HomeMy WebLinkAboutGRD2025-00003 - GRD Inspections - 2/21/2025 MASON COUNTY PERMIT NO.rig a� 0Q5-baoo3
DEPARTMENT OF COMMUNITY DEVELOPMENT
BUILDING•PLANNING•FIRE MARSHAL RECEIVE E
WWW.CO.MASON.WA.US (360)427-9670 Shelton ext.352
_ Mason County Bldg.8, (360)275-4467 Belfair ext.352 FEB 2 1 2025
gas, 615 W.Alder Street,Shelton,WA 98584 (360)482-5269 Elma ext.352
LAND MODIFICATION PERMIT (Grading Permit) 615 W. Alder Stree
OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME: NAME:
MAILING D RESS: J tha K1 MAILING AD RESS: vw
CITY: STATE: ZIP: q CITY: STATE:
PHONE: 0-b ELL: u PHONE: � b CELL:
EMAIL: EMAIL : ,
L&I REG# ° JaDZEXP.
PARCEL INFORMATION:
PARCEL NUMBER(12 DIGIT NUMBER) FIRE DISTRICT
LEGAL DESCRIPTIO VIATED)
SITE ADDRESS () 11 .AnO KA CI
ECTIONS TO SITI ADDRESS
Y
IS PROPERTY WITHIN 200 FT:
SALTWATER❑ LAKE❑ RIVER/CREEK❑ POND❑ WETLANDW*ESNO
AL RUNOFF ❑ STREAM❑
DOES PROPERTY HAVE SLOPE(S)WITHIN 300 FT THE PROJECT- N 14% YES❑ NO V,
WILL TIMBER BE CUT AND SOLD IN P C PREPARATION ®.
TYPE OF JOB: EXCAVATION ❑ XING ❑ GRADIN CUTTING ❑ OTHER ❑
TOTAL SIZE OF PARCEL C ESQ FT SIZE TO BE EFFECTED-) CRES Q FT
ESTIMATED AMOUNTY OF CUBIC Y 1�l[�
DOES THE SITE HAVE SLOPES 14% G ATER YE ❑ O
DESC ORK II
WIL FILL BE BROUGHT ON I 1F YES,SITE ADDRE
WIL EXCAVATED MA E TAKEN OFF SITE?IF YES,SITE ADDRESS:
DOE FILL CONT P TE HAZARDOUS MATERIALS? YES❑ NO-S
HAS SOILS REPO BEEN OMPLETED ON SITE?IF YES,INCLUDE A COPY. YES❑ NO
WILL OPSAL RES T IN REDIRECTION OF ANY SURFACE WWATER RUNOFF? YES ❑ NO Ja
WILL RK ALTER RE STORMWATER OF GROUND WATER ENTERS OR EXISTS THE SITE? YES ❑ NO
WILL QUALITY,QUANTITY OR VELOCITY OF STORM/GROUND WATER BE ALTERED? YES❑ NO
WILL THE RUNOFF BE COLLETED/CONTROLLED BY INTERCEPTORS,CURTAIN DRAINS OR OTHER DEVICES? YES`K NO❑
WILL THE LAND BE REPLANTED UPON COMPLETION? YES ❑ NO
WILL THE PROPOSAL RESULT IN SLOPES STEEPER THAN THOSE CURRENTLY ON SITE? YES ❑ NO
IS THE SITE WITHIN 200 FT OF A DESIGNATED SHORELINE OR A WETLAND? YES❑ NO 14
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 entitledas to rec ' e this permit and to do the work as proposed. I have obtained permission from all the necessary
parties, including any eeme older or parties of interest regarding this project.The owner or authorized agent represents that the
information provided is aJ
and grants employees of Mason County access to the above described property and structure(s)for
review and inspection.Tit/application becomes null&void if work or authorized construction is not commenced within 180
days or if construction wspended for a period of 180 days. PROOF OF CONTINUATION OF WORK IS BY MEANS OF
INSPECTI IN TI ITHIS PERMIT APPLICATION OF 180 DAYS W L INVAL14ATE THE APPLICATION.
x _y .
r f Applicant
X �� @;NEt6REPRESENTATI CONTRACTOR
Print Name DIC
'd s amr+ra MATLOCK PROJECT
. • "ismT.19 N. R.6 W.
W 'A of SE 'l of
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SE Y of SECTION 5
PARCEL #619054400020
ORIGINAL PARCEL DESCRIPTION b
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