HomeMy WebLinkAboutBLD2004-00395 111
MANUFACTURED/MOBILE HOME INSTALLATION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT#: BLD04-00395 Received Date: 6/16/2004
SITE ADDRESS: 241 W ISLAND VIEW AVE Issue Date:
PORT TOWNSEND, 98368 8/27/2004
APPLICANT: JONCAR, INC
BISHOP BROTHERS CONST
PO BOX 417
PORT SUBDIVISION: ONDALE DLOCK WA 98339-0417
Block: 114 Lot: 38-43
PARCEL#: 962111410 Section: 34 Township: 30 N Range: 01 W
CONTRACTOR/
DEALER
INSTALLER: JAIME KOZELISKY WAINS0626 Expires: 7/31/200
1112 S JACOB MILLER RD PORT TOWNSEND WA
98368
PROJECT DESCRIPTION: NEW MANUFACTURED HOME
MAKE: MARLETTE
YEAR: 2003
SIZE: 28 X 70
THIS PERMIT IS VALID FOR ONE YEAR.
THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR.
THE EXPIRATION DATE IS 8/27/2005.
REQUIRED INSPECTIONS:
°[ ] Setbacks/Footing (CONTINUOUS FOOTING, SLAB or PADS USED):
Stormwater FINAL Approval:
`* Blocking/Plumbing:
[ ] Propane Tank/LinesR--
[ ] Zoning Final Approval:
Septic System Final Approval:
Road Approach Final Approval:
Final/Skirting/Vents/Porches/Steps: t< -car c/o 2//,, 25
HEALTH DEPARTMENT AND PUBLIC WORKS APPROVAL REQUIRED PRIOR TO FINAL INSPECTION
BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS.
Office Hours 9:00 a.m. -4:30 p.m.
SPECIAL CONDITIONS APPLY-SEE REVERSE
HOT-LINE AVAILABLE 24 HOURS A DAY
1110 MLA04-00354
Review Type:I
MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD04-00395 Received Date: 6/16/2004
SITE ADDRESS: 241 W ISLAND VIEW AVE
PORT TOWNSEND, 98368
APPLICANT: JONCAR, INC PHONE:
BISHOP BROTHERS CONST
PO BOX 417
PORT HADLOCK WA 98339-0417
SUBDIVISION: IRONDALE Block: 114 Lot: 38-43
PARCEL NUMBER: 962111410 Section: 34 Township: 30 N Range: 01 W
CONTRACTOR/ JAIME KOZELISKY PHONE: (360)385-3215
DEALER: 1112 S JACOB MILLER RD
PORT TOWNSEND WA 98368
Contractor's License WAINS0626 Expires 7/31/2004
INSTALLER: JAIME KOZELISKY WAINS0626 7/31/2004 (360)385-3215
1112 S JACOB MILLER RD PORT TOWNSEND WA
98368
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION: NEW MANUFACTURED HOME
TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE:
TYPE OF IMP NEW MAKE: MARLETTE SETBACK:
VALUATION 69,000.00 YEAR: 2003
LABOR & INDUSTRIES APPROVAL?
SIZE: 28 X 70 BANK HEIGHT:
SEWAGE DISPOSAL: CON
WATER SYSTEM: PUD
BEDROOMS: BATHROOMS: PARCEL TAGS: YES NO
STORMWATER: YES_ NO
Exist: Exist:
Prop: 3 Prop: 2 AREA Plat Conditions
Total: 3 Total: 2 Wetland Erosion
Seismic Streams
Flood Way Floodplain
Routing Date: F&W Landslide
1/44' ((1 ., ( Shoreline Aquifer
Type Amount Paid By: Date: Receipt: APV E
Manufactured Homes $154.00 KAS 06/16/04 66375
Potable Water Application $52.00 KAS 06/16/04 66375 AUG 2 2 2004
Total: $206.00
33Q"").30r._„144 Jefferson County Planning
te...ict..Q...t..),& Building Department
ULD
JEFFERSON COUNTY( UNITY DEVELOPMENT 621 SHERIDAN ST•RT TOWNSEND WA 98368
MANUFACTURED HOME INSTALLATION PERMIT APPLICATION
-�-ca
NEW BUILDING ❑ REPLACEMENT - i ��
Z� 70 J
SIZE
YEAR -7 c� 17.,
is
V �
MAKE '(. f' 1Z
COST `TW 7 oc�✓ ;c-3'
-6-i
BEDROOMS: BATHROOMS: TYPE OF HEAT: '; a 1
EXISTING EXISTING X Electricity 0 Oil
PROPOSED ?j PROPOSED 2 0 Woodstove 0 Propane
TOTAL ZJ TOTAL Z. 0 Heat Pump 0 Other
TYPE OF SEWAGE DISPOSAL: WATER SUPPLY:
ER 0 COMMUNITY SYSTEM 0 PRIVATE WELL 0 TWO PARTY WELL
XINDIVIDUAL SYSTEM X Conventional X PUBLIC Name of water system:
PERMIT # SEPO3 C"7(1-1j Alternative
IF WATERFRONT PROPERTY,
DISTANCE TO BANK OR HIGH WATER LINE 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 attorney's fees and
expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit.
I further agree to provide access and right of entry to Jefferson County and it's employees, representatives or agents for the purpose of application
review and any required later inspections. Access and right of entry to the applicant's property or structure shall be requested and shall occur during
regular business hours. k �- Lr- ,
SIGNATURE !/7� - �- DATE 67 C S--v t 7
NAME (PLEASE PRINT) , IN(✓l c- ro 2, t___L S K' '
FOR OFFICE USE ONLY
CONSISTENCY REVIEW FEE '?j RECEIPT# (f)0 5
BASE FEE f/544 CI) S ? 9 9
CASH/CK# J
ADDITIONAL SECTIONS DATE (P/l 6 OY
POTABLE WATER 02
911/ROAD APPROACH '
PROPANE TANK '-►I9"
TOTAL —1,
g:\permitcenter\forms\bldg forms\mobileap revised 2-11-04.doc
PLEASE MAIL TO:
•
JEFFERSON COUNTY ASSESSOR
• JACK WESTERN III IIPEFFERSON COUNTY COURTHOUSE
ASSESSOR PO BOX 1220,PORT TOWNSEND WA 98368
(360) 385-9105
MOBILE HOME INFORMATION FORM
OWNER'S NAME / MAILING ADDRESS: THIS/S NOTA TAX STATEMENT
NAME: L
The purpose of this questionnaire is to obtain information
ADDRESS: 2- S ��}-L��jc ( (� regarding either the current location of a mobile home or the
` " previous ownership and location of a mobile home. This will
@YLT --�' _ n, ,� n help our office determine whether the mobile home is already
` 'll3 (f on the tax rolls in Jefferson County_or if it has been moved to
this county from-another area. Please see reverse side for
TELEPHONE NO: .j Ca -- 3 Z
3 S , additional Infgrnita0ort.:;. I I
' 11
JUN 1 6 2004 w' ,'
t) MOBILE HOME DATA:
(A) MAKE NA V7 R (B) MODEL ;":1
t (C) YEAR
(D) LENGTH -70 (E) WIDTH -Z (F)SERIAL NUMBER
(G) YOUR PURCHASE PRICE(DO NOT INCLUDE SALES TAXI( n�`� _ (H) PURCHASE DATE 19c1.'0 +�-
2) PREVIOUS OWNER/ LOCATION OF MOBILE HOME:
(A) FROM WHOM DID YOU PURCHASE MOBILE #J- R l 0( Hz)
ADDRESS . -tvJ( / ,...�-
(B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR? YES NO (IF NO,WHAT COUNTY?
IF YES,WHAT WAS PREVIOUS ADDRESS OF MOBILE?
3) WHERE MOBILE HOME IS TO BE LOCATED:
i
(A) WILL THE MOBILE HOME BE IN A MOBILE HOME PARK? YES ( NO/
(B) IF LOCATED IN A MOBILE HOME PARK:
NAME ex ADDRESS OF PARK SPACE NO.
(C) IF NOT LOCATED IN A MOBILE HOME PARK:
NAME OF LAND OWNER: (P(ski "ZE L
LOCATION(ADDRESS) V\4() 0. Le( ( t,
REAL PROPERTY PARCEL NUMBER/DESCRIPTION & I ( y r p
THANK YOU FOR YOUR HELP!
SIGNATURE
KELLI LARSON, Property Technician
THIS FORM CONFORMS TO THE STANDARDS OF THE STATE DEPARTMENT OF REVENUE AND IS SUBJECT TO AUDIT VERIFICATION.
i
SPECIAL CONDITIONS CASE # BLD04-00395
1.) The application was reviewed by the Jefferson County Department of Community
Development staff on June 22, 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:
Special Aquifer Recharge Protection Areas and Coastal Seawater Intrusion Protection
Zones (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.) 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.
4.) The subject property is near an airport where a variety of airport dependent uses occur
that are not compatible with development. Potential discomforts of inconveniences may
include, but are not limited to: noise, aircraft take-offs and landings.
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 coastal SIPZ (seawater intrusion protection zone) according
to the County GIS map. There are voluntary and 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 Coastal SIPZ is defined as: all islands and area within one-quarter mile of marine
shoreline, but no history of chloride concentration above 100 mg/L in groundwater sources
within 1000 feet.
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.) VOLUNTARY MEASURES OCOASTAL &AT 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.) VOLUNTARY MEASURES OF COASTAL &AT RISK SIPZ:
1. Installation of a flow meter.
2. On-going well monitoring for chloride concentration.
3. Submittal of monitoring data to County.
10.) MANDATORY MEASURES FOR COASTAL 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 requirement:
a. Chloride concentration of a laboratory-certified well water sample submitted with
building permit application.
3. If public water is unavailable, a qualifying alternative system may be used as proof of
potable water.
11.) The applicant is proposing to create or add 3600 square feet of impervious surface and
10500 square feet of land disturbing activities. Sections 6.6 and 6.7 of the Jefferson
County Unified Development Code requires that your proposal submit a stormwater plan
meeting Minimum Requirements#1 through#5 of the Stormwater Management Manual
for Western Washington.
12.) 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).
13.) The revised site plan as submitted on July 26, 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 August 26, 2004 shall be resubmitted for review and approval by Jefferson
County Department of Community Development.
14.) This approval is for a manufactured home and detached home 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.
15.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
16.) 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).
17.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
18.) The building height is not to exceed 35 feet.
•
19.) Minimum setback from W Is d View Ave right-of-way is 20 ft. Minimum setback from
the platted right-of-way (McLellan Ave) along western property bounary is 20 ft. Minimum
side and rear setbacks are 5 ft.
20.) Exterior lighting for commercial and industrial uses shall not exceed thirty feet(30') in
height from the finished grade. 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.
21.) 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.
22.) This parcel has been designated as Rural Residential 1:5 under the Jefferson County
Comprehensive Plan Land Use Map effective August 28, 1998.
23.) A septic permit(SEP03-00097)was approved on May 7, 2003 for a system of 360 gallons
per day.
24.) W Island View Ave (P397) is a private road. A road approach was reviewed under
RAP04-00205, and an address of 241 W Island View Ave has been assigned to the
parcel.
25.) This parcel was created through the Irondale Division No. 5 under AFN 29795, filed of
record April 2, 1910 in Plat Book 2, page 135 with Jefferson County Auditor's office.
26.) A minimum of two (2) on-site parking spaces are required for the single family residence.
27.) A stormwater plan for a medium project 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.
28.) A Notice to Title was recorded July 19, 1999 under AFN 425011 with the Jefferson County
Auditor binding lots 38-43 of Block 114, Irondale Division 5 for the purpose of meeting
bulk and dimensional requirements and minimum land area.
t
41.ggt zN °>, , JEFFERSON COUNTY -1 1' [ V `'
e
44,
DEPARTMENT OF COMMUNITY DEVELOPMENT
I
J
,, 4, 621 Sheridan Street • Port Townsend •Washington 98368 - AUG _ 6
360/379-4450 • 360/379-4451 Fax
http://www.co.jefferson.wa.usicommdevelopment/ JEF ERg0N couN rY
OVPT. OF CO+.1 I ,,4:TY(cvA.OP0E'dT
STORMWATER SITE PLAN SUBMITTAL TEMPLATE _____.
MLA# - s-c-f PROJECT/APPLICANT NAME: .0 ,S tics-
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. a
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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(Le.,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.
6. Describe any excess levels of noise generated by the proposed use or activiy:
APPROVED
STORMWATR PLAN
V101"► tr AUG 2 6 2004
'
stormwater site plan template—rev.10/1l2003 (3v JEFFERSON COUNTY 5
slAtu toga tits S D PT.OF 'N. UNITY D V PrA.....ii.
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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 location on the sitelmap.
/ „5,
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.).
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.
(y
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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.]
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11. Describe the performance goals and s andards applicable to the project. II_crr `c) OUN IY
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12. Describe the flow control system. ( '2 PI A R /9-c-j frV -I I ;Oi r` 1-'23
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13. Describe the water quality system. , t. r 5 )
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JEFFEHSUN COUNTY —
system ana — ec -. GAF C0.4,44 XDEvFi nPMENT
14. Describe the conveyance
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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.
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18. Describe methods for restoration of the situ
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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.
20. List here and include any special reports or studies conducted to prepare the Stormwater Site Plan.
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.
/
JEFrERSON
CO 41
stormwater site plan template—rev.10✓1/2003
7
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. 612 it ;, Yci l.,c-i to 0--',P'''l -..;/ c�oi,.4-✓A,_ n ,
4. Install Sediment Controls. c _
5. Stabilize Soils.
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6. Protect Slopes. -V 1 f
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7. Protect Drain Inlets.
i;')/storwater site plan template—rev.10V12003 m
12 Required Elements—Construction SWPPP(continued)
8. Stabilize Channels and Outlets. r;a V7
AUG - � 1 6 2004 I
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9. Control Pollutants.
JEFFERSON COUNTY
tc � DrpT OF (;OP?JUNIIY De✓`LOPMENT
10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site).
11. Maintain Best Management Practices(BMPs).
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12. Manage the Project.
2. Adjacent Areas.
a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential
areas,roads). f
S I 17—A— c crs• ?r
b. Description of the downstream 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.
storrnv ater site plan template—rev.10/12003
JEr1ERSON COUNTY 0 �
b. Description of special requirements for working in or near environmentally sensitive areas.
e-5
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).
5. Construction Phasing.
a. Construction sequence
b. Construction phasing(if proposed)
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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I I. Wet Season Construction Activities. ! t
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a. Proposed wet season construction activities. / s 6 �04 {v }
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b. Proposed wet season construction activities for environmentally sensive areas,.( } ,t ^;
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7. Financial/Ownership Responsibilities.
a. Identify the property owner responsible for the initiation of bonds and/or other financial securities.
ctc }. �-1.v►' 4 l �'1 v t. C / :-)
b. Descnbe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation
impacts.
8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following,if applicable.
a. Sediment Ponds/Traps. _
b. Diversions.
c. Waterways.
d. Runoff/Stormwater Detention Calculations
10
stormwater site plan terrplate—rev.10/12003
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 signing the Construction SWPPP worksheet, I as the applicant/owner attest that the information provided herein is true and
correct to the best of my knowledge. I also certify that this application is being made with the full knowledge and consent of all
owners of the affected property.
( •'• NER OR A RIZ REPRESENTATIVE SIGNATURE) (DATE)
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES,IF NEEDED:
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\\ AUG " 6
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12
stormwater site plan template—rev.1011/2003
RETURN ADDRESS
JEFFERSON TITLE COMPANY
Po BOX 256
PORT TOWNSEND , WA 98368
7ATE OF WASHINOTON MANUFACTURED HOME . PLEASE;CHECK,ONE;'.
L47 � APPLICATION ITLE jjçEfiSIflG ['TRANSFER IN LOCATION
Anyole who knowingly makes a false statement of a material fact is guilty ❑REMOVAL= FROM REAL PROPERTY
of a felony, and upon conviction may be punished by a fine,Imprisonment,or both.(RCW 46.12.210)
UANUFACTUREDHOME
TPO/PLATE NUMBER YF,p,FJ,0 5 MA. N WS T`LE FI-VWIDTH(F41 vG I OR l 3 FI N 2 8 8 61ER AB C
L\ND L U ((iiLL L4}(UJ X LEGAL DESCRIPTION ON PAGE
REAL PROPERTY TAX PARCEL NUMBER
MANUFACTURED HOME WILL BE 0 AFFIXED 0 REMOVED 9 6? 713 410
L0T8. 4 3 BLOCK 4 PLAT NAME SECTION7TOWNSHIP/RANGE
55 11 IRONDALE
Era RANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE
COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS
NJEAN OF REGISTERED
NAME OF ADDITIONAL REGISTERED OWNER
CLIFFORD H . HOHNSTEIN
ADDRESS CITY STATE ZIP CODE
1E1 SUNSET BLVD PT TOWNSEND WA 98368
NAME OF LEGAL OWNER
NAME C F ADDITIONAL LEGAL OWNER
ADORE 35 CITY STATE ZIP CODE
GRANTEE
NAME
I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE AM/ARE THE REGISTERED OWNER(S)OF THIS
VEHICLE AND THIS INFORMATION IS ACCURATE:
Signature of Registered Owner and Title,IF APPLICABLE
Signature of Additional Registered Owner and Title,IF APPLICABLE
NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION FOR REGISTERED OWNER(S)SIGNATURE
State of Washington Signed or attested
County of before me on
by Signature
PRINT NAME OF REGISTERED OWNER NOTARY OR AGENT
by PRINT NAME OF REGISTERED OWNER. PRINTED NAME OF NOTARY
County/Office No.OR
Title AND: Dealer No.OR
DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Date
4 TI rLE COMPANY CERTIFICATION
I certif""that the legal description of the land and ownership is true and correct per the real property records.
NAME('YPED OR PRINTED) TITLE COMPANY/PHONE NUMBER
SIGNATURE/POSITION DATE
Finali;.e this application with a Licensing Agent within 10 calendar days of the date Title Company Representative signs. ,
5 el IILDIN6 PERMITOFFICE CERTIFICATION
I Certify that: the manufactured me affid the prop described.
❑ a building permit hasho beenhas issuedbeen for thisxe purpose
real and theerty attachasment wilt be inspected upon completion.
NAME(TYPED OR PRINTED) BLDG PERMIT OFFICE/PHONE#30c 3 7`1-9'{5 O BLDG PERMIT K
A Ai
c �� � �� 10 b L o (1. yc 01ckv,_ i-t w1/4 -t-B Loc 4 3`1 c,Gig,_J.,
SIGNATUE/POSITIO � ".--, U' r
DATE
(. C CiiilLk.a/VC, C6 -'D- I L
TD•420.729 MANUF HOME APPL(R/8/98)OR Page 1 of 2 1D
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