HomeMy WebLinkAboutBLD2004-00232 •BUILDING PERMIT APPLICfION MLLA04-00p 94
RevieTye: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD04-00232 Received Date: 4/9/2004
SITE ADDRESS: 111 GEORGE LESLIE DR
PORT LUDLOW, 98365
OWNER: GE LAND LLC PHONE:
1125 57TH ST E STE D
SUMNER WA 98390
3 64261
SUBDIVISION: 25 AR82EN-ESTATES Block: Lot: 14
PARCEL NUMBER: 952900014 Section: 34 Township: 28 N Range: 01 E
CONTRACTOR: GE LAND LLC PHONE:
1125 57TH ST E
SUITE D
SUMNER WA 98390
Contractor's License GELANLL966DD Expires 3/4/2006
REPRESENTATIVE: GE LAND LLC PHONE: (253) 826-4261 X 123
THOMAS ANSMAN
1125 57TH STE STE D
PROJECT DESCRIPTIOI NEW SRF W/ATTACHED GARAGE AND COVERED PORCH
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 1,119
VALUATION 251,960.00 ADD'L: 1,558 HEAT TYPE: EEE
CODE EDITION: 1997 HEAT BASE: HEAT TYPE:
OCCUPANCY: R-3 UNHEATED: #OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: 5N GARAGE: 400 SHORELINE:
CONST TYPE: DECK: 110 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: CON
WATER SYSTEM: LUDLOW PARCEL TAGS: YES NO
BEDROOMS: BATHROOMS: STORMWATER: YES NO AREA
Exist: Exist: Wetland Erosion
Prop: 4 Prop: 3 Seismic Streams
Total: 4 Total: 3 Flood Way Floodplain
Routing Date: 2 ,� F&W Landslide
_� �' Shoreline Aquifer
Forest: Commercial Rural
E D
Type Amount Paid Bv: Date: Receipt: P'A'' DV
Permit $1,844.95 KAS 04/09/04 64138
State Building Code $4.50 KAS 04/09/04 64138 APR 2 3 2004
Potable Water Application $52.00 KAS 04/09/04 64138
Total: $1,901.45 Jefferson �` :_'
0 •
Jefferson County Department of Community Development
�,a
621 Sheridan Street,Port Townsend WA 88368[3601370-44.50
,,,,7".T J ti x Yam,.-- }-.3? - cal, on
Project Description:
Buildin e: Project Type: Frame Type:
Sin le Famil, MO 'oo
Garage Attached/Detached Addition ,teel
Modular Alteration/Remodel Concrete •
Commercial Repair Masonry
Multi-family/#of Units Demolition Other:
Industrial
Other:
Bathrooms: Bedrooms: Type of Sewage Disposal: Type of Heat:
Choose one:
Existing: Existing: Sewer Community System Electrici Oil
Proposed: QL..5 Proposed: Int„11'vidual System Woodstove Propane
Total: 2.S Total:
If not sewer,fill out the following: Heat Pump
onventional Alternative Other
Permit# SEP Oq', /8
Water Supply: y ��IA_( . 6
Private well Two PartyWell Public:Name of water system:
Square Footage: For Office Use Only
Main Floor 0:2, /�� �� t� ���-q.S-`1.7 Consistency Review D •00
2ND Floor 1 D 13Q6 . - Base fee (1, -.Q 5
3rd Floor Plan Check fee STDC41-PC$I2bO4..—1='
Htd Basement State Surcharge fee .'0
Unhtd Basement u /� Subtotal i gq-7. 145"
Garage/Carport -[M1.•N g142-.1 Pot Water Review fee 75 •00
Decks 911/Rd Approach fee
Commercial TOTAL £q g2. •4'5"
Industrial Receipt# 641 5S
Other (((,. ,(OQ Cash/Check# (O0 l 033
Total Valuation: $ (�\j We'll 25Q2"iV Initials P
Or .�
2G��(p�
�� 4--
Date4.
�
Estimated Cost:
If within 200' of the Shoreline,
Distance to Bank or Ordinary High Water Mark ft. Bank Height ft.
By signing the application form,the applicant/owner attests that the information provided herein is true and correct to the best of their knowledge. Any material falsehood or any
omission of a material fact made by the applicant/owner with respect to this application packet may result in this permit being null and void.
I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable attomey's fees and expenses which may in any way accrue
against Jefferson County as a res t of or in consequence of the granting of this permit.
I further agree to provide access nd right of e ro to Jef son County and it's employees,representatives or agents for the purpose of appli anion re iew and any required later inspections.
Access and right of entry to th aappplict's pro ay or sr rune shall be requested and shall occur during regular business hours.
Signature: ) i J Date: 246
OVER ►
1 I:HOME\PLNCNTR\INFOBLDG\FORMS\BLDpermit.kpplication 11-8-01
BUILDING PERMIT •
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD04-00232 Received Date 04/9/2004
SITE ADDRESS: 111 GEORGE LESLIE DR Issue Date 04/23/2004
PORT LUDLOW, 98365
APPLICANT: GE LAND LLC P-IONE: (253) 826-4261
1125 57TH ST E STE D
SUMNER WA 98390
SUBDIVISION: GARTEN ESTATES Block: Lot: 14
PARCEL NUMBER: 952900014 Section: 34 Township: 28 N Range: 01 E
CONTRACTOR: GE LAND LLC PHONE:
1125 57TH ST E
SUITE D
SUMNER WA 98390
Contractor's License: GELANLL966DD Expires: 03/04/2006
PROJECT DESCRIPTION: NEW SRF W/ATTACHED GARAGE AND COVERED PORCH
REQUIRED INSPECTIONS:
[ ] SETBACKS: 1. ! s/1/9
[ ] UFFER: Od)r.?c=
[ ] Footing: . '` ,6✓
[ ] Foundation: A/ WA2na eio,2s -0 'D,/ce
[ ] Underground Plumbing: /, ,z- di tk MDK 5/4/'1 —1 N7L1/Ie FG2 f76wrasPmcrs Attie" S'14740
[ ] Underground Insulation: �/ Arr5v'� NIL OK 7 o-
[ ] Shear Wall : EAr� 4r11&4,eGnga.. e�(A/t/ �t `
[ ] Framing: O 6OZ/f
1 1 Plumbing:a �/zf/41 1111
[ ] Propane Tank/ Lines:
[ ] Insulation: at 4/Z(/o9'
1 1 Sheetrock: ®K 7/2/s'
[ ] Stormwater FINAL Approva:
[ ] Septic Sytem Final Approval:
1 Road Approach Final Approval:
[ ] Zoning Final Approval:
( 1 Final/Occupancy Approval: 1Z 1 `l " 7•p�d�
HEALTH DEPARTMENT AND PUBLIC WORKS APPROVAL REQUIRED PRIOR TO FINAL INSPECTION
THIS PERMIT IS VALID FOR ONE YEAR OR IT MUST BE PROPERLY RENEWED
BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS.
Office Hours 9:00 a.m. -4:30 p.m.
HOT LINE AVAILABLE 24 HOURS A DAY
SPECIAL CONDITIONS APPLY-SEE REVERSE
•
SPECIAL CONDITIONS FORASE BLD04-00232
1.) The application was reviewed by the Jefferson County Department of Community
Development staff on April 15, 2004 for the potential presence of Environmentally
Sensitive Areas (ESAs) under the provisions of the Unified Development Code (UDC).
After an initial Geographic Information Systems mapping review and an investigative site
inspection, the following ESAs were confirmed to be present on the subject property:
SARPA& SUSC aquifer recharge area; High Risk SIPZ.
2.) Aquifer Recharge Areas in Jefferson County are characterized by porous geological
formations that allow percolation of the surface water into the soils and the underlying
zone of saturation. Aquifers are geologic formations that contain sufficient saturated
permeable material to yield significant quantities of water to wells and springs. Aquifers
serve as the source of drinking water within most of the rural portions of Jefferson County.
3.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions
that promote rapid infiltration of recharge waters to groundwater aquifers.
4.) Critical Aquifer Recharge Areas are defined as Seawater Intrusion Areas, and Special
Aquifer Recharge Protection Areas and the following land uses located within Susceptible
Aquifer Recharge Areas (1)All Industrial Land Uses (2)All Commercial Uses (3)All Rural
Residential Land Uses requiring a Discretionary Use or Conditional Use Permit(4)All
Rural Residential Land Uses with nonconforming uses that would otherwise require a
Discretionary Use or Conditional Use Permit(5) Unsewered Planned Rural Residential
Developments (6) Unsewered residential development with gross densities greater than
one unit per acre. All of the above listed uses shall be subject to the applicable
requirements and standards of the Jefferson County Unified Development Code.
5.) Marine shorelines and islands are susceptible to a condition that is known as seawater
intrusion. Seawater intrusion is a condition in which the saltwater/freshwater interface in
an aquifer moves inland so that wells drilled on upland areas cannot obtain freshwater
suitable for public consumption without significant additional treatment and cost.
Maintaining a stable balance in the saltwater/freshwater interface is primarily a function of
the rate of aquifer recharge (primarily through rainfall) and the rate of groundwater
withdrawals (primarily through wells). The Washington Department of Ecology is the
agency with statutory authority to regulate groundwater withdrawal for individual wells in
Jefferson County. New development, redevelopment, and land use activities on islands
and in close proximity to marine shorelines in particular should be developed in such a
manner to maximize aquifer recharge and maintain the saltwater/freshwater balance to
the maximum extent possible by infiltrating stormwater runoff so that it recharges the
aquifer.
6.) The parcel is located within a High Risk SIPZ(seawater intrusion protection zone)
according to the County GIS map. There are mandatory measures identified in the
Jefferson County Seawater Intrusion Policy (Resolution 44-22, effective September 23,
2002)that apply to well drilling proposals and building permit applications on existing lots
of record.
A High Risk SIPZ is defined as: areas within 1,000 feet of a groundwater source with a
history of chloride analyses above 200 milligrams per liter(mg/L).
7.) Critical Aquifer Recharge Areas may require special protection measures to mitigate water
quality degradation. The submitted proposal does not require additional aquifer
protection measures. However, during construction the project shall follow the Best
Management Practices (BMPs) and facility design standards as identified and defined in
the Stormwater Management Manual for the Puget Sound Basin.
•
8.) MANDATORY MEASURPOF HIGH RISK SIPZ:
Water conservation measures:
1. Roof and other intercepted precipitation shall be routed to on-site detention ponds
and/or other approved means and allowed to be released to the soil slowly.
2. Water collected from Storm water and roof catchments may be used for watering
lawns and gardens. Unless catchment water has been treated to meet drinking water
standards, there shall be no cross connections allowed between the potable supply and
impounded water.
3. Water withdrawn from wells on each property shall not be used for watering of lawns
and/or gardens.
4. Ground water withdrawn from each property shall be restricted to a rate of three (3)
gallons per minute.
5. Installation of water conserving fixtures such as low flow toilets, faucets and shower
restrictors and other water saving plumbing fixtures.
6. Landscaping plan (xeriscaping, native vegetation with minimal amounts of irrigation).
Please NOTE that the above listed measures are not intended to be exhaustive, but rather
is intended to be illustrative of the types of water conservation measures.
9.) MANDATORY MEASURES FOR HIGH RISK SIPZ:
1. For proof of potable water on a building permit application, applicant must utilize
DOH-approved public water system if available.
2. If public water is unavailable, a qualifying alternative system may be used as proof of
potable water or an individual well may be used as proof of potable water subject to the
following requirements:
a. Variance from Chapter 173 WAC standards granted by Ecology per WAC 173-160-106
for a new groundwater well within 100 feet of a sea-salt water intrusion area per WAC
173-160-171 (i.e., within 100 feet of a groundwater source showing chloride
concentrations above 200mg/L or within 100 feet of the marine shoreline); or for an
existing or proposed groundwater well not subject to an Ecology variance, applicant must
provide evidence through a hydrogeologic assessment(relevant components of an
Aquifer Recharge Area Report per UDC 3.6.10.e) of a reasonable probability that the
subject aquifer will not be degraded by the proposed use of well.
b. Installation of a flow meter.
c. On-going well monitoring for chloride concentration.
d. Submittal of flow and chloride data to the County per monitoring program.
3. If public water is unavailable, a qualifying alternative system may be used as proof of
potable water.
10.) The property owner shall comply with Water Conservation Measures (per list maintained
by the UDC Administrator).
11.) The applicant is proposing to create or add 2860 square feet of impervious surface and
3777 square feet of land disturbing activities.
12.) The project shall adhere to the Best Management Practices (BMPs) to control stormwater,
erosion and sediment during construction. BMPs shall address permanent measures to
stabilize soil exposed during construction, and in the design and operation of stormwater
and drainage control systems.
13.) A Stormwater Site Plan has been submitted and approved by the Department of
Community Development. Once the subject permit has been issued the applicant shall
fully implement the provisions of the submitted plan and contact the Jefferson County
Department of Community Development to arrange a schedule to inspect the property for
plan compliance. A Certificate of Occupancy will not be issued until the Department
verifies plan compliance. No clearing for roadways or utilities shall occur on the project
site until clearing necessary for the installation of temporary sedimentation and erosion
control measures have been completed.
14.) Jefferson County determined that this proposal is categorically exempt from review under
the State Environmental Policy Act(SEPA) pursuant to WAC 197-11-800(1)(b)(i).
15.) The site plan as submitted v�ith the single family residence building permi application on
April 15, 2004 has been reviewed for consistency under the UDC, and has been approved
by Jefferson County Department of Community Development. Any modifications,
changes, and/or additions to the stamped, approved site plan dated April 15, 2004 shall
be resubmitted for review and approval by Jefferson County Department of Community
Development.
16.) This approval is for a single family residence with attached garage and covered porch
only. Any future permits on this site are subject to review for consistency with applicable
codes and ordinances and does not preclude review and conditions which may be placed
on future permits.
17.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
18.) Not more than two (2) unlicensed or inoperable vehicles shall be stored on any lot less
than one-half acre unless totally screened from view of neighboring dwellings and
rights-of-way. Such screening shall meet all applicable performance and development
standards specific to the district in which the storage is kept, and shall be in keeping with
the character of the area. Screening shall meet the requirements of Unified Development
Code (UDC) Section 6. Outdoor storage of thirteen (13) or more unlicensed or inoperable
vehicles is prohibited except in those districts where specified as an automobile wrecking
yard or junk(or salvage) yard and allowed as a Permitted Use in Table 3-1 of the UDC,
and such storage shall meet the requirements of UDC Section 4.10. In no case, shall any
such unlicensed or inoperable vehiclesbe stored in an Environmentally Sensitive Area
(ESA).
19.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
20.) The building height is not to exceed 35 feet.
21.) Minimum setback from George Leslie Drive right-of-way shall be 20 feet. Minimum side
yard setbacks shall be 5 feet. Minimum rear yard (south) setback shall be 20 feet.
22.) Exterior lighting for residential uses shall not exceed twenty feet(20') in height from the
finished grade, excepting when such lighting is an integral part of a building or structure.
Ground level lighting is encouraged.
23.) Lighting fixtures shall be designed and hooded to prevent the light source from being
directly visible from outside the boundaries of the property. The intensity or brightness of
all lighting, during construction and after project completion shall not adversely affect the
use of surrounding properties or adjoining rights-of-way.
24.) A minimum of two (2) on-site parking spaces shall be provided for the single family
residence.
25.) The lot has been designated as RR 1:5 under the Jefferson County Comprehensive Land
Use Map effective August 28, 1998.
26.) An address of 111 George Leslie Drive, Port Ludlow has been assigned to the lot.
George Leslie Drive is a private road (P581).
27.) The lot is served by a public water system that has been approved by the Department of
Health and therefore the SIPZ requirements do not apply since potable water has been
proven.
28.) A septic permit(SEP04-0018) has been approved on February 7, 2004.
29.) The lot was created through the Garten Estates Subdivision on February 14, 2003 under
AFN 465764.
I:\F_BLD_Permit_Buildng.rpt 10/29/1999
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91. PERMIT # 8i0
, o JEFFERSON0 4. _.0232
tier/ COUNTY
q - = ,. DEPARTMENT OF COMMUNITY DEVELOPMENT 1
I FFEBSRCO
621 Sheridan Street • Port Townsend •Washington 98368
Q 360/379-4450 • 360/379-4451 Fax
' NG'` http://www.co.jefferson.wa.us/commdevelopment/
STORMWATER SITE PLAN SUBMITTAL TEMPLATE
MLA# V If f q1- PROJECT/APPLICANT NAME: d-E--1..04,1cO ,Q
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Please answer all of the following questions to the best of your ability. Where the question calls for depiction on a site map, the
applicant may choose to either incorporate the elements into the general plot plan for the Master Land Use Application or to submit a
separate stormwater site plan map.
Project Overview
1. Describe the proposed developed conditions of the site. Indicate position and relative size of proposed improvements on the
site map.
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Existing Conditions Summary
2. Describe the existing topography. Indicate contours on the site map.
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3. Describe the existing vegetation. Indicate native vegetation areas on the site map.
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4. Describe the existing soils. Indicate soil type on the site map.
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5. Describe the existing site hydrology(i.e., drainage;behavior of water on the site—above, below, and on the ground). Indicate
existing stormwater drainage to and from the site on the site map. Depict separate drainage basins on the site map, if
applicable,and indicate acreage of each.
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6. Describe any excess levels of noise generated yprfpgsgcQpr„ .
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stormwater site plan template-rev.10/1/2003 JEFFERSOT CO TY 5
DEPT.OF C . .'1 Y DE ELOP ENT
SIGNATURE:
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7. Describe significant geographic features and critical areas (i.e., environmentally sensitive areas such as wetlands, streams,
steep slopes,etc.)on the site. Indicate loc tion on the site map.
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8. Describe the general vicinity of the site, including adjacent land uses and structures, utilities, roads, and sensitive/critical areas
(streams,wetlands,lakes,steep slopes,etc.).
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Permanent Stormwater Control Plan
This portion of the Stormwater Site Plan consists of the selection and installation of the appropriate stormwater control BMPs
and facilities to remain in place after construction of the project is completed.
"Medium" size projects are required to have the totals calculated of all impervious surfaces, pollution-generating impervious
surfaces, and pollution-generating pervious surfaces to verify that the thresholds for treatment facilities and flow control
facilities are not exceeded.
g. Describe the developed site hydrology, as proposed. Indicate whether stormwater will be fully dispersed (i.e., per BMP T5.30
in the Manual) or,if not, what types of stormwater flow control will be utilized for the site or specific threshold discharge areas
within the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities.
curt SotL-S PCQvious StLr s octC.S wrc,c. lSrc 1"1sr44,c,E'c
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10. If the project requires the use of stormwater treatment facilities,describe the types of stormwater treatment facilities proposed
for use on the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities. [This is
normally for large"projects or projects that involve the potential for dispersion of contaminants.]
11. Describe the performance goals and standards applicable to the project.
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12. Describe the flow control system.
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stormwater site plan template—rev.10/1/2003 6
RI' PERMIT # OLD
04 - 0232
13. Describe,th 1 water quality system. f ru
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14. Describe the conveyance system analysis and design. , l
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15. Describe the source of fill material,physical characteristics of fill material,and deposition of excess material.
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16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the
Uniform Building Code.
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17. Describe the proposed surfacing material.L/
18. Describe methods for restoration of the site.
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19. An Operation and Maintenance Manual is required for each flow control and treatment facility. [This is normally required for
large"projects only and only those for which facilities are required to control flow or treat runoff.] If included,list the Manuals
here. ✓r
elAc-
20. List here and include any special reports or studies conducted to prepare the Stormwater Site Plan.
A./4
21. List other necessary permits and approvals as required by other regulatory agencies. If those permits or approvals include
conditions that affect the drainage plan or contain more restrictive drainage-related requirements,describe those conditions or
restrictions here. 14/4
stonnwater site plan template—rev.10/1/2003 7
API
CONSTRUCTION STORMWATER POLLUTION PREVENTION PLAN(SWPPP)
The Construction SWPPP addresses sediment and erosion control during construction. The BMPs indicated by the applicant in the
template that follows must be installed on the ground during all construction phases of the project. The proponent is responsible for
preventing sediment and erosion impacts to environmentally sensitive areas and off-site areas. Consult the Construction Stormwater
Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet for guidance, particularly with rural residential
development.
SECTION I-CONSTRUCTION SWPPP NARRATIVE
1. Construction Stormwater Pollution Plan Elements. Describe how each of the Construction SWPPP elements has been or
will.be addressed. Identify the type and location of BMPs used to satisfy the required element. If an element is not applicable
to the proposal,justify in writing. Descriptions of the 12 Elements are found at section 2.5.2 of the Manual(beginning on page
2-15).
12 Required Elements-Construction SWPPP
1. Mark Clearing Limits.
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2. Establish Construction Access.
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3. Control Flow Rates.
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4. Install Sediment Controls.
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5. Stabilize Soils.
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6. Protect Slopes.
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7. Protect Drain Inlets.
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APR - 9 2004
stormwater site plan template-rev.10/1/2003 8
PERMIT # RlD
fl4 - 0232
12 Required Elements-Construction SWPPP(continued)
8. Stabilize Channels and Outlets. COUNTS QCt
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9. Control Pollutants.
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10. Control De-Watering(the act of pumping groundwater or stomiwater away from an active construction site).
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11. Maintain Best Management Practices(BMPs).
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12. Manage the Project.
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2. Adjacent Areas.
a. Description of the adjacent areas that may be affected by site disturbance (e.g. streams, lakes, wetlands, residential
areas, roads).
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b. Description of the downst eam drainage path leading from the site to the receiving body of water(minimum distance of 400
yards).
3. Environmentally Sensitive Areas.
a. Description of environmentally sensitive areas that are on or adjacent to the site.
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stormwater site plan template—rev.10/1/2003 9
b. Description of special r uirements for working in or near environmentally sensitive areas.
4. Erosion Problem Areas. Description of potential erosion problems on site in the context of the characteristics of the on-site
soils(e.g.,erodibility, settleability,permeability,depth,texture,soil structure).
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5. Construction Phasing.
a. Construction sequence
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b. Construction phasing(if proposed)
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6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual).
I. Provide a proposed construction schedule.
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II, Wet Season Construction Activities.
a. Proposed wet season construction activities. APR _ q 9004
b. Proposed wet season construction activities for environmentally sensitive areas.
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7. Financial/Ownership Responsibilities.
a. I�ntify the property owner responsible for the initiation of bonds and/or other financial securities.
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b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation
impacts.
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8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following,if applicable.
a. Sediment Ponds/Traps. 91(//
b. Diversions. /t/A-
c. Waterways. N4--
d. Runoff/Stormwater Detention Calculations /I/i4--
stormwater site plan template—rev.10/1/2003 10
API
Stormwater Site Plan Changes
If the designer wishes to make changes or revisions to the originally approved Stormwater Site Plan, the proposed revisions shall be
submitted to DCD prior to construction. The submittal shall include substitute pages that include all proposed changes, revised
drawings showing any structural changes,and any other supporting information that explains and supports the reason for the change.
Final Corrected Plan Submittal
If the project included construction of conveyance systems,treatment facilities,flow control facilities, or structural source control BMPs
(not standard on-site stormwater management BMPs), the applicant shall submit a final corrected plan ("as-builts")when the project is
completed. These should be engineering drawings (stamped by a licensed civil engineer) that accurately represent the project as
constructed.
APPLICANT SIGNATURE
By sig ing the Construction SWPPP worksheet, I as the applicant/owner attest that the information provided herein is true and
correc to the best of y knowledge. I also certify that his application is being made with the full knowledge and consent of all
own s of the ffected p perry.
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(LANDOWNER OR AUTHORIZED REPRESENTATIVE SIGNATURE) (DATE)
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED:
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9 2004 ,
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12
stormwater site plan template—rev.10/1/2003