HomeMy WebLinkAboutADR2008-00094 1 ,
REC JVE D
ADDRESS REQUEST MACS 2 6 2008
JEFFERSON COUNTY PERMIT CENTER nr 7y
621 Sheridan,Port Townsend,WA 98368 (360) 379-4450 JEFff�JON p1NJY DCo
APPLICANT: Please fill out item 1 through 8. Fee as per Jefferson County Fee c e u
1. l71 New Address U Correction U Change [JReview RIFF LEFT ' Ma'. RIGI T " =D FF'
2. Applicant Name: g0J Ua n 01Q_())42.5/01._
3. Mailing Address: 3`t) �S p�{t�
Town/State/Zip ��( L.)Pi- 1 c7 3
4. Telephone: Work Home: tD'tce
5. Location: Attach a Detailed Drawing or Map.
Additional Fees May Be Required if More Than One
Site Visit Is Necessary
*******PLEASE FLAG YOUR DRIVEWAY.*******
Date Flagged: 3 /2G/°S Flagging Color oka..
Nine Digit Tax Parcel Number i Z 2-}3 3
Plat Name Block Lot
6. Road Name: —
Is this a PRIVATE or COUNTY road? CIRCLE ONE
Nearest Cross Road: we7
7. Neighbors'Address if Known:
Name/Address: (uc t_)1,17<,,V') w (1 2 cx
Name/Address: LAJ-rt JeAR c(2a+oe
8. Do You Ne,ed,To Construct a Driveway?
YES or CIRCLE ONE
9. Was This Submitted With A Building Permit? x> ,£c w FIELD NOTES•YES or NO) CIRCLE ONE $
SIEI)ARAMFACE USE ONLY ,.. � ,r
New Address: 4 ✓, '
Postal District: t,1{ (
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Real Milepost: t Road #: _
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Left / Yt Tire District Building Permit# T Plate Sent / ,.
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JEFFERSON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT
ADDRESS REQUEST INSTRUCTIONS
o Complete the address request form in as much detail as possible. The most important
information to include is the complete name of the road where your property is located,
whether or not the property is in a plat, the nine digit parcel identification number and
the block/lot number. The fee is $
o You must also attach a vicinity map or drawing.
o Use the survey ribbons provided to flag both sides of your driveway. If your driveway is
not in yet, mark the location where the driveway will be. You must apply for a road
approach permit if your driveway will connect with a county road.
o The address technician from the Permit Center will assign your address within 5 working
days. The technician will visit the site and determine the address according to the
nearest milepost distance from the start of the road.
o The red address plate will be sent to your current mailing address, as indicated by you on
the address request form, within one week to ten days. The plate is to be posted at the
end of your driveway and is to be clearly visible from both directions.
o The Permit Center will notify the appropriate postmaster, fire district and emergency
services of your new address.
****#.***********.**********************************
ROAD APPROACH INSTRUCTIONS
o If you are constructing a driveway that will connect with a county road, you must apply for
a road approach permit. The fee is $
o To complete the application for the permit, you will need to indicate the nature of work
and to include a simple sketch of the proposed work. You will also receive a survey
ribbon to mark the site.
o Once the permit inspector has visited the site, a permit will be drawn up and will include
the general conditions as well as any specific requirements concerning your site.
o The permit will be sent to you for you to read and sign. You are then asked to return the
permit to the Permit Center for the permit inspector to sign. You will receive a copy of the
signed permit. The permit is valid for a period of one year.
IF BOTH THE ADDRESS REQUEST AND THE ROAD APPROACH PERMIT IS APPLIED FOR
AT THE SAME TIME, THE TOTAL FEE $ ) ;
If you have additional questions, call the Department of Community Development at(360)379-4450.
h 1home tpIncntrinfodpehnstruct.doc 1/1/05
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P T 3:PLOT PLAN
The plot plan st show the following:
• Well radius . 100',including all potential sources of contamination on the lot and th- • 'ected portions of
adjacent lot(s);
• Property boundaries;
• Sources of contamination(inclu.•• :septic systems,barns,stock- 1 ,sewage lagoons,hazardous waste
sites,marine shorelines,or any other pa. ial source listed •• ' AC 173-160-171);
• Existing wells, including all wells that are to b- o • issioned;
• Proposed septic systems,septic approvals(SP- • : , 6-rmitted septic systems,including affected
adjacent lots;
• Measurements from the proposed we . decommissioned well to property lines;
• Measurements from the propose, • ell or decommissioned well to all score- : contamination and septic
approvals,including affects• :.jacentlots;
• Natural features,such .: areas of permanent or seasonal surface water,streams,rivers,blu •, - ;
• Existing roads : . .1 er constructed or developed features(to help in locating the site);
• North arrow.
NOTE: If p. el can be served by an approved public water supply,the owner must agree to not cross-connect
the indi ual well to the approved public water supply,and that this well cannot be utilized for a building
pen•• . This agreement must be signed and submitted to Jefferson County Public Health prior to beginning any
we I construction.
PLOT PLAN
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FOR INFORMATIONAL PURPOSES ONLY-
Jefferson County does not attest to the accuracy of the data contained herein and makes no warranty with respec
correctness or validity. Data contained in this map is limited by the method and accuracy of its collection. Wed Ma
13:53:56 2008
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