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Home My WebLink AboutBLD2015-00216 - 01 PERMIT APPLICATION `sON c%) DEPARTMENT OF COMMUNITY DEVELOPMENT � 621 Sheridan Street,Port Townsend,WA 98368 { Tel:360.379.4450 Fax:360.379.4451 Web:www.co.iefferson.wa.us/communitydevelopment C'p E-mail:dcd(alco.jefferson.wa.us S'IiN CERTIFICATE OF OCCUPANCY PERMIT #: BLD15-00216 APPLICANT: BRANDON HUNTINGFORD PHONE: 360-643-3578 1864 BEAVER VALLEY RD PORT LUDLOW WA 98365-9211 SITE ADDRESS: 24 EMBODY RD Issue Date: 07/29/2015 PORT LUDLOW, 98365 Final Date: 9/21/2015 SUBDIVISION: Block: Lot: PARCEL NUMBER: 821072002 Section: 7 Township: 28 N Range: 1E PROJECT DESCRIPTION: MOVING EXISTING M.H. FROM 90 EMBODY RD- TO 24 EMBODY RD. (MODULINE 52X14) SEP95-00573 THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING CODE 2012 EDITION. OCCUPANCY GROUP: TYPE OF CONSTRUCTION: SPRINKLER SYSTEM yes 8 THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 9/21/2015 lltidemarkldatalforms\F_BLD_Occupancy.rpt 9/29/2015 • • MANUFACTURED/MOBILE HOME INSTALLATION PERMIT Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT#: BLD15-00216 Received Date: 6/26/2015 SITE ADDRESS: 24 EMBODY RD Issue Date: 7/29/2015 PORT LUDLOW, 98365 APPLICANT: BRANDON HUNTINGFORD 1864 BEAVER VALLEY RD PORT LUDLOW WA 98365-9211 SUBDIVISION: Block: Lot: PARCEL#: 821072002 Section: 7 Township: 28 N Range: 1E CONTRACTOR/ OWNER/BUILDER PHONE: DEALER PROJECT DESCRIPTION: MOVING EXISTING M.H. FROM 90 EMBODY RD-TO 24 EMBODY RD. (MODULINE 52X14) SEP95-00373 MAKE: MODULINE YEAR: 2000 SIZE: 52X14 THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 7/29/2016. CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT. Setbacks/Footing (CONTINUOUS FOOTING, SLAB or PADS USED): 9/f��S tiL Stormwater FINAL Approval: Blocking/Plumbing: Ve/i5 6V P.94• kirr�s Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: /'^�• Final/SkirtingNents/Porches/Steps: DK .P.54 q/ )/s c HEALTH DEPARTMENT AND PUBLIC WORKS APPROVAL REQUIRED PRIOR TO FINAL INSPECTION THIS PERMIT IS VALID FOR ONE YEAR OR IT MUST BE PROPERLY RENEWED • • To schedule inspections, call (360)379-4455 no later than 3:00 PM the day before the inspection is needed. Requests received after 3:00 PM will not be scheduled for the next day's inspections. Office Hours 9:00 -4:30 MONDAY-THURSDAY ELECTRICAL PERMITS are issued by the Washington State Department of Labor& Industries. The electrical permit must be signed off by the State Inspector prior to the County's Framing Inspection Inspection Item Date Approval Signature Notes Septic System Finaled sep95-373 A final inspection will not be scheduled until all of the following are completed and signed off by the applicable Department: • Building Permit Conditions are met • Septic Permit Final/Complete for any building containing plumbing • Land Use Conditions met and signed off • Public Works Permit Final(where applicable) FINAL INSPECTION FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED THIS PERMIT IS VALID FOR ONE YEAR SPECIAL CONDITIONS APPLY-SEE REVERSE • • SPECIAL CONDITIONS CASE # BLD15-00216 1.) This permit approval involves relocating the mobile home permitted under BLD92-253 connected to SEP90-635 to the location where mobile permitted under BLD99-445 was located and connect to SEP95-373. The mobile home from BLD99-445 was moved without permit approval by the prior owner. Prior to final occupancy verification that the prior home permitted under BLD99-445 is no longer on the site or connected to the system SEP95-373 and that the septic system associated with SEP90-635, (second septic system on the parcel) has no structures connected to it. An additional fee may be charged for this insepction verification. 2.) 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. 3.) This approval is for moving existing motorhome from 90 Embody Rd to 24 Embody Rd 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. 4.) The site plan as submitted with the application to move existing motor home from 90 Embody Rd to 24 Emobody Rd on June 25, 2015 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 July 9, 2015 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 5.) EDB 6.) Jefferson County has determined that the use of real property for agriculture and forestry operations is a high priority and favored use in the county. The county will not consider to be a nuisance those inconveniences or discomforts arising from such operations, if such operations are consistent with commonly accepted best management practices in compliance with local, state, and federal laws. If your real property includes or is within five hundred (500)feet of real property designated as Rural Residential 1:10 or 1:20, Rural Industrial, Rural Commercial, Agriculture, or Forestry, you may be subject to inconveniences or discomforts arising from such farming and forestry operations, including but not limited to noise, tree removal, odors,flies,fumes, dust, smoke, the operation of farm and forestry machinery during any 24-hour period, the storage and disposal or manure, and the application of permitted fertilizers and permitted pesticides. One or more of these inconveniences may occur as a result of agricultural and forestry operations which are in conformance with existing laws and regulations. 7.) The existing well for this development lies within the WRIA 17. Prior documentation in the county records indicate the well has been used prior to 2009, supporting a determination that the well is exempted and not subject to the in-stream flow rule for domestic use, metering, and exempt well irrigation. \\tidemark\data\forms\F_BLD_Permit_Mobile.rpt 7/29/2015 • a Jefferson County DCD Building Division Correction Notice PERMIT NUMBER 15 - CJULIh OWNER ilag9/1/4-)4PCED JOB LOCATION (77 6-1 by ,PP' Inspection of this structure has found the following violati : ��v �LJAP 1IMO,, 1,S -% 17s /AJS�BCTE 8 J C 1-1g,o,Ly'5Ll DEPT, °t/'ar 0 6LECTIZre$t. 70 lig INSPEc-r.41) BY /)25.74I STAN ,r6 Pr A l= 2. 4' 1. R H- Laok5 7°0 A46 -t rr -rn ALP--rQu Aelt. prre i.141___Iiizigg r13 S1‘u9v or 15'i- 4 1 You are hereby notified that no more work shall be done upon these premises until the above violations are corrected, unless noted otherwise. When corrections have been made, call for inspection. r Date 9�8/�s Inspector�;G: .• _so BUILDING DIVISION(360)379-4450 INSPECTION HOTLINE (360)379-4455 THIS NOTICE MUST BE KEPT WITH APPROVED PLANS ON SITE Frank Hall From: Susan Porto Sent: Wednesday, September 09, 2015 4:27 PM To: Frank Hall; Jim Coyne Cc: Emma Bolin Subject: BLD15-216 EH inspection Frank and Jim, I got a call from Brittney Huntingford because she wanted to schedule an inspection by our office because that was a deficiency one of you two noted with your last inspection. EH DOES NOT NEED TO MAKE A SITE INSPECTION. The hold activity was signed off because Emma informed me that she had been to the site and verified the mobile was removed. So, I signed off the hold condition. If you have any questions let me know. Thanks. SuSRw Porto 12.S. Jef ferstm.Gou tt j Public 1 teatth Pliowe 360. 3559404 FRX 360.3 .4487- Alwaus Worl-iwo far R safer i-tealthi.erjef fersow Cots t CONFIDENTIALITY NOTICE: This e-mail message,including any attachments,is for the sole use of the intended recipient(s)and may contain confidential and privileged information. Any unauthorized review,use,disclosure,or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message. PUBLIC RECORDS ACT NOTICE: All e-mail sent to this address has been received by the Jefferson County e-mail system and is therefore subject to the Public Records Act,a state law found at RCW 42.56. Under the Public Records law the County must release this e-mail and its contents to any person who asks to obtain a copy(or for inspection)of this e-mail unless it is exempt from disclosure under state law,including RCW 42.56. 1 ■ lip Front Parcel Review 0 QED ( -5-0094 Parcel 821072002 Printed: June 29, 2015 BRANDON HUNTINGFORD Site Address(es): 1864 BEAVER VALLEY RD 24 EMBODY RD PORT LUDLOW,WA 98365 90 EMBODY RD PORT LUDLOW,WA 98365 PORT LUDLOW,WA 98365-9211 Parcel Number: 821072002 S-T-R: 7-28N-1 E Total Acreage 6 Legal Description S7 T28 R1E TAX 8 Land Use: 1101 Flood District: Fire District: 3 Planning Area: 6 Flood Map(FIRM)Panel No: School District 49 Zoning: g811 co COMP PLAN DESIGNATION: COMMUNITY PLAN: UGA: UGA Trans 1c] Plot plan states "property line" ] Assessor's Map(Property line submitted plot plan must match the property lines as identified on the Assessor's 1/4 map) Legal Access to Property a NO [(;4_ Parcel Tags or Scanned Documen YES NO ,M •. .. „ a t a_ 1101" *id ' _ • ` t 1�vt l'' ESA's: Special Reportearby let NO `Z a sir.gr KIM. Designated Ag YES Vi Shoreline Designation: YES `0 Shoreline Slope Stability: YES 6 Stream Type:YES _i I IIIIChl� . �.Z _:.e%ate 1• ` 'o�15 FWHCA: YES O Wetlands: YES Rare Plants:YES t Seismic: 6 No Landslide: YES t Flood: YES !ta Erosion: YES 0 Aquifer Rec a• _e • e. NO NO P ! a SIPZ: no : At Risk High Risk t astal CMZ: iiiiii�' High Risk Moderat- 'iskDisconnected CMZ Stormwater site plan s itted: Ye ' l] Forest Lands: YES Adjoining Forest Lands: ,.., Commercial/ Rural/ Inholding (>4 Mineral Lands: Y S C P 'k j Agricultural Lands: i NO .. 1 a. • •lr l A,. + i- 1 = A f de i• L. Ct • • C.-15C.,6 x1 Archaeology: YES `'�. No Shooting Zone: pl.. Stormwater: New Im._-.ous Surface II Land Disturbing Activity ESA's Stormwater Reg's:l in Req • Min Req#1 thn5#5 Min Req#1 thru#10 Engineering Notice Provisions •i :- ' e:Airport YEs MRL YES Cam! Forest Lands YES 0 ]- Landscaping Required: Yes ] Parking Spaces Re fired NO 0 Other XI Building Height: 5' UBC Standard * ui (3,12,\c( as 7 a35. } a`"'a f Ci9e -57 we4-ka4d = no Dcks,ed Cart cffv■r ir 9le ).\ v atiy'i a\ iveQ_ 1,4 Impervious Surface coverage p tentage: CO°?C) Resource Lands&Public: 10% Rural Residential ter Rural Industria UDC Sec 6.7 Rural Commercial: 60% of Building Coverage:60%in Rural Industria ds only [56 Total Building(s) Size: A]/, RVC:20,000 SF CC:5,000 SF NC:7,500 SF GC: 10,000 SF All others:subject to septic t&water constraints/None specified Setbacks: Front: 02� r I Left Side: ;� t Right Side: 2jb Rear: Fj 1 Shoreline Setback: ►J (Pt LSHA Setback: ' ' [XI Road Classification: CC ' ∎ -Sf a%Oct oT Road Approach: EXISTING l REQ'D [> SEPA Required: Y /`7i:."i�'' [x.,1 Flood Certificate: V+ Existing Case(s)& dition(s): AO / r-e_. no k 1 M oto i I P 'lorbtO cer et) t 5 a Violations: Yes o -1a-coy y5 ] Recorded Date of Su division: AFN Over 5yrs=UDC Plat Conditions: <Syrs=Plat Conditions on plat or Old Ordinance Lots/Require Declaration of Restricti� ovenant YES , submitted: YES NO UGA No Protest Agre ai YES 'V submitted: YES NO ` j' / [7Q Site Visit conducted a NO �0 �j-�-re atfIiS A�7 ,AQ evY of (),9e1"(Cc tt� [ ] Require Final Zoning As . oval YES NO 1 [ ] ADMIN: Setbacks entered in Permit Plan case N/A YES New Parcel Tags entered in Permit Plan N/A YES Special Reports Scanned N/A YES Title Notes Updated Parcel tags found for parcel 821072002 1.) AQUIFER RECHARG critical aquifer 12/21/1995 Parcel tags found for parcel 821072002 2.) Customized Warn TEMPORARY FAMILY HARDSHIP MOBILE 01/09/1996 Cases Associated with APN 821072002 Review Cases Name Type Status Planner BLD15-00216 HUNTINGFORD P Application Received: 6/26/2015 Permit Issued/Case closed: Case Finaled: MOVING EXISTING M.H. FROM 90 EMBODY RD-TO 24 EMBODY RD. (MODULINE 52X14) SEP95-00373 BLD92-00253 WOODWARD F Application Received: 4/24/1992 Permit Issued/Case closed: 4/30/1992 Case Finaled: mobile home installation BLD95-00650 WOODWARD F Application Received: 11/6/1995 Permit Issued/Case closed: 11/13/1995 Case Finaled: 11/14/1996 GARAGE BLD96-00012 WOODWARD F Application Received: 1/8/1996 Permit Issued/Case closed: 1/9/1996 Case Finaled: 11/14/1996 TEMPORARY FAMILYAAR135RIP mobile home installation:ADU as of 4/5/96 BLD99-00445 DEMSTTOS F Application Received: 7/12/1999 Permit Issued/Case closed: 7/20/1999 Case Finaled: 10/28/1999 manufactured home repacemen CAR95-00155 BURNETT/WOODWARD F Application Received: 12/15/1995 Permit Issued/Case closed: 1/17/1996 Case Finaled: 1/17/1996 CAR99-00285 BURNETT F Application Received: 7/12/1999 Permit Issued/Case closed: 7/15/1999 Case Finaled: 7/15/1999 manufactured home rep agent-accessory dwelling unit OTH96-00005 WOODWARD A Application Received: 1/8/1996 Permit Issued/Case closed: 1/12/1996 Case Finaled: TEMPORARY FAMILY HARDSHIP mobile home installation; individual well PRE95-00024 WOODWARD C M GREWELL Application Received: 11/14/1995 Permit Issued/Case closed: Case Finaled: \\tidemarkldatalforms\RParcel CRMLA.rpt 6/29/2015 Page 2 of 3 PRE98-00034 BURNETT C M GREWELL Application Received: 8/31/1998 Perm/toed/Case closed: Cas aled: SEP90-00635 WOODWARD F Application Received: 9/6/1990 Permit Issued/Case closed: 9/17/1990 Case Finaled: 10/24/1990 SEP95-00373 WOODWARD F Application Received: 12/15/1995 Permit Issued/Case closed: 1/18/1996 Case Finaled: 2/7/1996 ZON99-00026 BURNETT C M GREWELL Application Received: 7/12/1999 Permit Issued/Case closed: Case Finaled: An accessory dwelling unit(AUU) replacement. BLD94-00755 WOODWARD F Application Received: 10/31/1994 Permit Issued/Case closed: 10/31/1994 Case Finaled: 11/29/1994 propane tank installation SOM90-00635 DE MATTOS RCR Application Received: 10/24/1990 Permit Issued/Case closed: 3/6/2015 Case Finaled: SOM95-00373 DE MATTOS RCR Application Received: 2/7/1996 Permit Issued/Case closed: 3/6/2015 Case Finaled: \\tidemark\data\forms\R_Parcel_CRMLA.rpt 6/29/2015 Page 3 of 3 • • • BLD15-00216 Review Type: MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD15-00216 Received Date: 6/26/2015 SITE ADDRESS: 24 EMBODY RD PORT LUDLOW, 98365 APPLICANT: BRANDON HUNTINGFORD PHONE: 1864 BEAVER VALLEY RD PORT LUDLOW WA 98365-9211 SUBDIVISION: Block: Lot: PARCEL NUMBER: 821072002 Section: 7 Township: 28 N Range: 1E CONTRACTOR/ OWNER/BUILDER PHONE: DEALER: REPRESENTATIVE: PHONE: PROJECT DESCRIPTION: MOVING EXISTING M.H. FROM 90 EMBODY RD-TO 24 EMBODY RD. (MODULINE 52X14) SEP95-00373 TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW MAKE: MODULINE SETBACK: VALUATION YEAR: 2000 LABOR& INDUSTRIES APPROVAL? SIZE: 52X14 BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: 1 PWELL BEDROOMS: BATHROOMS: Exist: Exist: Prop: 2 Prop: 1 Total: 2 Total: 1 Routing Date: Type Amount Paid By: Date: Receipt: e Manufactured Homes $546.00 SRE 06/25/15 156217 � �VE® Potable Water Application $129.00 SRE 06/25/15 156217 JUL 2 9 2015 State Building Code $4.50 SRE 06/25/15 156217 Total: $679.50 Jefferson County DCD \1firlomorNrInfn1fnrrmc\R RI fl Ann 11.1nh mf F/7 I.7n15 r • • <'"SON of DEPARTMENT OF COMMUNITY DEVELOPMENT Gz,, f 621 Sheridan Street,Port Townsend,WA 98368 W Tel:360.3794450 I Fax.360379.4451 Web:www.co.jefferson.vva.us/corninunitydevelopmelit �� . rS- I-snail dcd�u?conthr.onwa.us �j- �� YSNI NG`S0 `V� PERMIT APPLICATION ° 2 5 2015 Steps in the Permit Process: ;\ NC f� COI -Review application checklist to ensure all information is completed prior to submitti 1 ap• icat�cOMM N1ClaE�� -Make sure septic has been applied for and water availability has been proven. pE�• -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 Only Building Permit# Related Application#s: MLA# Site Information _ Assessor Tax Parcel Number: 821072002 Site Address and/or Directions to Property:24 Embody Road Port Ludlow, WA 98365 Access(name of street(s)) from which access will be gained: Embody Road Present use of property: Residential Description of Work (include proposed uses): - Moving mobile home within the property -9 Wastewater-Sewage Disposal This property is served by Port Townsend of Port Ludlow sewer system? YES _ — NO _1 + ‘ If not served by sewer identified above, identify type of septic system below: V ° Type of Sewage System Serving Property: �/_ Septic Septic Permit#: SEP95-00373 9 _ Community Septic Name of System: Gravity Case#: SEP95-00373 Are other residences connected to the septic system? No (�(y Additions or repairs to sewage system: None Is it a complete or partial system installation: Complete _1 Partial Has a reserve drainfield been designated? Yes ✓ _ No Date of Last Operations& Maintenance check: 03/06/2015 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 will mail/ e-mail requests and information about the application to the authorized agent/representative and will co. -- •' per noted below. The authorized agent/representative is responsible for communicating the inform..•• .. . e a:.l th the application. It is the responsibility of the authorized agent/representative and owne . -n -: rJl o'\ c.F- s ty email i.e. County email is not blocked or sent to "unk mail" . Applicant/Property Owner Information ± 'L)Property Owner: y � ,�\ 301, 25 2.015 Name: Brandon & Brittany Huntingford Address: 1864 Beaver Valley Road, Port Ludlow, WA 98365 1L`ttRgpN000Nn Phone#: 360-643-3579 / 360-640-4249 E-mail Address: b hunfin f i • °PMlrn - - Please contact Authorize' Agent/Representative with project info. (select only one). Property Owner Signature: 6Vl �j[. �<•L' Date: 06/08/2015 Note: For projects with multiple owners,attach a sep.r. e sheet with e. owner(s)information and signatures. Applicant: Authorized Agent/Representative (if other than owner) Name: Address: Phone#: E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO 1 YES Engineer Architect Surveyor Contractor Consultant Name: Address: Phone It 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 7 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 that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that they will be ass min the responsibility of the General Contractor for the proposed project. Signature: r '9 iii a i rint Name: A�git?,• , j Lan is Date: lR 1812-015 IP • �, ON ,-, DEPARTMENT OF COMMUNITY DEVELOPMENT k 621 Sheridan Street,Port Townsend,WA 98368 /J ,W Tel:360.379.4450 Fax:360.3 79.4451 5� Web:www.co.jefferson.wa.us/communitvdeveloprnent I I i("� E-mail:dcd(co jefferson.wa.us i I ��®` -°�o ' ,n \ jo 2 5 2015 HIND MOBILE OREMANU MANUFACTURED HOME�JEFFERSO WIN ill'nF C, ■ , 4F UCl ''. ',T For Department Use Only Receipt#: Related Application#s: Payment#: Building Information !: Property Owner Name: c`p1,n(A0rl'S Pjri-t�un }r6(W�lk she sorTax Parcel#: g2,_1 012 0 p`2_, Type of Manufactured Home: Check One: New Replacement Moved Demolition Check One: Park On a Lot x Temporary Construction Living Quarters Proposed Building/Project: Square Footage: P7t 8 r-r i Number of Bedrooms: Z Type of Heating: *arum /3i-i•-/i0044 Number of Bathrooms: Deck: Sq/Ft: Garage: Q Sq/Ft: Installer: 'RM.. c3 (l,PJJ Address, City,State, Zip: Phone: e2)C,12_0'C,Q L13-3j'75/1 Installer Email: Contractors License#: Assessor Information Home Data: Make: Nlad at.∎ Model: 25 2-2- -- Year: 2-CM Length 67- Width: ‘y Serial#: l"1/3L-1(4) Your Purchase Price (Don't include sales tax): $pci portuyJ 0-9, o - Purchase Date: 312 nv?A(.5 Previous Owner/Location of Home(if new move to question next question): From whom did you purchase your manufactured home: co Address E)cU-'c . p irmk 4* , G,100_,- \n cc.,„_'k-(Ov c r' f rope r o Was manufactured home assessed in Jefferson County last year: YESO NO a Y ��vr.�D�v\t�LJ.. cJ �' v If yes, Previous address of manufactured home: J 0%K��as J 4 m If no,what County was M/H assessed in last year: K Where is the manufactured home to be located: x Will the home be in a mobile home park? YES NO X If located in a mobile home park: Name and address of park: If not located in a mobile home park: Name of land owner: 4 grj sny 'h 7x Location address: Zcf bo�� pi J `J Assessor tax parcel#: 82I C 7Z o&2. • List existing buildings on property(i.e. house, garage, accessory dwelling unit, shed, barn, mobile home, other): All Existing Buildings on Property Use C--14.41X-Sp 617PrA-SP pomp h6ukP—J Public Health Information Water Source Existing Proposed Attach Copies of: Private well X 1) Well Logs(if no log report on file,a 1 hr stabilization test may be substituted.) 2) Lab analysis tested within 3 years of application. -Total Coliform, Nitrate-N,Chloride 2-Party Well Items above AND recorded Operations& Maintenance agreement and recorded Easement. Alternative Provide justification and design per Jefferson County System: Environmental Health policy 97-01. http://www.jeffersoncountypublichealth.ordpdf/Policy_97- 01_Rai nwater_Collection.pdf Valid Water Right Permit: Generally applies to springs, attach copy. Public Water: Name of Water Provider: -Submit Water Availability Notification form completed by your water purveyor. NOTE: If any of the above utilities need to be installed and disturbance will occur in a public maintained or unmaintained County road and/or Right-of-Way easement,then a Right-of-Way application will be needed. Resolution#99-90 requires building permit applications to provide evidence of an adequate potable water supply per the conditions of RCW 19.27.097 and the Guidelines for Determining Water Availability for New Buildings.http://www.co.jefferson.wa.us/commissioners 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 its 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 or agents for the sole purpose of application review and any required later inspections. Applicant may request notice of the County's intent to enter upon the property for visits related to this application and s bsequent pe I it issuance. Signature: 4 I LI Print Name:' • 'kko_r J 1N\(' r K? Date:t(44\k%J OFFICE USE ONLY 1) Water Right Permit# 3)Individual Well 2)Public Water Supply WS ID# Meets Water Quality Standards? Yes No In Compliance Yes No WRIA 17 Subbasin SIPZ -Coastal/Moderate/High Yes No Based upon information provided by the applicant,it appears that the potable water supply: Meets Conditionally Meets Does not Meet • i File Original aid First Co Toy with Start Card No. 4/®66'6 2 O Department of Ecology WATER WELL REPORT UNIQUE WELL I.D.0 Second Copy—Owners COPY ADti 7 J/ STATE OF WASHINGTON Third Copy—Drillers Copy Water Right Permit No. L (1) OWNER: Name %/ rI £✓nad wa/CI Add�ss C? e�T - i?,l• / z-d L'.. ./(3?c✓ 9 a (2) LOCATION OF WELL: county l ea •-Sor7 - SG/ >µ f- , ` .1 .4'A wM. Q (2a) STREET ADDRESS OF WELL(or nearest address) .S'4/he_ tI 1 el (3) PROPOSED USE: IrtImesbc Industrial ❑ Municipal ❑ (10) WELL LOG or ABANDONMENT PROCEDURE B£SCRIPt[Ip N ❑ Irrigation �4 ❑ DeWater Test Well ❑ Other ❑ Formation Descnbe by color,character,else of metddai and.struclure,and show th, J�}sr�I aquifers and the kind and nature of the material M each stratum penetrated,with at least nay for each N (4) TYPE OF WORK: Owner's number of well change of information �J ', t (If more than one) y Abandoned❑ New well L7 Method Dug❑ Bored❑ MA1ER _ V ` `."1� FROIf �O != Deepened ❑ Cable dr Ddven❑ TOPfdt r'I )�i,`" i �" � o Reconditioned❑ Rotary❑ Jetted❑ / o (5) DIMENSIONS: Diameter of well-, 6 r� Inches S4'id 5, lct✓(? I rC!a 1 / z 7 i+ Drilled I V / feet Depth of completed well 0 ft ..l cz Cernen•`e.,/ Sq rid e Q E (6) CONSTRUCTION DETAILS: J ." /- Z 7 �a ry o Casing installed: C • Dram from O ft to /CI I n W/Q 5.ra ria I .\ri d S 8— S 9 C liner installed❑ Diem from ft to ft a Threaded ❑ DWm from ft to n cep e eo( stead 5',ea ve/ S 9 7 3 yPerforations: Yes❑ No J L Type of perforator used s' ,ro( it Sew✓e-I /B 7 3 7-1 0 SIZE of perforations in by In 0 perforations from n.to It C e-+r e of e d Set.n d d4 3.,-41/e/ 7.1 9 Z f8 perforations from ft to ft cu perforations from ft to ft S./ /Pl- C I a YU Screens: Yes ❑ No 0 Manufacturer's Name _ Sa/74 f r/^°t- e"e r AJ/R 5 4' !O / 0 Type Model No t E +■1 Dram Slol size from ft 10 ft. i y Dam Slot size from ft.to ft I Trn N13 C Gravel peeked: Yes ❑ No N"� Sire of gravel 6""-* -v- LGravel placed from fL to ft. r-O P.y., �/ _ Surface seek Yes Lr No❑ To vv(hat depth? ft "1 Material used m seal @�14q.1e C 11-"-ac � G O Did any strata contain unusable water? Yes❑ No E`;r Z Type of water? Depth of strata I C T: �?` I a Method of sealing strata on y L. • (7) PUMP: Manufacturer's Name E — - Type H P >e 0)� pp(8) WATER LEVELS: Land-surface elevation Work I ! 19 Completed bier I q 19 /-T O .. above mean sea buret fr Stank level 8 n below top of well Date V Artesian pressure Os per squats)rich Data WELL CONSTRUCTOR CERTIFICATION: W Artesian water is contused by I constructed and/or accept responsibility for construction of this well, and its �- (Cap,valve,etc) compliance with all Washington well construction standards Matenals used and the Information reported above are True to my best knowledge and belief (9) WELL TESTS: Drawdown is amount water level is lowered below static level //y/y/J 4),f1/,,a 1 /r C Was a pump test made? Yes❑ No❑ ryes.by whom? NAME / //,./ r�1..r 0 .1 / r 74 Inc_ Q) Yield gal/min with ft drawdown after hrs / (PER,SON:FIRM OR CORPORATION) (TYPE OR PRINT) E " Address 7 L/ I W , 1 [1 Rd- �-{ / / ��G r 4 CL Recovery data(time taken as zero when pump turned off)(water level measured from well (Signed) .�}.Gai�(.tN 1/DRRILI�iLER) Ucense No ZOO I 0) top to water level) vww171€€€luul 0 lime Water Level Time Water Level lime Water Level Contractor's (� q NconrCf) W, Di'0�POS Date be--C 1 / ,19 iS ~ (USE ADDITIONAL SHEETS IF NECESSARY) Date of test Baler test 12 gal/min with ,I.:3-- n drawdown after hrs. lunest gal/min with stem set at ft.for hrs. Ecology is an Equal Opportunity and Affirmative Action employer.For spe- Artesian Sow g p m Date oaf accommodation needs,contact the Water Resources Program at(206) Temperature of wafer_Was a chemical analysis made? Yes III No 407-6600 The TDD number is(206)407-6006. ECY 050-1-20(9(931•'1 III 26276 Twelve Trees Lane,Suite C • TW 1 S Sr Poulsba,WA 98370 .. LABORATORIES (360)779-5141 II, f ._.__A aSPECTRA La4ummimmm_y _ COLIFORM BACTERIA ANALYSIS Date Semple Collected Time Sample ( County I Collected 01-0 1 I IZ9t5 :Ov 01 PM ��k? o+� Month Day Year _. _- Type of Water System(check only one box) . [�. ❑Group A ❑Group B Qther Group A and Group B Systems-Provide from Water Facilities Inventory(WFl): ID# _ —. System Name: — Contact Person: ,I( - f1 —..-.- Day Phone:(3t..olQ.kn�O,y y q Cell Phone: e,tya.{c3. Eve.Phone:( R T FAX:(—3--- ' .Email 6 Send esuulisto (Pint full name address and zip cod -y� r� --. _—__— — v CL\ I aok-• : lst`�. 0\ 03 s'-tit R 41' S SAMPLE INFORMATION Samp a cted by(name): 5y %WA, ' Specific Location where as 4 collected: Sped- nstructionsorcomments. 2"4 Etes1rDO 41-3 W.-,-- '{fi n Sr A(\k0-- Type of Sample(must chuck only one box of#1 through#4 rsted below) - 1.0 Routine Distribution Sample 2.Repeat Sample(after unsatisfactory routine) Chlorinated:Yes _No -. ❑Distribution System Chlorine Residual:Total_Free_ ❑Source Groundwater Rub(GWR) (Population of 1,000 or less) 3.Raw Water Source Sample Unsatisfactory routine lab number. (2I E.oak-GWR source sample ❑Fecal-Surface,GWi,some springs ❑Other Unsatisfactory routine collect date: 1 S J 1 Chlorinated:Yes_ No __sse Pdd'csYS6m'malp-,/.ifoxenunarSem WFI i '... Chlorine Residual:Total__Free__ 4.i 1 Sample Collected for Information Only Inve tigative _ Construction/Repairs__ Private Residence_ Other_ LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY Analyst Remarks: ❑Unsatisfactory Total Conform Present and atlafaetory ❑E.cofi present ❑E.coli absent ❑Fecal coliform present ❑Fecal coliform absent i Replacement Sample Required: ❑Sample too old NO hours) ❑TNTC ❑__ ❑Improper Container ❑Turbid culture Bacterial Density Results:Plato Count /ml. E.coL. _,/100ml. Total Coliform _J100ml, Fecal Coilform_.... _ /100ml. Date and Time Received: �r Method Code: ;-- , MICR- 2730 - . .—--—— b �--7- t r Date Repotted:Date Analyzed: LY 8) 3 __ kelpie Number(UCH number plus five digis) Lab Use 6Ny: 0 1 0 . 3 9) el--__-- J 15_3 9)-Q, 00b1 Fa m#371-319(rea[5ed 11110) Lab revision 11/14 ■ • • TWISS LABORATORIES 26276 Twelve Trees Lane,Sutte C Poulsh°,WA 98370 Telephone(360)779-5141 fAX(76111 7/9-S 150 IOC- SHORT IOC-SHORT by Various EPA Approved Methods Source/Point of Entry-Report of Analysis Date Collected: 6/18/2015 Group: Private System ID No: Private System Name: Private Lab-Sample#: 01039702 County: Jefferson Sample Location: Kitchen Sink DOH Source No: Sample Purpose: 0 Date Received: 6/18/2015 1 Sample Composition: S Date Analyzed: 6/18/2015 Send Report To: Brittany Huntingford Date Reported: 6/23/2015 1864 Beaver Valley Rd 1 Sample Type: Pre-treatment/Raw Port Ludlow,WA 98365 Collected By: Brittany Huntingford Phone Number: 360-640-4249 Bill To: Brittany Huntingford 1864 Beaver Valley Rd Port Ludlow,WA 98365 T DOH# 1 Analyte Results units SRL Trigger MCL* MCI. Method I Exceeded 1 _ (Analyst Init.) j EPA 300.0 ._ 20 _._1 Nitrate-N 05S ( _re I 5 u_10 ... 21 .....1 Chloride _.. .4,03 ,------mg/L. . i0__. 250 ■ I EPA..2.04 4.(1``µ') — SRL: (State Reporting Level),indicates the minimum reporting level required by the Washington Department of Health (DOH). Trigger Level: DOH Drinking Water response level. Systems with compounds detected at concentrations in excess of this level are required to take additional samples.Contact your regional DOH office for further information. MCL: (Maximum Contaminant Level),If the contaminant amount exceeds the MCL,immediately contact your regional D011 office. NA: (Not Analyzed),in the results column indicates this compound was not included in the current analysis. ND: (Not Detected),in the results column indicates this compound was analyzed and not detected at a level greater than or equal to the SRL <(0.00x): indicates the compound was not detected ie the sample at or above the concentration indicated. The 0.010 mgt MCL for Arsenic is for Group A NTNC systems. All other systems should cheek with their county Health District to determine what level is applicable. 150397 O i 6/9/2015 Enviro Check, LLC 1612 Hastings Ave. West 360-379-9400 Port Townsend, WA 98368 PROPERTY INFORMATION Mobile Location:24 EMBODY RD Port Ludlow Tax ID:821072002 Man To: NANCY DE MATTOS PO Box 451 Use:Residential,Single Family Chimacum,WA System Design Flow 360 • 98325 GENERAL SYSTEM TYPE:Gravity Owner.NANCY DE MATTOS ON ID:SOM95-00373 Fold r— ON-SITE WASTEWATER TREATMENT SYSTEM INSPECTION REPORT Fold Here Here inspected:03/06/2015 - Inspection Type:PROPERTY SALE - Correction Status:Some Corrections Made Company: Work Performed By: Submitted 03/06/2015 by: Enviro Check,LLC Dale Wurismith Dale Wurtsmith This report does not assure approvals by Jefferson County Public Health for ANY future building permits or development. COMMENTS&GENERAL INSPECTION NOTES Deficiencies Noted:deficiencies must be corrected to ensure proper longevity of the Onsite Sewage System. 1-Risers are mandatory on next inspection. 2-The drainfield area is overgrown and needs to have trees and brush removed. 3-SYSTEM-What I observed was consistent with plan,County date stamped 020996. APPURTENANCES-A revised"Plot Plan"is en route to County,Ref-Structures and tank locations only. GENERAL SITE&SYSTEM CONDITIONS The General Site and System Conditions were: Fully Inspected All Components accessible for maintenance.secure and in good condition: NO-See Comments Surfacing effluent from any component(including mound seepage): NO Components appear to be watertight no visual leaks: ♦� YES Improper encroachment(roads,buildings,etc.)onto component(s): NO omp nn . �i \II Component settling problems observed: ` NO «� �wpa _ Abnormal pondmg present for one or more of the disposal components: N/A Subsurface components adequately covered ('a '4 \� , YES Owner compliance issues noted `' � 'SO�G� � J NO Site maintenance required(e.g.Landscape maintenance)If yes describe in comm -. ` (� 1. YES Occupant compliance problem(occupant not operating the system properly). If YES, •-- •• fp notes: ``,\k, NO If deficiencies were identified on last inspection were they corrected before or during thl§ -•,,. n? JV UN.rfc° N/A O (If NO,describe in notes,NA=no deficiencies on last report): , 0 0 OSS Components,structures and appurtenances located per as-built/record drawing(If N®, �F��S%N�.rO NO Sae Comments in notes). If no as-built exists or changes made,state NO and provide record to Health De•7\ _ �0 Alterations made to the OSS(valves adjusted,timer settings modified,ports installed,etc.)(If S, fit?. �F NO describe in notes): 0 The house/structure was vacant or used infrequently,assessment of the drainfield was not possi e. NO Is the SEP case in a finaled/completed status?(if NO explain in comments) YES ONSITE SEWAGE SYSTEM INSPECTION DETAIL TANK:Septic Tank-2 Compartment 1000 gal This component was: Fully Inspected • Component appears to be functioning as intended: YES Effluent level within operational limits(if NO explain in comments): YES All required baffles in place(N/A=No baffles required): YES Effluent Filter Cleaned(N/A=Not Present): NIA Compartment 1 Scum accumulation(Inches,if other specify): 0 Effluent filter/screen needed cleaning on arrival NIA • Compartment 1 Sludge accumulation(Inches,if other specify): 6 • Compartment 2 Scum accumulation(Inches,if other specify): o • Compartment 2 Sludge accumulation(Inches,if other specify): 4 • Pumping needed: NO I ReportlD:426135 View inspection reports online at www.onlinerme.com Page 1 of 2 Parcel Details • 41 Page 1 of 2 iefferson County Hal ..„ r I me County info ry Departments Search Parcel Number: 821072002 SEARCH Parcel Number: 821072002 Printer Friendly Owner Mailing Address: BRANDON HUNTINGFORD 1864 BEAVER VALLEY RD PORT LUDLOW WA98365-9211 Site Address: 90 EMBODY RD PORT LUDLOW 98365 Section: 7 School District: Chimacum (49) Qtr Section: NW1/4 Fire Dist: Port Ludlow (3) Township: 28N Tax Status: Taxable Range: 1E Tax Code: 0231 Planning area: South Chimacum/Inland Valleys/Center (6) \� Sewer: Drainage: Bank: View 1: View 2: Zoning 1: RR-10 - Rural Residential Zoning 2: Zoning 3: Sub Division: Assessor's Land Use Code: 1101 - Residential - MH W/Land Property Description: S7 T28 R1E TAX 8 Tax.A/V. Sales, Photos, and Permit Data Bldg Data Map Parcel Plats&Surveys Septic Monitori11.1_10 ,,. Jefferson {g l . HOME I COUNTY INFO I DEPARTMENTS I SEARCH Best viewed with Microsoft Internet Explorer 6.0 or later Windows- Mac http://www.co.jefferson.wa.us/assessors/parcel/parceldetail.asp?value=821072002 6/16/2015 • L")(2_ BLD15-00216 Review Type: MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT#: BLD15-00216 Received Date: 6/26/2015 SITE ADDRESS: 24 EMBODY RD PORT LUDLOW, 98365 APPLICANT: BRANDON HUNTINGFORD PHONE: 1864 BEAVER VALLEY RD PORT LUDLOW WA 98365-9211 SUBDIVISION: Block: Lot: PARCEL NUMBER: 821072002 Section: 7 Township: 28 N Range: 1E CONTRACTOR/ OWNER/BUILDER PHONE: DEALER: REPRESENTATIVE: PHONE: PROJECT DESCRIPTION: MOVING EXISTING M.H. FROM 90 EMBODY RD-TO 24 EMBODY RD. (MODULINE 52X14) SEP95-00373 TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW MAKE: MODULINE SETBACK: VALUATION YEAR: 2000 LABOR& INDUSTRIES APPROVAL? SIZE: 52X14 BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: 1 PWELL BEDROOMS: BATHROOMS: Exist: Exist: Prop: 2 Prop: 1 Total: 2 Total: 1 Routing Date: Type Amount Paid BV: Date: Receipt: Approved/Date Manufactured Homes $546.00 SRE 06/25/15 156217 Potable Water Application $129.00 SRE 06/25/15 156217 State Building Code $4.50 SRE 06/25/15 156217 Total: $679.50 \ltiifcmnhlrlofnlfnrrnc\C RI fl Ann lnnk rnt Rl9R/411F • • CI DEPARTMENT OF COMMUN �' ?" 1MN-Ti r 621 Sheaidan Sticct Poit'Iown,cnd,\w':4 933G8 1 d:360 379.4450 11 ax:360 3?9.4451 ' I 11 Wcb:wwwco.idtcnrmwa.0 /conimUitvdevelopment I I,mail dcd([?;c J ffe on.wa.us , �I� JUN 2 5 201� u — PERMIT APPLICATION 1 _PEPT. 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. For Department Use Only Building Permit# Related Application#s: MLA 14 Site Information Assessor Tax Parcel Number: 821072002 Site Address and/or Directions to Property:24 Embody Road Port Ludlow, WA 98365 Access(name of street(s)) from which access will be gained: Embody Road Present use of property: Residential Description of Work(include proposed uses): Moving mobile home within the property Wastewater-Sewage Disposal This property is served by Port Townsend of Port Ludlow sewer system? YES _ — NO ,7 If not served by sewer identified above, identify type of septic system below: Type of Sewage System Serving Property: _1 Septic Septic Permit#: SEP95-00373 _ _ Community Septic Name of System: Gravity Case #: SEP95-00373 Are other residences connected to the septic system? • No Additions or repairs to sewage system: None Is it a complete or partial system installation: Complete ✓ Partial — — Has a reserve drainfield been designated? Yes _✓ _ No Date of Last Operations & Maintenance check: 03/06/2015 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 will 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 rnfoR < ' ed with -� the application. It is the responsibility of the authorized agent/representative and owner to eity iris tl r a l a c [County email (i.e., County email is not blocked or sent to "junk mail"). Applicant/Property Owner Information Property Owner: Name: Brandon & Brittany Huntingford Address: 1864 Beaver Valley Road, Port Ludlow, WA 98365 1CFFE6011 COUNTY Phone#: 360-643-3579 / 360-640-4249 E-mail Address: b_huntingford@yT;1hogii DMEVELDPM` — — Please contact Authorize. Agent/Representative with project info. (select only one). Property Owner Signature: �' Date: 06/08/2015 Note: For projects with multiple owners,attach a sep r e sheet with e. owner(s)information and signatures. Applicant: Authorized Agent/Representative(if other than owner) 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: Professional: Is this an Authorized Agent/Representative for this project? NO ✓ YES Engineer Architect Surveyor Contractor Consultant Name: Address: Phone It: 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 that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that they will be assumin,:�the responsibility of the General Contractor for the proposed project. Signature: r ry 1$ t • Fjj nt Name: �" n(f� l'1 '"W/(_ Date: Le lQ��IS wsk-.4°N co", DEPARTMENT OF COMMUNITY DEVELOPMENT �4, ,�, 621 Sheridan Street,Port Townsend,WA 98368 W A Tel: 360.3'9.4450 Fax 360 379 4451 �/� ti Web www.co.l efferson.wa.us/commmnitrdevelopment L__ i[— Il �°J (- �■ F-mail:dcd�co iefferson wa.us , _- - -1 ISNI N� -�� SUPPLEMENTAL APPLICATION - 1 MOBILE OR MANUFACTURED HOME, fI J,) For Department Use Only Receipt#: 1 Date `{Ut livTY I? ;pIlfi lfkIFNI Related Application#5: ' Payment#:— Building Information Property Owner Name: pf e\00.c. Yl Ylt1� i"tiNOV C'sorTax Parcel#: g?1 0-1"Z L) b` � Type of Manufactured Home: J Check One: New Replacement Moved Demolition Check One: Park On a Lot ) Temporary Construction Living Quarters Proposed Building/Project: Square Footage: -12.% z vu Z Number of Bedrooms: Type of Heating: -1-Porccri A-ie/LoJcoui Number of Bathrooms: Deck: EE�,,,__^^ Sq/Ft: Garage: O Sq/Ft: T,U+; Installer: '` c. ()to Nu,/ Address, City, State, Zip: Phone: -t-e-0'L L«- 3'511 Installer Email: Contractors License#: Assessor Information Home Data: Make: NI) 1■u l(k-P Model: 2527 K_ Year: 9_ tDQ Length Z Width: ,i-1 Serial #: I—t'4tp Your Purchase Price (Don't include sales tax): $pro porti3,,,3 OA, wavo Purchase Date: 3 0 oo ,oc Previous Owner/Location of Home(if new move to question next question): From whom did you purchase your manufactured home: m Address F-)Gt 1`flP pas Lp_A , c..tICJLYI�re n t ucc.-h0✓1 0l/■ pi U ? r p Was manufactured home assessed in Jefferson County last year: YES NO ci „ If yes, Previous address of manufactured home: GlDelin t),41.1�(1_6e t D'4�W-At i3O,c - ' If no, what County was M/H assessed in last year: `) K Where is the manufactured home to be located: it Will the home be in a mobile home park? YES NO X If located in a mobile home park: Name and address of park: If not located in a mobile home park: Name of land owner: area. ctbrl 4 864—kn4 Hio-ClilltJat Location address: 2..t Emnbo..t`�° a°' J Assessor tax parcel#: 82,/ 0 72 66'2— • • List existing buildings on property(i.e. house, garage, accessory dwelling unit, shed, barn, mobile home, other): All Existing Buildings on Property Use Ss—, 51T5 2 pomp k}6uke , Public Health Information Water Source Existing Proposed Attach Copies of: Private well 1) Well Logs(if no log report on file, a 1 hr stabilization test may be substituted.) 2) Lab analysis tested within 3 years of application. -Total Coliform, Nitrate-N,Chloride 2-Party Well Items above AND recorded Operations& Maintenance agreement and recorded Easement. Alternative Provide justification and design per Jefferson County System: Environmental Health policy 97-01. http://www.jeffersoncountypublichealth.org/pdf/Policy_97- 01_Rainwater_Collection.pdf Valid Water Right Permit Generally applies to springs,attach copy. Public Water: Name of Water Provider: -Submit Water Availability Notification form completed by your water purveyor. NOTE: If any of the above utilities need to be installed and disturbance will occur in a public maintained or unmaintained County road and/or Right-of-Way easement,then a Right-of-Way application will be needed. Resolution#99-90 requires building permit applications to provide evidence of an adequate potable water supply per the conditions of RCW 19.27.097 and the Guidelines for Determining Water Availability for New Buildings.http://www.colefferson.wo.us/commissioners 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 its 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 or agents for the sole purpose of application review and any required later inspections. Applicant may request notice of the County's intent to enter upon the property for visits related to this application and subsequent per it issuance. ` Signature: ►' (Y 1 1 46 Print Name:?YY1N X Zrn- N Date U2 4\1% OFFICE USE ONLY 1) Water Right Permit# 3)Individual Well 2)Public Water Supply WS ID4I Meets Water Quality Standards? Yes No In Compliance Yes No WRIA 17 Subbasin SIPZ -Coastal/Moderate/High Yes No Based upon information provided by the applicant,it appears that the potable water supply: Meets Conditionally Meets Does not Meet SON c DEPARTMENT OF COMMUNITY DEVELOPMENT w o\ W a 621 Sheridan Street,Port Townsend,WA 98368 i ,.< Tel 360.379.4450 I Fax: 360.379.4451 Web:www co.jef ferson.wa.us/communitydevelopment. LI r E-mail:dcd ntco.iefferson.wa.us 95771 N G'CO PERMIT FEES WORKSHEET Name Huntingford Parcel # SZb"1Z002, - Estimated Cost of Project Permit# Building Base Fees Building Base $546.00 Plan Check Review Land Use Review $234.00 Septic Review $129.00 Potable Water $170.00 Technology/Scan $19.50 State Fee $4.50 Other Fees Shoreline Exemption Zoning Zoning New Address Public Works Total Fees $1,103.00 Office Use Only Receipt Number: Cash/Check/CC: Date: