HomeMy WebLinkAboutZON2019-00012 - 01 APPLICATIONDEPARTMENT OF COMMUNITY
621 Shcriden Strcct, I)ort'[iru'nscnd, \\',\ 983(18
'l el: 360.379.4450 | lrax: 360.319.4451
\{'cb: rvrvrv.cr >.ic itcrson.rva.us/ commtrnit},dcryckrpmcot
I r-meil: dctl@co.icf-itrson.u,a.us
PERMIT APPLICATION
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 proiect specific supplementat apptication.
-Fees will be collected at intake. Additional fees may apply after review and payment is required before permit is issued
APR - 1 2019
tr
Building Permit f
MLA#7-
For Department Use Only
Related fis:
Site lnformation
Assessor Tax Parcel Number:*2tggc,
Site Address and/or Directions to Propefi
48 3aq
Access (name of street(s)) from which access will be gained:'o
Present use of property:
Description of Work (include proposed uses)
Wastewater - Sewage Disposal
This property is served by Port Townsend or Port Ludlow sewer system?YES Nox7-
lf not served by sewer identified a bove, identifo type of septic system below:
Tyoe of Sewage System
f, t"0,,.
Community
Serving P roperty:
Septic Permit #'.e -oo 3
Se ptic Name of System:(aro.v IN Case #:
Are other residences connected to the septic system?
Additions or repairs to sewage system:lrln
ls it a complete or partial system installation: Complete Y partial
Date of Last Operations & Maintenance check: 2- - 28 - R Attach last report to
Describe or attach any drainfield easements, covenants or notices on title, which may impact the property:
application
JI
llAr,a,a Rrr ?i t1"rf"-
rrlo I
The ail
le-
bel
i.e.,
or sent to nk mai
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.
Applicant/Property Ourneri lnformation
_ Please contact Authorized Agent/Representative with project info. (select only ond).
Property Owner Signature: Date:
Propertf owr6*&
E-mailAddress: daVt * dbb\v)z*t ,.*A
Name:
Address:
Phone #:
Note: For projects with multiple owners, attach a separate sheet with each owner(s) information and s'tgnatures
Applicant: Authorized Ageffi/Bepresentative (tf other than ownerl
Name:
Address:
Phone #:
f\fl.a l* Blcve U ?q04 HiarrJn,ltd flrre, Erp,yrnzr4zvt rtuG q04+
-------1-------
13OO- ln/t:,- 84b?* E-mailAddress:4*n l1
Professional:ls this an Authorized Agent/Representative for this iect?NO YE5
Engineer Architect Surveyor Contractor
License #
Consultant
Name:
Address:
Phone #:E-mailAddress
Professional:ls this an Authorized Agent/Representative for this NO YES
Architect Surveyor Contractor
License #
Consultant
Name:
Address:
Phone f:E-mailAddress
Professional:ls this an Authorized Agent/Representative for th3s proiect?NO YE5
Engineer Architect Surveyor Contrastor
License #
Consultant
Name:
Address:
Phone #:E-mailAddress
Sign ature:Print Name I DAY€ /n Y*P t1 Date: 3-aa'tl
I
I
Engineer
s r-' ai
',r 3 Sr)" Flrenrertorr \\'.!. 9il Jli,
ll
' 119
or:l'1'N"'*T
360-r - 360..i;97-r?71
,p, Nlirsort, Pii:rce ,li Jel'fers,x (lounties
"We Get'Iher Sludge, Out"
,!iite ,\ddru'ss dd r ess
Billir,_s lr,ame:
-_r----- -Contact Name: 1 rru, f D4r,d yr.,l., r'c
Contact Phrne: 3bA\ 3-l tt A1
3:uLqS
1--H
Dor t; I ,rd \ o;
I S''lt {, 3€,uo\ ,)1i cit g11,'lL,t!.i.\r
.,,d
<oDLt lb
ER VtSrT _
DESCRIPTION
INSPECTION
PUVIPI\C
DIGiLOC'ATE
NOTES
-rf,- Fiet:r.r-'sted Not l(e; r.rested
f rvs .err..t'r o['l
\G[.\.t uPu, 'rE ___
(1,
h\ 11.,\ l: I
)l'4.L: l1(rl
catr.d [l :l c
3
DA
\ iu' fh/u(E fo\{ER ?--lt\tc l;, .l
.\l)l). litlED-r \\ lt.:i-f
oR s\r('ol. l (1')\lE
(. RI:A'tED']
l)O Tl:llEY tl,\\'I
lr ts ullsl
AMOUNT
J-.Js""
J+,1{
l3ukcr Scpli,; Purriring. ,nc.. tlb,r [)arro's Sc;:tic. has bccn hircd nr purnp;rtrl or insp!'ct )('ufsl'l]tic tn[k
responsible t.rr drnrrge o r otir sePllc tank or oll rcr propcrti rcsultr:rg l rrlt ; hc scr r iccs pcLli'Lnrcd bl
0l l)ir,(r s Sc )!.c.grosS
L)ttr
cs ScpLi.. u
Hl - L(.)WATER LEVEL
FII,TER CLOGCED
FILTER CLEI\}IING
S!'STEII TYPE.{,\IK SIZE
.G.dLLO\S PT]I{PED
c,'nv5K ,t
CAL
--LL-l;'t-
lr_ C __ PX ltcplacc_
1,1_ C_ t'-[ Rcplacr'__
\1_ C+ ['___ Replacc-_
RECO]IIIE\DEI)
),{llXT Il(SPEC'rl0N
NE:(T PLi}IPI\C .]_
''{:i
a'{:;
INLET BAFFLE
OU'TLET'BAFFLE
CE-\..TER BAFFI-E
17
\ES\o J-
vrs x, _\o
E FOR ADDITION,A.L NEEDS:
ljl
Contact Phor.t;:
)
PRIPA,ID CC#,CK#
ese are on
il'AS-lS" basis, withor:t
uarranty of any type,
erpressed or implied, includin
fut not limited to arry warranty
as to their performance,
merchantability, or fitness for
any particular purpose.
821355056 Site Plan
247 Olympic Ridge Drive, Port Ludlow WA 98365
Date: 3/1912019
t-r:-
this m+ b mt a sLbstitrio f s aruEte fdd s[vsys a for bcding actud proFrty tn6 and ay aqmrt fstu6s.
lG N, andt"'
Oprn Sprco
F?IffiPSS
ti
Accessory bldg square
footage:
l-/
Residence sq ua re footage:I
i
\r
II
I
E2 13 550 57
21
ol
r)l3if,.r [:: h) tx1,,.giat) E,(. ) E :r rl j r-:fz r I
?.3 Liirr C)crrrritrt;.11 ,I
1:1,128
6 621355042
A
N