The URL can be used to link to this page

Home My WebLink AboutSUB2017-00014 Application materialsSteps in the Permit Process: DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street, Port Townsend, WA 98368 Tel: 360.379.4450 1 Fax: 360.379.4451 TM Web: �4�1 u.rcr..g r' o i 4 tonin a tics o f E-mail: OCT D 4 2017 PERMIT APPLICATION JEFFERSON COUNTY DCD -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. For Department Use Onl j t(% Building Permit # —oto( Related Application #s: MLA # OLA4irOUJi'V Site Information I Assessor Tax Parcel Number: 4-085-001 Site Address and/or Directions to Property: 300 Walden Ln., Port Ludlow, WA 98365 Access (name of street(s)) from which access will be gained: Beaver Valley Road Present use of property: Residential Description of Work (include proposed uses): 'hort 13 Wastewater - Sewage Disposal This property is served by Port Townsend of Port Ludlow sewer system? YES NO i ^ If not served by sewer identified above, identify type of septic system below: Type of Sewage System Serving Property: Septic Septic Permit #: Community Septic Name of System: Case #: Are other residences connected to the septic system? Yes 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 authored agent/representative is the primary contact for all project -related questions and correspondence. The County will mail / c -snail requests and information about the application to the authorized agent/representative and will copy (cc) the owner noted below, The authorized a;enc/representative is responsible for communicating the information to all parties involved with tinea )pplication. It is the responsibility of the authorized agent/representative and owner to ensure their mailbox accepts County ema" fi.e.- Counry efnail is not blocked or Sent to "mink mail" i. Applicant/Property Owner Information Property Owner: Name: Greg and Sandi Johnson Address: PO Box 65361, Port Ludlow, WA 98365 Phone #: 360-460-9447 E-mail Address: sandij25@olypen.com Please c ntac u orized Age nt/Representativ ith roject info. (select only one). Property Owner Signature: _j Date: /U' Y-117 Note: For projects with multiple own r , JtJAWseparate sheet with each owner(s) information and signatures. Applicant: Authorized Agent/Representative (If other than owner) Name: Address: Phone M E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor V Contractor Consultant Name: SCOT CLARK, OF CLARK LAND OFFICE Address: PO. BOX 2198 SEQUIM WA 98382 Phone#: (360)681-2161 E-mail Address: SCOT@CLARKLAND.COM Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant Name: Address: Phone #: E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant Name: Address: Phone #: E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant Name: Address: Phone #: E-mail Address: Attach additional pages if necessary Builders Statement The signer of this statement certifies tV thwre the Owners of the parcel referenced herein, that they are not licensed contractors and hat ey iil be assn n responsibility of the General Contr r for fh osed project. Signature: rin Name: +e '� p t sr p l -0joa..(,n�!S15Z)t�j _ 1 `f DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street, Port Townsend, WA 98368 � Tel: 360.379.4450 Fax: 360.379.4451 (Clam Web: �ytiy�y.r�eftcr�ott.wa-tip/crxnirltinit.tfS.ve�nnirnt E-mail: �Ic_c!(rlcn.jc:ffcnoii. va.��s SUPPLEMENTAL APPLICATION LAND DIVISION JEFFERSON COUNTY DCD MLA PROJECT/APPLICANT NAME: •$'plA1VJ01V 6 14oRT FLA 7- # L1itG-(n PO4D S/AN Q t Sa k4V-fa ✓ Submittal Requirements 1. A completed Permit Application and State Environmental Policy Act (SEPA) Checklist (if applicable). Representative authorization is required if application is not signed by owner. 2. Short Plat, Long Plat or Binding Site Plan application fee (as applicable), as set forth in the Jefferson County Fee Ordinance, as amended. 3. Any supplemental information identified by the Administrator. 4. Certificate of Water Supply Utility Service Form. 5. Five (5) paper copies of a preliminary plat meeting the requirements of Jefferson County Code (JCC) 18.35.110 and 18.35.120 for short plats, or JCC 18.35.290 and 18.35.300 for long subdivisions/binding site plans and identifying points of access, all easements, deeds, restrictions, or other encumbrances restricting the use of the property, as applicable. Copies of the applicable JCC sections are attached for your use. 6. Where site conditions require a special report to assess or address any probable significant adverse environmental impacts, a study (or studies, as applicable) prepared by a competent professional may be required if deemed necessary by the Administrator. 7. Evidence of compliance with JCC 18.30.070, Stormwater Management Standards, as deemed necessary by the Administrator. 8. The preliminary plat must be prepared in accordance with JCC 18.35.110 for short plats, or 18.35.290 for long plats. The contents of the preliminary plat must provide the information listed in 18.35.120 for short plats and 18.35.300 for long plats. 9. The following supplemental information: Subdivision Name: Land Use (check one): (Industrial 91 Residential ❑ Commercial ❑ Total Acreage of Property: Total Lots Proposed: 2 Water Supply (check one): ❑ Individual Wells ® Community Water System Sewage Disposal Method: aLYM PI C -S C- C 2 AN() WAT&tt n/ C Avera a Lot Size: `i • $ A C Minimum Lot Size: 73 . `P f Ac- Oen S ace: Page 1 10. I, Wj v - %e- - hereby swear and certify that in addition to the land subject to Ns application (check Me box below which applies): 01 have no interest in .�,, lI have an interest in land within 300 feet of any portion of the subject property by reason of ownership, contract for purchase by agreement or option by any person, family member. jrm, or corporation in any manner connected with me or the de lopM.ent. f% I DATE 11. The applicant hereby certifies that the preliminary plat provides an accurate representation of the proposed land division; and the applicant hereby acknowledges that any approval issued on this application may be revoked. any such statement is found to a false. ATUR DATE Page 2 OLYMPIC WATER AND SEWER, INC. 70 BREAKER LANE PORT LUDLOW, WA 98365 (360) 437-8246 owsi@portlndloivassociates.com OCT o 4 2017 Assessor Parcel ID 821085001 JEFFERSON COUNTY DCD Legal Description Lot 1, Port Ludlow No. 6 Site Address Walden Lane WATER AVAILABILITY NOTIFICATION PUBLIC WATER SYSTEM Water System Name OLYMPIC WATER & SEWER, INC. System Operator OLYMPIC WATER & SEWER, INC. State ID Number 68700L Total Connections for which system is approved 2,427 Number of service connections existing— 1,581 as of 8/31/2017 Number of service connections committed 1,606 Most recent water bacteriological analysis: September 2017 =SATISFACTORY OLYMPIC WATER AND SEWER, INC-, water s}est will erovid currentl irovides potable water service at the above referenced location: SEWER AVAILABILITY NOTIFICATION Olympic Water and Sewer, hKM available domestic sewer service server service piping not one single family residence at the above referenced location. Operator Signature Larry Smith, nt Date September 14, 2017 **NOTE: This notificafion automatically expires 1.80 (lays following the issuance date** Via email: sandij25@olypen.com