREA". ALL SEWAGE, INCLUDING SINK AND LAUNDRY WASTE, MUST BE
CONNECTED TO THE SEPTIC TANK.
FINAL INSPECTION REQUIRED BEFORE BACKFILLING
OFFICE USE ONLY TO BE BACKFILLED
AFTER INSPECTION
DATE APPLICANT MUST CALL FOR INSPECTIONS LISTED BELOW 12" TO 24"
SITE: APPROVED ❑ NOPROVED (i 2" STRAW
BY: 'o �� STONE
NOT O OVER TILE
SEWAGE: ❑ APPROVED ❑ APPROVED
BY: STONE
WATER: El APPROVED ❑ NOT BY. UNDER TILE
APPROVED
CROSS SECTION OF TRENCH OO M
BUILDING PERMIT PLOT PLAN
MASON COUNTY
DEPARTMENT of GENERAL SERVICES
P.O. Box 186 SHELTON, W�'I.SHINGTON 985484
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Indicate te!cw.. (.7- Prcpe,-,, I;n; - zrd damens'---s.41 r.L FL
O' Easements and roads. — —
e Septic, drainfield and reserve area, or Sewer.
d Septic tank and drainfield setback distances frcn foundations.
a Location (of proposed construction on property.
Q Building & septic system setback distances fron all property fires & easements.
Indica North 0 Well and water line. -
Saitwater, lakes, rivers, streams, wetlands, drainage.
n Lircie Araclh copy of septic system"as builr or septic permit-approval.
Q ndicate topography profile of property and structure on reverse side.
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