HomeMy WebLinkAboutMLA16-00035-FPA16-00001 Permit Applicationt
DEPARTMENT OF COMMUNI
621 Shrndan Sneet, Pon Towvsead, WA 98368
Tc! 360.379.44501 Fax: 360.379.4451
Wcb:�cn1 9=—Lrr mmrnt
E..21 d d(al Efeann cora
PERMIT APPLICATION
0[5�
APA 7 2016 D
PiV Inna,FNr
Steps in the Permit Process:
-Review application checklist to ensure all information is completed prior to submitting application.
-Make sure septic has been applied for and water availability has been proven.
-Make an appointment to meet with the Permit Technician by calling 360-379-4450.
-This is not a standalone application; it must be accompanied by a project specific supplemental application.
-Fees will be Collected at intake. Additional fees may apply after review and payment is required before permit is issued.
Fa Department Use Only
Related Applicat... =PAU, - O CDCI MLA# (d - tno(1'�:n
Site Information
Assessor Tax Parcel Number:
Site Address and/or Directions to Property: 5-1,95 WA 58.37
Access (name of street(s)) from which access will be gained: fisb
Present use of property: GK "r
Description of Work (include proposed uses):
C6n e un O fi(rn Nery (+
Wastewater •Sewage Disposal
This property is served by Port Townsend or Port Ludlow sewer system? YES NO 1<
If not served by sewer identified above, identify type of septic system below:
Type of Sewage System Serving Property: /V//4
Septic Septic Permit N: _
Community Septic Name of System: Case
Are other residences connected to the septic system?
Additions or repairs to sewage system:
Is it a complete or partial system installation: Complete Partial
Has a reserve drainfield been designated? Yes No
Date of Last Operations & Maintenance check: Attach last report to application
Describe or attach any drainfield easements, covenants or notices on title, which may impact the property:
The authorized agent/representative is the primary contact for all project -related questions and correspondence. The County wilt mail
/ e-mail requests and information about the application to the authorized agent/representative and will copy (cc) the owner noted
below. The authorized agent/representative is responsible for communicating the information to all parties involved with the
application. It is the responsibility of the authorized agent/representative and owner to ensure their matlbox accepts County email (i.e.,
County email is not blocked or sent to "junk mail").
Applicant/Property Owner Information
Property Owner:
Name: WAI
e�Tr'O
Address:
A11R,7'
Phone #: 360
E -mail Address: 4,2
Please contact Aut o_rized Age t/Re ese tative with proje
o we
info. (select only unej.
Property Owner Slgnature:
Date:
Note: For prorcts with multiple owners,attache s ratesheet with each own s) information and si
.tures.
Applicant: Authorized Agent/Representative(If1mr rhanownei)
Name: M.ke
_ o
Address:
r f ow
A
Phone If: 3a
E-mail Address:
Professional:
Isthis an Authorized Agent/Representative for this project?
NO
Engineer
Architect Surveyor Contractor
Consultant
Name:
License #
ct q,;/
Address:
Phone #:
E-mail Address:
Professional:
Is this an Authorized Agent/Representative for this
project?
NO YES
Engineer
Architect Surveyor Contractor
Consultant
Name:
License #
Address:
Phone If:
E-mail Address:
Professional:
Is this an Authorized Agent/Representative for this
project?
NO YES
Engineer
Architect Surveyor Contractor
Consultant
Name:
License If
Address:
Phone #:
E-mail Address:
By signing this application form, the owner/agent attests that the information provided herein, and in any attachments, is true and
correct to the best of his or her knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with
respect to this application packet may result in making any issued permit null and void.
I further agree to that all activities I intend to undertake or complete associated with this permit will be performed in compliance with
all applicable federal, state and county laws and regulations and I agree to provide access and right of entry to Jefferson County and its
employees, representatives dr. agents for the sole purpose of application review and any required later inspections. Applicant may
request notice of the
CCountyntent to enter upon the property for visits related to this application and subsequent permit issuance.
Signature: /.y/print Name:A kf rly_OA n Dater