HomeMy WebLinkAbout04 Application FormDonna Frostholm
From:
rrathvon@gmail.com
Sent:
Tuesday, July 9, 2024 6:22 AM
To:
Donna Frostholm
Cc:
'Richard Rathvon'
Subject:
RE: SDP2023-00020 for NSFR
Attachments:
Permit application_master.pdf
ALERT: BE CAUTIOUS This email originated outside the organization. Do not open attachments or click on links if you are
not expecting them.
Donna,
I have attached a completed Master Permit Application form. (It does look familiar, but I did not search my
files.) Please let me know if you have any questions or need additional information.
I will be in the area on August 6, and could come by first thing in the morning of that day (if that works for
you).
Just let me know. Thank you.
Best regards,
Rich
From: Donna Frostholm <DFrostholm@co.jefferson.wa.us>
Sent: Monday, July S, 2024 6:12 PM
To: Richard Rathvon <rrathvon@gmail.com>
Cc:'Richard Rathvon' <rich@rathvonconsulting.com>
Subject: SDP2023-00020 for NSFR
Richard,
You may have filled out a master permit application form, but I did not see it in your shoreline or building case
files. Here is the link: htts: www.co.iefferson.wa.us DocumentCenter View 545 Permit -A iication-PDF?bidld=
Please complete and return to me.
Also, would you remind me of the dates you will be here in August so I can try to schedule noticing for that timeframe?
Thanks much,
Donna FrosthoCm, P-WS
Associate Planner - Lead/WetCancdSpeciaC%st
Jefferson County Department of Community Development
621 Sheridan Street, Port 7o-wnsencC ^Washington 98368
360-379-4466 Crostr �r a ers rlr.sva_ !S
DCD IS OPEN MONDAY—THURSDAY FROM 9:00-12:00 and 1:00 - 4:30; CLOSED FRIDAY.
All emails sent to and from this address will automatically be archived by Jefferson County and emails may be subject to Public Disclosure under Chapter 42.56 RCW.
SON �'oG DEPARTMENT OF COMMUNITY DEVELOPMENT
Ct� 621 Sheridan Street, Port Townscnd, WA 95368
W Tel: 360.379.4-450 1 l as: 360.379.+151
ar dcr •Iw r
I? -mail: drdLfep i.jc•F(crm at." :t.us
IN- '�o
PERMIT APPLICATION
Steps in the Permit Process:
-Review application checklist to ensure all information is completed prior to submitting application.
-Make sure septic has been applied for and water availability has been proven.
-Make an appointment to meet with the Permit Technician by calling 360-379-4450.
-This is not a standalone application; it must be accompanied by a project specific supplemental application.
-Fees will be collected at intake. Additional fees may apply after review and payment is required before permit is issued.
For Department Use Only
Related Application #s:
Site Information _
Assessor Tax Parcel Number: 701164005
Site Address and/or Directions to Property:
Building Permit #
MLA #
660 Twana Way, Quilcene, WA 98376
Access (name of street(s)) from which access will be gained:
Coyle Road to Toandoes Road to Twana Way
Present use of property: Vacant Land
Description of Work (include proposed uses)
i-
Construction of single family residence
Wastewater - Sewage Disposal
This property is served by Port Townsend or Port Ludlow sewer system?
If not served by sewer identified above, identify type of septic system below:
Type of Sewage System Serving Property:
Septic Septic Permit #:
Community Septic Name of System:
Are other residences connected to the septic system?
5EP2022-00114
Conventional trench
YES NOJ
Case #:
NO
Additions or repairs to sewage system: Not yet installed
Is it a complete or partial system installation: Complete Partial
Has a reserve drainfield been designated? Yes_ No
Date of Last Operations & Maintenance check: Attach last report to application
Describe or attach any drainfield easements, covenants or notices on title, which may impact the property:
The authorized agent/representative is the primary contact for all project -related questions and correspondence. The County will mail
/ e-mail requests and information about the application to the authorized agent/representative and will copy (cc) the owner noted
below. The authorized agent/representative Is responsible for communicating the information to all parties involved with the
application, it is the responsibility of the authorized agent/representative and owner to ensure their mailbox accepts County email (i.e.,
County email is not blocked or sent to "junk mail"
Applicant/Property Owner Information
Property Owner:
Name: Richard Rathvon
Address: 20 Liberty Knoll, Colts Neck, NJ 07722
Phone #: 914-61(1-5097 E 'I dd
Property Owner Si
Note: For projects with
-mai A ress. Pathvon@gman.com
Please contact Authorized Agent/Representative with project info. (select only one).
it re: Date: 07/08)
nt: Authorized
Name:
Address:
Phone M
Professional:
attach a separate sheet with each owner(s) information and
Is this an Authorized A
(It other than owner)
E-mail Address-
-nt/Representative for this project? NO V YES
Engineer
V Architect Surveyor
Name:
Everett Sorenson
Address:
715 Grant Street
Phone
360-821-9960
Professional: Is this an Authorized A
Engineer
Name:
Address:
Phone #:
Architect
Joey Pasquinelli
Surveyor
Contractor
License #
E-mail Address: ev s
itative for this project?
Contractor
License #
Consultant
totmail.com
NO �% - YES
Consultant
3309 Walingford, Seattle, WA 98103
206-728-0480 E-mail Address: joey@mctarch.com
Professional: Is this an Authorized
Engineer
Name:
Address:
Phone #:
Architect
agent/Representative for this project? NO
Surveyor Contractor
License #
E-mail Address:
Consultant
YES
By signing this application form, the owner/agent attests that the information provided herein, and in any attachments, is true and
correct to the best of his or her knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with
respect to this application packet may result in making any issued permit null and void.
I further agree to that all activities I intend to undertake or complete associated with this permit will be performed in comps€ante with
all applicable federal, state and county laws and regulations and I agree to provide access and right of entry to Jefferson County and its
employees, representatives or agents for the sole purpose of application review and any required later inspections. Applicant may
request notice a the County's int;U!ter upon the property for visits related to this application and subsequent permit issuance.
Si nature:LL g PrintName: 12 l (t-tr1 aO VZ4— Hild11 Date: elz
r