HomeMy WebLinkAboutBLD2004-00563 • • MLA04-00522
Review Type: I
MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT#: BLD04-00563 Received Date: 9/2/2004
SITE ADDRESS: ; t TOTEM RIDGE RD
PORT HADLOCK, 98339
APPLICANT: HARVEY T WINDLE PHONE: (360) 732-0348
SUSAN J WINDLE
PO BOX 1482
PORT HADLOCK WA 98339-1482
SUBDIVISION: GARY VAN TROJEN SHORT PLAT Block: Lot: 2+
PARCEL NUMBER: 901114027 Section: 11 Township: 29 N Range: 01 W
CONTRACTOR/ CELSO LAMAS PHONE: (800) 490-9424
DEALER: WASHINGTON HOME CENTER
61 SE RYAN RD
SHELTON WA 98584
Contractor's License WAINS1420 Expires 2/28/12jui 426-8493
INSTALLER: CELSO LAMAS WAINS1420 2/28/2004 (800)490-9424
WASHINGTON HOME CENTER SHELTON WA 98584
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION: NEW MFH
TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE:
TYPE OF IMP NEW MAKE: SILVERCREST SETBACK:
VALUATION 37,600.00 YEAR: 2004
LABOR & INDUSTRIES APPROVAL?
SIZE: 40 X 26 BANK HEIGHT:
SEWAGE DISPOSAL:
WATER SYSTEM: PUD
BEDROOMS: BATHROOMS: PARCEL TAGS: YES NO
STORMWATER: YES NO
Exist: Exist: AREA Plat Conditions
Prop: 3 Prop: 2 Wetland Erosion
Total: 3 Total: 2 Seismic Streams
Flood Way Floodplain
Routing Date: a to / F&W Landslide
/ Shoreline Aquifer
Type Amount Paid By: Date: Receipt:
Approved/Date
Manufactured Homes $154.00 KAS 09/02/04 67604 APPROVED
\/
Potable Water Application $52.00 KAS 09/02/04 67604
Total: $206.00 FEB 2 5 2005
Jefferson County Planning
4_, 31 }34 L
•
MANUFACTURED/MOBILE •
HOM i
Jefferson County Department of Community Developm
LATION PERMIT
621 Sheridan Street, Port Townsend, WA 98368 ent
360 379-4450 FAX 360 379-4451
PERMIT#: BLD04-00563
SITE ADDRESS: 86 TOTEM RIDGE RD
Received Date:
PORT HADLOCK, 98339 Issue Date: 9/2/2004
APPLICANT: HARVEY T WINDLE 2/25/2005
SUSAN J WINDLE
PO BOX 1482
SUBDIVISION: PORT HADLOCK WA 98339-1482
GARY VAN TROJEN SHORT PLAT
PARCEL#: 901114027 Block:
Section: 11 Township: Lot: A
CONTRACTOR/ 29 N Range: 01 W
DEALER
INSTALLER: CELSO LAMAS
Expires: 2/28/200;
WASHINGTON HOME CENTER SHELTON WA 98584
PROJECT DESCRIPTION: NEW MFH
MAKE: SILVERCREST
YEAR: 2004
SIZE: 40 X 26
THIS PERMIT IS VALID FOR ONE YEAR.
THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED
THE EXPIRATION DATE IS 2/25/2006. THIN THAT YEAR.
CALL IN FOR THE REQUIRED INSPECTIONS THAT APPL TO YOUR PROJECT.
Setbacks/Footing (CONTINUOUS FOOTING, Lor PADS USED - 7 �l�
e �
Stormwater FINAL Approval:
Blocking/Plumbing:
Propane Tank/Lines
Zoning Final Approval:
Septic System Final Approval (If not on sewer):
Road Approach Final Approval:
Final/Skirting/Vents/Porches/Step . 53
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 Office Hours 9:00 a.m. - SCHEDULE INSPECTIONS.
p.m.
HOT-LINE AVAILABLE 24 HOURS A DAY
SPECIAL CONDITIONS APPLY- SEE REVERSE
• •
SPECIAL CONDITIONS CASE # BLD04-00563
1.) The application was reviewed by the Jefferson County Department of Community
Development staff on September 29, 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: Type
5 Stream, Level I Landslide Hazard Areas and Susceptible Aquifer Recharge Areas.
2.) Aquifer Recharge Areas in Jefferson County are characterized by formations that allow percolation of the surface water into the soils porous
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.) Geologically Hazardous Areas in Jefferson County are characterized by slope, soil type,
geologic material, and groundwater that may combine to create problems with slope
stability, erosion, and water quality during and after construction or during natural events
such as earthquakes or severe rainstorms.
5.) Buffers are areas that shall be maintained in their natural condition, however, minor
pruning or alteration of vegetation may be permitted as long as the function and character
of the buffer are not diminished.
6.) Among the native conifer species which may be used in buffers or for re-vegetation
include, but are not limited to: Grand Fir(Aibes grandis), Sitka Spruce (Picea Sitchensis),
Shore Pine (Pinus Contorta), Douglas Fir(Pseudotsuga Menziesii), Western Red Cedar
(Thuja Plicata), and Western Hemlock (Tsuga Heterophylla).
Among native tree species which may be used includes: Vine Maple (Acer Circinatum),
Big-Leaf Maple (Acer Macrophyllum), Red Alder(Alnus Rubra), Pacific Madrone (Arbutus
Menziesii), Quaking Aspen (Populus Tremula), Black Cottonwood (Populus Trichocarpa),
Bitter Cherry (Prunus Emarginata), Oregon White Oak (Quercus Garryana), Cascara
(Rhamnus Purshiana), Pacific Willow(Saliz Lasiandra), and Scouler's Willow(Saliz
Scouleriana).
Among the native shrub species which may be used are: Sevice-Berry(Amalanchier
Alnifolia), Red Osier Dogwood (Cornus Stolonifera) Salal (Gaultheria Shallon), Ocean
Spray(Holodiscus Discolor), Indian Plum (Oemlaria Cerasiformis), Pacific Ninebark
(Physocarpus Capitus), Red Flowering Currant(Ribes Sanguineum), Wild Rose (Rosa
Nutkana), Swamp Rose (Rosa Pisocarpa), Willows (Salix ssp.), Red Elderberry
(Sambucus Racemosa), Snowberry(Symphoricarpos Albus), Evergreen Huckleberry
(Vaccinium Ovatum), Red Huckleberry(Vaccinium Parvifolium).
7.) A vegetative buffer of 30-feet shall be permanently maintained from the top or edge of the
Landslide Hazard Area. All buffers shall be measured perpendicularly from the top of the
Landslide Hazard Area.
8.) A Geotechnical Report was submitted in conjunction with this application. The report
addressed the stability of the geologic hazard area. A setback of 30-feet shall be
measured perpendicularly from the top or toe of the geologic hazard to the proposed
manufactured home and garage.
9.) Landslide Hazard Areas and their associated buffers shall remain naturally vegetated.
Should buffer disturbance occur during construction, the Unified Development Code
(UDC)Administrator shall require replanting with native vegetation. No alterations shall be
made to the Landslide Hazard Area or its associated buffer without prior authorization by
the UDC Administrator.
10.) Prior to and during approved construction activities, the perimeter of the landslide hazard
area buffer shall be marked with a temporary sign. The sign shall be placed in such a
manner that it can be directly observed from the construction area. The sign shall contain
the following statement: "Landslide Hazard Area and Buffer- Do not Remove or Alter
Existing Vegetation."
11.) All construction activities shall not encroach upon the buffer. This includes the storage or
preparation of materials.
III12.) The applicant shall permanen I separate the boundary of the Landslide Hazard Area
Buffer from the remainder of the subject property through installing logs, trees, a hedge
row, or any other prominent physical marking approved by the UDC Administrator.
13.) 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.
14.) The applicant is proposing to create or add 2800 square feet of impervious surface and
10000 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.
15.) 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.
16.) 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).
17.) The revised site plan as submitted on September 20, 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 February 23, 2005 shall be resubmitted for review and approval
by Jefferson County Department of Community Development.
18.) This approval is for a manufactured home and garage 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.
19.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
20.) 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 vehiciesbe stored in an Environmentally Sensitive Area
(ESA).
21.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
22.) The building height is not to exceed 35 feet.
23.) Minimum setbcak from the ingress/egress easement shall be 20 ft. Minimum side and
rear setbacks shall be 5 ft. Environmentally Sensitive Areas further impact setbcaks.
24.) A Geotechnical Report prepared by Northwestern Territories Inc dated December 19,
2001 on APN 901 114 027 (the westerly lot prior to the boundary line adjustment) was
submitted in conjunction with the application to address the slopes in the area and the
relative stability.
25.) The Department of Natural Resources investigated the property for a potential stream. A
letter from DNR dated August 31, 2004 which concluded that no evidence of a defined
channel and therefore no typed water.
26.) This parcel has been designated as Rural Residential 1:20 under the Jefferson County
Comprehensive Plan Land Use Map effective August 28, 1998.
27.) Access to the subject parcel is from a 30 ft easement along the western boundary, as
depicted on the face of the survey filed under AFN 494925.
28.) A septic permit(SEP05-00012) was approved on February 18, 2005 for a system of 360
gallons per day.
29.) This parcel was created through Gary Van Trojen Short Plat under AFN 417694, filed of
record December 29, 1998 in Volume 4 of SHort Plats, page 83-86 with Jefferson County
Auditor's office.
30.) A Boundary Line Adjustment application (SUB04-00563) was finaled on February 15,
2005. The final survey was recorded under AFN 494925.
31.) A stormwater plan for a mediur1project has been submitted and approved y 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.
32.) A geotechnical report was submitted in conjunction with a building permit application on
an adjacent parcel, APN 901 114 027 (before boundary line adjustment, the westerly lot).
The report concluded that the proposed building sites are grossly stable. The following
recommendations should be considered with regards to development of the subject
property:
1. Bare soils are subject to erosion, thus ground cover should be encouraged and
maintained. Native vegetation that requires little or no irrigation would be most beneficial.
Also the existing established trees and brush provide stabilization to the slopes and should
be left in a relatively natural state.
2. The area where the gully used to drain into the ravine should be revegetated to reduce
erosion. If erosion persists, it may need to be further protected from erosion (i.e. lined
with rock, etc).
3. The pond created in the gully should have a way of releasing excess water to reduce
the possibly of overtopping or breaking through the driveway leading to the shop. During
the site visit, there appeared to be only a couple feet or so of water in the pond. It may be
that the soil can infiltrate the water sufficiently enough that the pcnd would not fill up and
that a release mechanism is not needed. It may be possible to monitor the situation to
determine if improvements are necessary. A portable sump pump and hoses could be
kept on hand if needed.
4. Heavy irrigation on other activities that would contribute large quantities of water to the
soil should be avoided. One cause of landslides is the presence of excessive
groundwater in the soil near slopes.
5. Runoff from roofs and other hard surfaces such as driveways and patios should be
controlled and routed to a detention basin, dry well, other drainage control device such
that surface water discharge or sedimentation to adjacent properties will not be higher
than predevelopment conditions. Further, footing drains should be incorporated into the
design of the home.
6. All drainage control devices should be maintained in good working order and inspected
at least once a year.
7. Silt fence or other sediment control devices may need to be utilized in order to prevent
sedimentation to adjacent properties during construction.
33.) A minimum of two (2) on-site parking spaces are required for the manufactured home
installation.
EFFERSON COUNTY ASSESSOR
JACK WESTE (AN III JEFFERSON COUNTY COURTHOUSE
ASSESSOR PO BOX 1220,PORT TOWNSEND WA 98368
I
(360) 385-9105
MOBILE HOME INFORMATION FORM
OWNER'S NAME / MAILING ADDRESS:
THI
S IS NOT A
TAX STATEMENTNAME: ///i !L V C 1 (i()I ki
The purpose of this questionnaire is to obtain information
ADDRESS: C ES 0 x I 4 Qj regarding either the current location of a mobile home or the
previous ownership and location of a mobile home. This will
14 help our office determine whether the mobile home is already
O r` L.,O LI< < �'A `��� > >`f on the tax rolls in Jefferson County_or if it has been moved to
t, this county from another area. Please see reverse side for
TELEPHONE NO: `J 3 Z b3 4 i N additional information.
1) MOBILE HOME DATA:
(A) MAKE S( (2-L- r (B) MODEL f) 'PI 3 (` (C) YEAR Q
(D) LENGTH /70 /
(E) WIDTH -2 !o (F) SERIAL NUMBER
(G) YOUR PURCHASE PRICE(DO NOT INCLUDE SALES TAX) 7 (I,O ZU (H) PURCHASE DATE a ( i 7
2) PREVIOUS OWNER / LOCATION OF MOBILE HOME:
(A) FROM WHOM DID YOU PURCHASE MOBILE L&)A f4 I Ki( rT L f o Nk& C._-LI-; T€2
ADDRESS j. C CO I —el A►_.t P.OA J NC[.-.T—O>L r (. 1 S f
(B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR? YES 0 (IF NO,WHAT COUNTY? (CT( J )
IF YES,WHAT WAS PREVIOUS ADDRESS OF MOBILE?
3) WHERE MOBILE HOME IS TO BE LOCATED:
(A) WILL THE MOBILE HOME BE IN A MOBILE HOME PARK? YES NO,
(B) IF LOCATED IN A MOBILE HOME PARK:
NAME at ADDRESS OF PARK �-
SPACE NO.
(C) IF NOT LOCATED IN A MOBILE HOME PARK:
NAME OF LAND OWNER: _HA}12V�1 (t i1 i�Lc=
LOCATION(ADDRESS) A-p f6 R
REAL PROPERTY PARCEL NUMBER/DESCRIPTION j U ( I —t D Z TL4 ( .L ?R0C LLS-S 5
oT I ('AI11 UA►4 TrR0 c,i-1 S - o e.21—
THANK YOU FOR YOUR HELP!
A S NAT RE
KELLI LARSON, roperty Technician
THIS FORM CONFORMS TO THE STANDARDS OF THE STATE DEPARTMENT OF REVENUE AND IS SUBJECT TO AUDIT VERIFICATION.
• OWNER BUILDER STATEMENT •
The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that
they will be a ••
Date: '.,2 (,, (O -{g the responsibility of the General Contractor for the proposed project.
Signature- "0, d�'--
I
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
6 L S 0 X K icei ON r3 (goO) ++et 0 41,-12 4 (31.0 ) L{z <<, 84 1 3
MAILING ADDRESS: G 61 RI A t,.t P.J S td L L7)Li (),MAIL:
CONTRACTOR'S LICENSE a es-la,c.( WAINS
NUMBER: NUMBER
( ems laze
ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
New tr-Wood Existing: $ ❑ Sewer
O Addition [ 'gteel Proposed: 2 Bank ❑ community System
❑ Alteration/Remodel 0 Concrete Total: 2_ Height. m Individual System
❑ Repair ❑ Masonry L\ SEP Permit#
O Demolition ❑ Other: Bedrooms: Water Supply:
Existing: -E�" Setback:
Ni o i t 4.` ❑ Private well 0 Two Party
Type of Heat: Proposed: 3 LitiSublic
Ay -r-a`i Total: Name of System: P o, ,-
0 1-- JGr r ki Oka Cu
If this is a Commercial Project you must answer the following:
Number of Parking Spaces: Current Proposed: >K Number of ADA Parking Spaces:
Number of occupants(includes owners,tenants,employees,etc) Current 7` Proposed X
IBC Occupancy: IBC Type of construction: X Will you have Food Service? Yes / No
If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply:
❑ Underground Tank ❑ Above ground Tank Size of Propane Tank: )
❑ Heat Stove ❑ Cook Stove ❑ Woodstove ❑ Fireplace Insert ❑ Hot Water Tank ❑ Pellet Stove ❑ Other
Is this appliance being installed in a Manufactured/Mobile Home? Yes / No
When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property
lines, tank location and size,distances from the propane tank to all property lines,buildings and septic system components,
including the reserve area.
Square Footage For Office Use Only - .1, x'` -
Current I Proposed Amount ,,,.,
Main Floor Consistency Review: S
2""Floor Base fee:
I 64
31°Floor / Additional Section: 0
•
Mezzanine: / - Plan Check fee:
Heated Basement State Surcharge fee:
Unheated Basement / Pot Water Review fee:
le idie .s ',
Other Unheated 911/Rd Approach fee:
Garage/Carport y*
/ TOTAL $ 3 t
Decks
Receipt Number: i cC,9..
Other / Cash/Check Number.
ESTIMATED COST(REQUIRED) Date sti
".Fair market value of all labor and materials fot/ndation to finish r (a 1_ I
Initials. .:� , Y:' •
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc J(
4,�'SON cor,. JEFFERSO&LINTY • -i ;,
'444k0
j DEPARTMENT OF COMMUNITY DEVELOPMENT I U "1
illik
621 Sheridan Street • Port Townsend •Washington 98368 (�.?'
360/379-4450 • 360/379-4451 Fax I e� n
0� www.co.jefferson.wa.us/commdevelopment L '1 `� � ^
LINO !
Master Permit Application MLA 0 'i i'i ,'i {
'0: Doiiii . i yr r,c 1.: ,.,
Project Description(include separate sheets as necessary): A di-, A. l S i/4- -pile cee_S 0 t~'rtP_c. 1-.4-
q o t I t,-( U ) 1 + c A i s 1Z C-7 S i1L-r r&f t t 0 t-A c P/4,-rL-(=c- tot L, /-/ek v r;' f fH. r,Eo pt s l) /6 24;'=F
Tax Parcel Property 1-‘0 r i_e:
Number: 1 L ( I I `I 0 7 b ( ,/.A UV p 1 Size: [ 0 -I- / (acres/square feet)
Site Address and/or Directions to Property: . (.i Sr-t H t, I OO o f r c e r O u C rt t<,k 0 L- 4D R-.t'c:Ly A y A ,--
jw rein--e-c, rr tt o i---- Fc -c-vt Li y,Tai AA r-r I:)i,c+t3g°c,KS,AA"
Property Owner(s)of Record: //A/2 V El Li t fi.pLG
Telephone: '3(crO 73z O-� Fax: email:���-�;&-&-"c-t /,1z�r_A4re
Mailing Address: I'O LeaX. 1`-4 '2)Z Agz- NA ar:,.oc_K- 1WA'1 `1 :S. c't , ,i_t,=T
Applicant/Agent(if different from owner): X
Telephone: -,/ Fax: >( email: X
Mailing Address: �.
What kind of Permit?(Check each box that applies)
❑ Building ❑Variance(Minor,Major or Reasonable Economic Use)
0 Demolition Permit ❑ Conditional Use[C(a), C(d),or C]**
❑Single Family ❑ Discretionary"D"or Unnamed Use Classification
❑parage Attached/Detached ❑ Special Use(Essential Public Facilities)**
0 Manufactured Home ❑ Boundary Adjustment
Adjustment
❑ Modular ❑ Short Plat**
❑Commercial* ❑ Binding Site Plan**
❑Change of Use ❑ Long Plat**
0 Address [1 Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments**
❑Propane ❑ Plat Vacation/Alteration**
❑Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions**
❑ Stormwater Management ❑ Shoreline Management Substantial Development**
❑ Site Plan Approval Advance Determination(SPAAD)* ❑ Shoreline Management Variance
❑Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment
❑Wireless Telecommunication* ❑Jefferson County Shoreline Master Program Amendment
❑ Forest Practices Act/Release of Six-Year Moratorium
*May require a Pre-Application Conference **Requires a Pre-Application Conference
Please identify any other local, state or federal permits required for this proposal, if known:
DESIGNATION OF AGENT
I hereby designat47/ Sr:4_ t= to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURi /7------ Date: Vq 6 /C y
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,her or it's 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 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 its employees,representatives or agents for the sole purpose of application
review and any requir later inspections.Access and right of entry to this property shall be requested and shall occur only during regular business
hours. l--7�_—
Signature: li Date: e/12(n l0 Li
The action or actions Applicant will under-take as a result of the issuance of this permit may negatively impact upon one or more threatened or
endangered species and could lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the
"Endangered Species Act"or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this
permit has been issued will not violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your
action(s)even if you are in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transferabl ponsibility for adhering to and complying with the ESA. The Applicant has read this disclaimer and sns and dates it below.
Signature: . _.-— Date: l( (e 10,4
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
4 JEFFERSON COUNTY E -.
• DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street • Port Townsend • Washington 98368
360/379-4450 • 360/379-4451 Fax
xN� http://www.co.jefferson.wa.us/commdevelopment/ f'I
STORMWATER SITE PLAN SUBMITTAL TEMPLATE
MLA# PROJECT/APPLICANT NAME: 'f'
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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Si..) A5 II2 4/.417 I..jF— nk. ur t, [ i C_ C / (1f--, I TcL
3. Describe the existing vegetation. Indicate native vegetation areas on the site map.
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LUbJLy /fees!-I /4/46 I'-2"L),H /4 -(c LCTL-� nAlter(� l�l' AcC/A..( (,
A J A L A rV r) t`' blr L+✓S r �s (-tii c�t 4.7)<_ %l
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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)(4:0 1( �"R L1 A- 'l_ CA/'Q {' ate 4)/z- 7 /T ( y 4�
Dt) T- T-N .
6. Describe any excess levels of noise generated by the proposed use or actVity: APPROVED
6 ` STORMWATER PLAN
[ 123 2005 I —4
JEFFERSON COUNTY
stormwater site plan template-rev.10/1/2003 DEPT.OF UNITY DP • OPM t ' 5
SIGNATURE ; Ant1
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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 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.
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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 standards applicable to the project.
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12. Describe the flow control system.,_ __,.__,__....,.
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CONSTRUCTION STORMWATER POLLUTION PREVENTION PLAN(SWPPP)
The Construction SWPPP addresses sediment and erosion control during construction. The ISMPs 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 then Construction,Stormwater
Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet for guidance, paif'icularly 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.
5. Stabilize Soils.
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6. Protect Slopes.
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7. Protect Drain Inlets.
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8
stormwater site plan template—rev.10/1/2003
13. Describe the water quality system.
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14. Describe the conveyance system analysis and design.
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 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. /
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.
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stormwater site plan template-rev.10/1/2003 7
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12 Required Elements—Construction SWPPP(continued)
8. Stabilize Channels and Outlets.
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9. Control Po utants.
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.
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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 downstream drainage path leading from the site to the receiving body of water(minimum distance of 400
yards). _
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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.� rD scription of special requirements for working in or near environmentally sensitive areas.
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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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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.
_1 J a. Proposed wet season construction activities.
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b. Proposed wet season construction activities for environmentally sensitive areas.
7. Financial/Ownership Responsibilities.
a. Identifyd 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. , VAT
b. Diversions. aC///t
c. Waterways. //4
d. Runoff/Stormwater Detention Calculations �9
10 stormwater site plan template—rev.10/1/2003
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.
ci 12
(LAN E OR AUTHORIZED REPRESENTATIVE SIGNATURE) (DATE)
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED:
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