HomeMy WebLinkAboutBLD2015-00050 - 01 PERMIT APPLICATION BUILDING PERMIT APPLICATION BLD15-00050
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD15-00050 Received Date: 2/23/2015
SITE ADDRESS: 4429 COYLE RD
OWNER: PEN AIR LLC NORTHERN CANAL INVESTMENTS LLC PHONE: 360-301-0257
PO BOX 130
QUILCENE WA 98376-0130
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 701142002 Section: 14 Township: 27 N Range: 1\
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: DAVID WARD PHONE: 360-301-0257
P.O. BOX 130
QUILCENE WA 98376
PROJECT DESCRIPTION NEW COMMERICAL STEEL POLE BUILDING 50X84
BUILDING B (1-502)
SEP 15-00002
TYPE OF WORK COM SQUARE FOOTAGE: COMMERCIAL:
TYPE OF IMP NEW MAIN: 4,200 INDUSTRIAL:
VALUATION 40,000.00 ADD'L: HEAT TYPE: EEE
CODE EDITION: 2012 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: ALT NUMBER OF EMPLOYEES:
WATER SYSTEM: 1 PW ELL
BATHROOMS:
Exist: 0
Prop: 0
Total: 0
Routing Date:
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $487.00 SRE 02/23/15 154126
Plan Check $316.55 SRE 02/23/15 154126
State Building Code $4.50 SRE 02/23/15 154126 APFROVED
Potable Water Application $0.00 SRE 02/24/15
Total: $808.05 ADR 1 2015
ieiferson County DCD
\\tidemark\data\forms\F_BLD_App_Bld.rpt 2/24/2015
.
�4SON c DEPARTMENT OF COMMUNITY DEVELOPMENT
X44 °,� 621 Sheridan Street,Port Townsend,WA 98365
W ,.< Tel:360.379.4450 Fax:360.379.4451
Web:www.co.iefferson.wa.us%communitadevelopment
E-mail: dcdaco.jefferson.wa.us
PERMIT FEES WORKSHEET
Name Building B Parcel# 701142002
Estimated Cost of Project $40,000.00 Permit# 1
Building Base Fees
Building Base -olimover 451,- • Ov
Plan Check Review $179 , !Me t7S--
Land Use Review (.2., 4 • 00
Septic Review $160.00
Potable Water -$189.00L,
Technology/Scan $19.50
State Fee $4.50
Other Fees
Shoreline Exemption
Zoning
Zoning
New Address
Public Works
Total Fees I__I $733.55
1 ] ,Or vE �
Office Use Only
Receipt Number: 2 3 2015 �1
Cash/Check/CC: - l J
Date: JEFFERSON COUNTY
rr•2T.OF COMMUNITY DEVELOPMENT
lv9te -s"C-- 1LS .° °
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�gil
goN rod DEPARTMENT OF COMMUNITY DEVELOPMENT
`L 62_1 Sheridan S urcct Port I ow nsend,AY�A 98368
W fel 360 379.4450 1 Fax:360 179.4451
tiv Web w W. . tfctcon.wn is'c mmmu ... •1 xm i� C c i V
F:mitildcd@co iettccsonwa.u� —
's/'' 1v10. 1-1 FEB 232015
PERMIT APPLICATIONI J
V
JEFFERSON COUNTY
Steps in the Permit Process: r'°T.OF COMMUNITY DEVELOPMENT
-Review application checklist to ensure all information is completed prior to submitting applica i. .
-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# p _ se)
Related Application#s: MLA#
Site Information
Assessor Tax Parcel Number: 701142002
Site Address and/or Directions to Property: 4429 Coyle rd.
Access(name of street(s)) from which access will be gained: Coyle Rd.
Present use of property: Commercial Forest Land
Description of Work(include proposed uses):
We are building 1 steel pole buildings 50'x84' (BUILDING "B") and we are building 3 soft sided
temporary greenhouses.
Wastewater-Sewage Disposal
This property is served by Port Townsend of Port Ludlow sewer system? YES _ NO
If not served by sewer identified above,identify type of septic system below:
Type of Sewage System Serving Property: N
✓_ Septic Septic Permit#:
[ 15-000Oo -
_ Community Septic Name of System: 09-FPrrt:4";u e — Case#:
Are other residences connected to the septic system? NO
Additions or repairs to sewage system: NO
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 an .. -::-: -. i . , ill
mail/ e-mail requests and information about the application to the authorized agent/res c1t ear l c�4,,r n r
noted below. The authorized agent/representative is responsible for communicating the mfbriiarion to ail parues i
the application. It is the responsibility of the authorized agent/representative and owner to ensure their mailbox accepts'dot}�i ,•
email (ii.e.,County email is not blocked or sent to`junk mail'].
Applicant/Property Owner Information '-I F c B 2 3' 2015 H
Property Owner: _} I
Name: Northern Canal Investments LLC I
Address: P.O. Box 130 Quilcene WA 98376
Phone#: 360-301-0257 E-mail Address: davewnolypen.com
i_ Please contact Authorized Agent/Representative with project info. (select only one).
—Property Owner Signature: ,41_,_ ,L/ --�-1 Date:Jai /2015
Note: For projects with multiple owners,attach a separate sheet with each owner(s)information and signatures.
Applicant: Authorized Agent/Representative(If other than owner)
Name: David Ward
Address: P.O. Box 130 Quilcene WA. 98376
Phone#: 360-301-0257 E-mail Address: davewia7,olypen.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:
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 assuming the responsibility of the General Contractor for the proposed project.
l `
Signature: �� � ljv� Print Name: rtlt„ e( 1NQr 2 Dater?3/2015
• •
44f<'
.,13 coo DEPnARTrMENT eetOF,Port COMMUNITY DEVELOPMENT
621 ShedanW
Tel:360.379.4450 j Fax:360.379.4451 r7 /
-< Web:www.co.jefferson.wa.us/communitydevelopment ^
E-mail:dcdCco.jefferson.wa.us
�SkrN0 ° SUPPLEMENTAL APPLICATION
RESIDENTIAL OR COMMERCIAL BLDG PERMIT
For Department Use Only Receipt#: Date:
Related Application#s: Payment#:
Site Information
Owner Name: Assessor`sTax Parcel#: 3O1 I Z-11_
Type of Building ! 41� 7
New � Replacement !Li Relocad ,
Addition Repair rj� ( p�,�olit( n
FEB 2 3 C!115
UYeparate permit is required
I i i—
SeectOne E
Jr_ir,uUIVTY
Single Family Residence Modular 'T OF CONiiMUMITY DfV tfFpthTkr list
Proposed Building/Project
Number of floors l #new bedrooms O existing total bed cO
#new bathrooms O existing total bath �'i
Heat Source
Select all that apply: U rt hc` {Kf
Electric Heating Oil Wood Propane
Enter the square footage(sq/ft)that applies in each field:
Structure Existing Sq/Ft Proposed Sq/Ft
Residential/Commercial Main Floor 142)
Residential/Commercial Second Floor
Additional Floors-heated/unheated
Basement- unfinished
Basement-finished space or habitable
Detached Garage- heated/unheated
Attached Garage- heated/unheated
Garage 2nd fl- unfinished storage
Garage 2nd fl-finished space or habitable
Carport- 2 walls or less
Deck- uncovered
Covered porch
Other(shed, barn, pole bldg,etc.)
Estimated Cost of Project (Required): $ 5'0 D cl 0
List existing buildings on property(i.e. house, garage, accessory dwelling unit, shed, barn, mobile home,other):
AII.Existing Buildings on Property Use
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 permit issuance. 41-V/<Signature: (N Print Name: •h Q.✓ad (,c)a✓a� Date:
Estimated Cost of Project $
For Department Use Only
Building Base Fees
Building Base [2 + •oO
Plan Check Review 3k ID "
Land Use Review $234.00
Septic Review $86.00
Potable Water $109.00
Technology/Scan $19.50
State Fee $4.50
Other Fees
Shoreline Exemption
Zoning
Zoning
Other
New Address
Road Approach
Total Fees
Receipt # Date: Cash/Check/CC:
•
G —
DEPARTMENT OF COMMUNITY DEVELO � -1
621 Shcnm,htitrcct. Volt 1'owmscncl, A 98368 - � P
1.4:11"360 i r9-1-1-50 l i i60 179 4431 %
Wel):www.co is ttcreou u u ./cnoinwnitc,Icvclopncm i ,
Iu1.�,l.dcJ�acnlcftursnu,e,.nc Iii FEB 2 3 2015 �'L1
AL
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STORMWATER CALCULATION WORKSHEET
ell �st!1;COUNTYe /+ R C-0PIidNITY DOROPMFNT
MLA# PROJECT/APPLICANT NAME: rl/a/ rf-{tev„ Ca.&ta.I In St-At€4.1.5
DETERMINING STORM WATER MANAGEMENT REQUIREMENTS:This stormwater calculation worksheet should be completed first to
classify the proposal as "small," "medium," or "large." The size determines whether a Stormwater Site Plan is required in
conjunction with a stand-alone stormwater management permit application, building permit application,or other land use approval
application that involves stormwater review. The basic information will also be helpful for completing a Stormwater Site Plan, if
required.
PARCEL SIZE(I.E.,SITE)
Size of parcel 100 acres An acre contains 43,560 square feet. Multiply the acreage by this figure.
Size of parcel in square feet 4,356,000 sq/ft
Land-disturbing activity is any activity that results in movement of earth, or a change in the existing soil cover(both vegetative and
non-vegetative)and/or the existing soil topography. Land disturbing activities include,but are not limited to clearing,grading,filling,
excavation, and compaction associated with stabilization of structures and road construction.
Native vegetation is vegetation comprised on plant species, other than noxious weeds,that are indigenous to the coastal region of
the Pacific Northwest and which reasonably could have been expected to naturally occur on the site. Examples include species such
as Douglas fir, western hemlock, western red cedar, alder, big-leaf maple, and vine maple; shrubs such as willow, elderberry,
salmonberry,and salal;herbaceous plants such as sword fern,foam flower,and fireweed.
LAND DISTURBING ACTIVITY,CONVERSION OF NATIVE VEGETATION,AND VOLUME OF CUT/FILL
Calculate the total area to be cleared, graded,filled, Answer the following two questions related to
excavated, and/or compacted for proposed development conversion of native vegetation:
project. Include in this calculation the area to be cleared for:
70 000 Does the project convert%acres or more of
Construction site for structures sq/ft native vegetation to lawn or landscaped areas?
Drainfield,septic tank,etc. 5,000 sq/ft Circle: Yes No
Well, utilities, etc. 1000 sq/ft Does the project convert 2%acres or more of
21,000 native vegetation to pasture?
Driveway, parking, roads,etc. sq/ft
Circle: Yes No
Lawn, landscaping,etc. sq/ft
Other compacted surface,etc. sq/ft Indicate Total Volumes of Proposed:
Total Land Disturbance 97'000 sq/ft Cut 250 Fill (cu/yd)
Impervious surface is a hard surface that either prevents or retards the entry of water into the soil mantle as under natural
conditions prior to development. A hard surface area which causes water to run off the surface in greater quantities or at an
increased rate of flow from the flow present under natural conditions prior to development. Common impervious surfaces include,
but are not limited to roof tops,walkways, patios,driveways, parking lots or storage areas, concrete or asphalt paving,gravel roads,
packed earthen materials,and oiled,macadam or other surfaces which similarly impede the natural infiltration of stormwater.
stormwater talc worksheet-REV.102012014 1
• •
STORM WATER CALULATIONS–IMPERVIOUS SURFACE
NEW EXISTING
Structures(all roof area) 24,480 sq/ft Structures(all roof area) 0 sq/ft
Sidewalks 0 sq/ft Sidewalks 0 sq/ft
Patios 0 sq/ft Patios 0 sq/ft
Solid Decks 0 sq/ft Solid Decks 0 sq/ft
(without infiltration below) (without infiltration below)
Driveway,parking, roads,etc 3,000 sq/ft Driveway,parking, roads,etc 18,000 sq/ft
Other sq/ft Other sq/ft
Total New 27,480 sq/ft Total Existing 18,000 sq/ft
TOTAL NEW+ TOTAL EXISTING* 45,480 sq/ft *This amount will be used to check total lot coverage.
The following questions will help determine whether the proposed project is considered development or redevelopment.
DEVELOPMENT v.REDEVELOPMENT
Divide the total existing impervious surface above by the size of the parcel and convert to a percentage: 0.4
Does the site have 35%or more of existing impervious surface? Circle: Yes No n
FURTHER INSTRUCTIONS: If the answer is yes,the proposal is considered redevelopment and the attached Figure 2 should be used
to determine the applicable Minimum Requirements. If the answer is no, the proposal is considered new development and the
attached Figure 1 should be used. At this juncture, the applicant should refer to the applicable Flow Chart to determine the
Minimum Requirements for stormwater management. DCD staff will help verify the classification of the project and the application
requirements.
For proponents of "small" projects who must comply only with Minimum Requirement #2—Construction Stormwater Pollution
Prevention—an additional submittal is not required. The proponent is responsible for employing the 12 Elements to control erosion
and prevent sediment and other pollutants from leaving the site during the construction phase of the project. Pick up the
Construction Stormwater Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet. Proponents of "medium"
projects—those that must meet only Minimum Requirements#1 through#5—and for"large" projects—those that must meet all 10
Minimum Requirements—are required to submit a Stormwater Site Plan. DCD has prepared a submittal template of a Stormwater
Site Plan, principally for rural residential projects. Complete the template in the Stormwater Site Plan Instructions and Submittal
Template or prepare a Stormwater Site Plan using the step-by-step guidance in the Stormwater Management Manual.
APPLICANT SIGNATURE
By signing the Stormwater Calculation Worksheet,I as the applicant/owner attest that the information provided herein is true and correct to the
best of my knowledge. I also certify that this application is being made with the full knowledge and consent of all owners of the affected
property.
( 1*"`--79 )7/2015
(LANDOWNER OR AUTHORIZED REPRESENTATIVE SIGNATURE) (DATE)
FOR OFFICE USE ONLY
SMALL MEDIUM LARGE_ REDEVELOPMENT Stormwater Site Plan: Yes No
stormwater talc worksheet-REV.10/20/2014
Parcel Details Page 1 of 2
•
ffi
jJeffersonCounty
Home County Info Departments Search
Parcel Number: 701142002 SEARCH
Parcel Number: 701142002 Printer Friendly
Owner Mailing Address:
PEN AIR LLC
PO BOX 130
QUILCENE WA98376-0130
Site Address:
4429 COYLE RD
QUILCENE 98376
Section: 14 School District: Quilcene (48)
Qtr Section: NW1/4 Fire Dist: None
Township: 27N Tax Status: Taxable
Range: 1W Tax Code: 0302
Planning area: South Toandos Peninsula,Coyle Area (9)
Sewer: Drainage:
Bank: View 1:
View 2: Zoning 1:
Zoning 2: Zoning 3:
Sub Division:
Assessor's Land Use Code: 8800 - Designated Forest Land
9100 - Vacant Land
Property Description:
514 T27 R1W SW NW,NW SW, N1/2 SW SW
Tax, A/V, Sales, Photos, and
Permit Data Bldg Data Map Parcel Plats &Survev
Septic Monitoring Info
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• •
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Parcel Details
Jefferson County .A.:47 11,4
saats
Home County info Departments Search
Parcel Number: 701142002 SEARCH
printer Friendly
Parcel Number: 701142002
Owner Mailing Address:
PEN AIR LLC
PO BOX 130
QUILCENE WA98376-0130
Site Address:
4429 COYLE RD
QUILCENE 98376
School Distict:Quilcene (48)
Section: 14 Fire Dist: None
Qtr Section: NW1/4
Township: 27N Tax Status: Taxable
Range: 1W Tax Code: 0302
planning area:South Toandos Peninsula,Coyle Area (9)
Sewer: Drainage:
Bank: View 1:
View 2: Zoning 1:
Zoning 2:
Zoning 3:
Sub Division:
Assessor's Land Use Code: 8000 - Designated
Land Forest Land
9
Property Description:
S14 T27 R1W SW NW,NW SW, N1/2 SW SW
Tax A V Sales Photos ac Ma Parcel ats &Surve s
it Perm It Oata Blc�g Data -----
ISeptic Monitorinf ------ - SEARCH
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410 •
Soar DEPARTMENT OF COMMUNITY DEVELOPMENT
,., �G 621 Sheridan Street,Port Townsend.\VA 98368 I� ' 2 p
c: j Tel:360.379. 50 Fos'360.379 4 31 I J)I _I C__ v
-G \\'eb:w‘vsv.co j_efferson.wa.us/communitydevelopment j J)
E-mail:dcd@co.icfferson.w'a.us I I I , i
FH23201
.� I�
�SifINoS° SUPPLEMENTAL APPLICATION
DETERMINATION OF ADEQUATE POTABLE WATER
//�j `opmENT
co
Owner Name: /'y �1 141 7 L (_,C Parcel No. 70i/ `/ 6'v
cro
C n
Site Address: f�a % �``e
_r
Water Source Existing Proposed Attach Copies of: It
N../c. 1) Well Logs
Private well
( (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
www.jeffersoncountypublichealth.org/pdf/Policy_97-01_Rai nwater_Collection.pdf
Valid Water Right Generally applies to springs, attach copy.
Permit
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.
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 application 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 permit issuance.
Signature: + .--''/�
Print Name: ,li ,J2 (. (A—leo ,---e-9Date: cq-2j/ 7',3--
FOR 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 _
s •
P•ke odginal and first
or rxao��° WAT E R WE t t REPORT Notice of latent No. W E 19897
seconaaer
CRay•QweGanv STATE OF WASHINGTON UNIQUE WELL LD.# BCK627
Thy-Drillers-Copy
Water bights Permit Ho_
(1)OWNER: Name: PEN AIR LCC Address:PO BOX 130,QUILCENE,WA 98376
(2)LOCATION OF WELL: County: JEFFERSON NW 1/4 of the SW 1/4. Sec. 14, Tramp 27 N, R- 1 W W.M.
(2a)STREET ADDRESS OF WELL(or nearest-address 4429 COYLE RD, QUILCENE, PARCEL#701142002
(3)PROPOSED USE: I'Domestic r Test well
r irrigation — Municipal (10)WELL LOG or
r
industrial Dewater Ott ABANDONMENT PROCEDURE DESCRIPTION
(4)TYPE OF WORK: Owner's number of we71(6 more than one): 1
Formation: Describe by color,character,size of material and
II—Decommissioned R New well Method: T pug r Bored
Deepened structure,and shave thickness of aquifers and the Kind and nature of
r Reconditioned � Cabler Driven the material in each stratum penetrated,with at least on entry for
, . licgly!.., rjetted each change of formation_
(5)DIMENSIONS: Diameter dwelt 6 inches
Kik-FERAL FROM TO
Drilled 284 feet Depth of completed well 282 feet
(6)CONSTRUCTION DETAILS: BROWN HARDPAN I 0' 28'
Casing installed: 6 in.diem.from 0 .ft.to 272 le- jI
W WeldedGRAY TILL 28' 35'
in.dor.from to ft
r Linerinshalied in.dfarn.from R.to R . BROWN TILL j 35' 44'
r Threaded in.diem.from ft to R BROWN HARDPAN
Perforations: Were perforations made?: r Yes i 55'
Perforator : GRAY SANDY CLAY j 55' 74'
Size cif perforAtm: fn. by. in.
f_ BROWN CLAY i 74' 85'
Perforations from:
R
Perforations from: ft.to R BROWN SAND&GRAVEL i 85' 97'
Screens: Screens installed BROWN SANDY CLAY W/GRAVEL j 9T 112'
Manufacturer's name: Johnson
Type: Telescoping BROWN SAND 112' 247'
Diem. 5 in,slot size .010 from 272 ft.to 277 ft.
Dian. in.slot sizeGRAY SILTY SAND l 247' j 253'
lXT8 from. 277 ft to 282 ft.
Gravel: r Yes Size of gravel: 44. BROWN SILTY SAND W/B i 253' 265'
Gravel Placed from: ft.to ft. BROWN SAND W/B
,
Surfacesead: X Yes To what depth?_ 18 ft 265 282
Material used in seal: Bentonite GRAY FINE SAND W/B i 287 ?
Did any strata contain unusable water% U Yes
Type of water: Depth of strata: ft
Method of sealing strata:
(7)PUMP: Manufacturers name:
Type: HP:
(8)WATER LEVELS Land-surface elevation
above mean sea-leve! 560 ft.
Static level: 228 ft below top of well Date: 2/12/2015 '
Artestian pressure.- PSI Date:
Artesian water is controlled by:
(9}WELL TESTS orswtlown s amount water iwtA is towered below$tatic
Was a pump test made? Yes,by. Work started: 1/31/2015 Work completed: 2/12/2015
Yield: GPM with ft drawdown-afterhrs WELL CONSTRUCTOR CERTIFICATION:
Yield: GPM with ft.drawdown after hrs , I constructed and/or accept responsibility for construction of this
Recovery data(time taken as zero when pump turned off)(water level well,and to the compliance with all Washington well construction
measured from well top to water level) standards. Materials used and the information
Waterreported above are
Water Water true to my best knowledge and belief_
Time level Time level Time level
Contractor. LOFALL WELL DRILLING, INC.
Date of test Address_ 180 NW Lofall Rd, Poulsbo, WA 98370
Bailer test 22 GPM with 14 ft drawdown after 3 hrs.
Air test GPM with stem set at ft.for hrs. Signed: i! 4::nse# 1029
Artesian trove GPM Date: i Driller)
Temp.of water Contractors
3- Was a chemicatanatysis rnade1 t Yes RegistraliOn t407 LOFALWD92213H Dale: 2/17/2015
• 26276 Twelve Trees Lange C
i1111 � 71_S S Poulsbo,WA 98370
• LABORATORIES (360)779-5141
1 a SPECTRA• . rumpaoy
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
Zr « ! t 7�Collected
o�d
Month nay Year
Type of Wafer System(check only one box)
❑Group A ❑Group B Other /'a
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID#
System Name: Da viej Ward. +
Contact Person: L.o4(( kA_J1 Dr if r TKC'_.
Day Phone(.760 ?7_//iL( Cell Phone:( �)
Eve.Phone:( ) FA)(:( )
Email Address: /o lh,..)a r ®coinca614:lie
Send results (Print full nay,address and zip code)
age
Igo//t,J La ,= 1/
Poulsbo W ? 370
SAMPLE INFORMATION
Sample collected by(name):
�
00f Zc7 2c. (r
location where sample collected:
Specific p Special instructions or comments:
(� !{ 7a�44'8C,/< Z7
Type of Sample(must check only one box of#1 through#4 listed below)
-• -1.❑Routine Distribution Sample 2.Repeat,Sample rafter unsatisfactory routine)
Chlorinated:Yes No ❑Distritution System
)
Chlorine Residual:Total Free ❑Source Groundwater Rule(GWR)
3.Raw Water Source Sample (Population of 1,000 or less)
❑E.coli-GWR source sample
Unsatisfactory routine lab number.
❑Fecal-Surface,GW I,some springs - - - -
❑Other Unsatisfactory routine collect date:
IS t I
1 sa,«n fom Chlorinated:Yes—No
Chlorine Residual:Total Free
44Sample Collected for Information Only
Investigative Construction/Repairs X Private Residence Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
Analyst Remarks: /
0 Unsatisfactory Totab6.orrform Present and -x - Satisfactory
❑E coli present ❑Erroll absent
❑Fecal colifonnpresent 0 Fecal coliform absent
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC ❑ 1
❑Improper Container 0 Turbid culture
' Bacterial Density Results:Plate Count• /ml. E. /100m1.
- 1
Total Coliform /100m1. Fecal Coliform /100m1.
Method Code: Dateandlime Received: nn
MICR- 273Q
Date Analyzed: Z JJr 1; A'S- Date Reported:
Sarrgle Number(DON ms4ber Wuxitne d'gits) Lab Use Only:
°__ 1 0 b1101 ?holt- 0J
rlhHFm)frAO1 10/ru,nrMA11fm
•
TWISS LABORATORIES
26276 Twelve Trees Lane,IOC Poulsbo,WA 98370 Telephone(360)779-5141 (360)779-5150
IOC -SHORT
IOC-SHORT by Various EPA Approved Methods
Source/Point of Entry-Report of Analysis
Date Collected: 2/12/2015 Group: Private
System ID No: Private . System Name: David Ward
Lab-Sample#: 01001102 County: Jefferson
Sample Location: Well Tag#BCK627 DOH Source No:
Sample Purpose: I Date Received: 2/13/2015
Sample Composition: S Date Analyzed: 2/13/2015
Send Report To: Lofall Well Drilling Date Reported: 2/17/2015
180 NW Lofall Rd
Poulsbo,WA 98370 Sample Type: Pre-treatment/Raw
Collected By: Lofall Well Drilling
Phone Number: 360-697-1194
Bill To: Lofall Well Drilling
180 NW Lofall Rd
Poulsbo,WA 98370
DOH# Analyte Results Units SRL Trigger MCL* MCL Method r1
Exceeded (Analyst Init.) 1
20 1 Nitrate-N 2.36 m• 0.5 5 10 EPA 300.0(KW) i
21 Chloride 4.17 i me, 20 250 EPA 300.0(KW)
SRL: (Stare 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: (Maxum Contaminant Level),If the contaminant amount exnYrls the MCL,immediate) contactyour
NA: (Not Analyzed),in the results column indicates this compoundr «Ronal DOH office.
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 in the sample at or above the concentration indicated
• The 0.010 mg/L MCL for Arsenic is for Group A NTNC systems. All other systems should check with their county Health District to determine what level is applicable.
147011
'PR.0
BLD15-00050
BUILDING PERMIT APPLIC ION Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368 jeiL, p ti
PERMIT #: BLD15-00050 Received Date: 2/23/2015
SITE ADDRESS: 4429 COYLE RD
OWNER: PEN AIR LLC NORTHERN CANAL INVESTMENTS LLC PHONE: 360-301-0257
PO BOX 130
QUILCENE WA 98376-0130
SUBDIVISION: Block:
PARCEL NUMBER: 701142002 Section: 14 Township: 27 N F
CONTRACTOR: OWNER/BUILDER PHOI
REPRESENTATIVE: DAVID WARD PHONE
P.O. BOX 130
QUILCENE WA 98376
PROJECT DESCRIPTIO NEW COMMERICAL STEEL POLE BUILDING 50X84
BUILDING B (1-502)
SEP15-00002
TYPE OF WORK COM SQUARE FOOTAGE: COMMERCIAL:
TYPE OF IMP NEW MAIN: 4,200 INDUSTRIAL:
VALUATION 40,000.00 ADD'L: HEAT TYPE: EEE
CODE EDITION: 2012 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: ALT NUMBER OF EMPLOYEES:
WATER SYSTEM: 1PWELL
BATHROOMS:
Exist: 0
Prop: 0
Total: 0
Routing Date:
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $487.00 SRE 02/23/15 154126
Plan Check $316.55 SRE 02/23/15 154126
State Building Code $4.50 SRE 02/23/15 154126
Potable Water Application $0.00 SRE 02/24/15
Total: $808.05
\\tidemark\data\forms\F_BLD_App_Bld.rpt 2/24/2015
• •
Northern Canal Investments LLC
P.O. Box 130
Quilcene WA. 98376
Joel Peterson
Jefferson County Assoc. Planner
The sides and roofs of our temporary greenhouses will be covered with Polyethylene,
Polyvinyl or a similar flexible synthetic material.
Sincerely, ,
e.
David Ward
Northern Canal Investments LLC
• •
�5ON DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Sneer.Prat Tuuvnscnd \\.\98368
Id:360 379.4450 Far 360.3-9-4-151 r'-
�'cb �r�ew.c 'icttct <m-a u;icommuni pdevc,ut m�nr FL
Wv) I m.til.dcIia cuacttc.r.un wt.u,
116'11 N G'CO� _�
I FE8 2 3 2015 ;I i
PERMIT APPLICATION ' Li,' I UJ
Steps in the Permit Process: ` in
n.C0';r.11,JP,IT'DE TI.00,E T
-Review application checklist to ensure all information is completed prior to submitting appl catisri-
-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# Pj_DIS
Related Application#s: MLA#
Site Information
Assessor Tax Parcel Number: 701142002 _
Site Address and/or Directions to Property: 4429 Coyle rd.
Access(name of street(s)) from which access will be gained: Coyle Rd.
Present use of property: Commercial Forest Land
Description of Work(include proposed uses):
We are building 1 steel pole buildings 50'x84' (BUILDING "B") and we are building 3 soft sided
temporary greenhouses.
Wastewater-Sewage Disposal
This property is served by Port Townsend of Port Ludlow sewer system? YES _ NO
If not served by sewer identified above, identify type of septic system below:
Type of Sewage System Serving Property:
Septic Septic Permit#: .. IS—0OOOo1
Community Septic Name of System: aQ-(-pyrv;4;u e - Case#:
Are other residences connected to the septic system? NO
Additions or repairs to sewage system: NO
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:
• S
The authorized agent/representative is the primary contact for all project-related questions andcorresperidence-3lW.,:c�xn 'ill
mail /e-mail requests and information about the application to the authorized agent/re reseptauve,and kill dp c kt-thy own
noted below. The authorized agent/representative is responsible for communicating the information to all partteainvolued di 7
the application. It is the responsibility of the authorized agent/representative and owner to ensure their mailbox accepts County
email(i.e. ,County email is not blocked or sent to"junk mail").
Applicant/Property Owner Information i i R 2 v 201
Property Owner:
Name: Northern Canal Investments LLC - .- .-.
Address: P.O. Box 130 Quilcene WA 98376Y
Phone#: 360-301-0257 E-mail Address: davew@olypen.com
✓— Please contact Authorized Agent/Representative with project info. (select only one).
—
Property Owner Signature: „%.- .t' Date:'o1i 3 /2015
Note: For projects with multiple owners,attach a separate sheet with each owner(s)information and signatures.
Applicant: Authorized Agent/Representative(it other than owner)
Name: David Ward
Address: P.O. Box 130 Quilcene WA. 98376
Phone#: 360-301-0257 E-mail Address: davew@olypen.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:
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 assuming the responsibility of the General Contractor for the proposed project.
Dater?J/2015
Signature: GZ4.7Print Name:
• .
SONEPARTMENT OF COMMUNITY DEVELOPMENT
4.
�tV OG 021 Sheridan Street,Pan
Townsend,\VA 98368
1-:_,,...< Tel:360.3'9.F4i0 Fax: 3603?9A l31 — IV /
1Dly
eU:�tsiw.co.iefferson.wa.uslcommunindevelopment
-mail:dcd(d.co.jefferson.wa.us
9S11tNO-CoSUPPLEMENTAL APPLICATIONESIDENTIAL OR COMMERCIAL BLDG PERMIT
For Department Use nReceipt#: Date:
Related Application#s: Payment#:
Site Information
Owner Name: i L
Assessor Tax PParrc/ell#: �O4L
1 - 1 --ciOL
Type.of Building y I �1 ill'(:71; - I: `J [ n
New Replacement Relocal&d
Addition Repair t7 r 9 o Demolition
tA eparate permit is required
Select One:
Single Family Residence Modular Other__ list
Proposed Building/Project
Number of floors j # new bedrooms (•J existing total bed C_
#new bathrooms (, existing total bath C)
Heat Source
Select all that apply: Ctrl hea t-e-i
Electric 4,, Heating Oil Wood Propane
Enter the square footage(sq/ft)that applies in each field:
Structure Existing Sq/Ft Proposed Sq/Ft
Residential/Commercial Main Floor 14 `
Residential/Commercial Second Floor
Additional Floors-heated/unheated
Basement-unfinished
Basement-finished space or habitable
Detached Garage- heated/unheated
Attached Garage- heated/unheated
Garage 2nd fl- unfinished storage
Garage 2nd fl -finished space or habitable
Carport-2 walls or less
Deck-uncovered
Covered porch
Other(shed, barn, pole bldg,etc.)
Estimated Cost of Project (Required): $ " '63�0 0 0
•
List existing buildings on property (i.e. house, garage, accessory dwelling unit, shed, barn, mobile home, other):
All.Existing Buildings on Property Use
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 permit issuance.
Signature: /4--,_„la l� Print Name: =,IJcLd LA)6t.✓ck Date: 44/45_,
Estimated Cost of Project $
For Department Use Only, rY
Building Base Fees
Building Base LI?) .vO
Plan Check Review 5 (.0 • 5 S
Land Use Review $234.00
Septic Review $86.00
Potable Water $109.00
Technology/Scan $19.50
State Fee $4.50
Other Fees
Shoreline Exemption
Zoning
Zoning
Other
New Address
Road Approach
Total Fees
Receipt# Date: Cash/Check/CC:
• •
ON c'o DEPARTMENT OF COMMUNITY DEVELOPMENT r it \ 7 { n.�
1. 621 Sheridan Street.Ih,rt Townsend,\' .\0836t5
L:7 '1C '1 d 360.3'9. 430 ! l'ax.360.3'9.4451 I,
\.\eh:www.cn.icfticrson.aa.us/0 nununiude;clupmcnr
� �
I'.-mail klal:aa�.icCfcr>on.��a.us
9pfflNG�O •
_� J
STORMWATER CALCULATION WORKSHEET r,p tftrr Ir^,T
MLA# PROJECT/APPLICANT NAME: /Y;,rtR a V?\ Ca,rtG,I Tin✓.e SI i%�2 s
DETERMINING STORM WATER MANAGEMENT REQUIREMENTS:This stormwater calculation worksheet should be completed first to
classify the proposal as "small," "medium," or "large." The size determines whether a Stormwater Site Plan is required in
conjunction with a stand-alone stormwater management permit application,building permit application,or other land use approval
application that involves stormwater review. The basic information will also be helpful for completing a Stormwater Site Plan, if
required.
PARCEL SIZE(I.E.,SITE1
Size of parcel 100 acres An acre contains 43,560 square feet. Multiply the acreage by this figure.
Size of parcel in square feet 4,356,000 sq/ft
Land-disturbing activity is any activity that results in movement of earth,or a change in the existing soil cover(both vegetative and
non-vegetative)and/or the existing soil topography. Land disturbing activities include,but are not limited to clearing,grading,filling,
excavation,and compaction associated with stabilization of structures and road construction.
Native vegetation is vegetation comprised on plant species,other than noxious weeds,that are indigenous to the coastal region of
the Pacific Northwest and which reasonably could have been expected to naturally occur on the site. Examples include species such
as Douglas fir, western hemlock, western red cedar, alder, big-leaf maple, and vine maple; shrubs such as willow, elderberry,
salmonberry,and salal;herbaceous plants such as sword fern,foam flower,and fireweed.
LAND DISTURBING ACTIVITY,CONVERSION OF NATIVE VEGETATION,AND VOLUME OF CUT/FILL
Calculate the total area to be cleared,graded,filled, Answer the following two questions related to
excavated, and/or compacted for proposed development conversion of native vegetation:
project. Include in this calculation the area to be cleared for:
70 000 Does the project convert%acres or more of
Construction site for structures ' sq/ft native vegetation to lawn or landscaped areas?
Drainfield,septic tank,etc. 5,000 sq/ft Circle: Yes No
Well, utilities,etc. 1000 sq/ft Does the project convert 2 Y:acres or more of
21 ,000 native vegetation to pasture?
Driveway, parking, roads, etc. sq/ft
Circle: Yes No
Lawn, landscaping,etc. sq/ft
Other compacted surface,etc. sq/ft Indicate Total Volumes of Proposed:
Total Land Disturbance 97'000 sq/ft Cut 250 Fill (cu/yd)
Impervious surface is a hard surface that either prevents or retards the entry of water into the soil mantle as under natural
conditions prior to development. A hard surface area which causes water to run off the surface in greater quantities or at an
increased rate of flow from the flow present under natural conditions prior to development. Common impervious surfaces include,
but are not limited to roof tops,walkways, patios,driveways, parking lots or storage areas, concrete or asphalt paving,gravel roads,
packed earthen materials,and oiled, macadam or other surfaces which similarly impede the natural infiltration of stormwater.
stormwater catc worksheet-REV.100012014 1
• i
STORMWATER CALULATIONS–IMPERVIOUS SURFACE
NEW EXISTING
Structures(all roof area) 24,480 sq/ft Structures(all roof area) sq/ft
Sidewalks 0 sq/ft Sidewalks 0 sq/ft
Patios 0 sq/ft Patios 0 sq/ft
Solid Decks 0 sq/ft Solid Decks 0 sq/ft
(without infiltration below) (without infiltration below)
Driveway,parking, roads,etc 3,000 sq/ft Driveway,parking, roads, etc 18,000 sq/ft
Other sq/ft Other sq/ft
Total New 27,480 sq/ft Total Existing 18,000 sq/ft
TOTAL NEW+TOTAL EXISTING* 45,480 sq/ft *This amount will be used to check total lot coverage.
The following questions will help determine whether the proposed project is considered development or redevelopment.
DEVELOPMENT v. REDEVELOPMENT
Divide the total existing impervious surface above by the size of the parcel and convert to a percentage: 0.4
Does the site have 35%or more of existing impervious surface? Circle: Yes No ✓
FURTHER INSTRUCTIONS: If the answer is yes,the proposal is considered redevelopment and the attached Figure 2 should be used
to determine the applicable Minimum Requirements. If the answer is no, the proposal is considered new development and the
attached Figure 1 should be used. At this juncture, the applicant should refer to the applicable Flow Chart to determine the
Minimum Requirements for stormwater management. DCD staff will help verify the classification of the project and the application
requirements.
For proponents of "small" projects who must comply only with Minimum Requirement #2—Construction Stormwater Pollution
Prevention—an additional submittal is not required. The proponent is responsible for employing the 12 Elements to control erosion
and prevent sediment and other pollutants from leaving the site during the construction phase of the project. Pick up the
Construction Stormwater Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet. Proponents of "medium"
projects—those that must meet only Minimum Requirements#1 through#5—and for"large"projects—those that must meet all 10
Minimum Requirements—are required to submit a Stormwater Site Plan. DCD has prepared a submittal template of a Stormwater
Site Plan, principally for rural residential projects. Complete the template in the Stormwater Site Plan Instructions and Submittal
Template or prepare a Stormwater Site Plan using the step-by-step guidance in the Stormwater Management Manual.
APPLICANT SIGNATURE
By signing the Stormwater Calculation Worksheet,I as the applicant/owner attest that the information provided herein is true and correct to the
best of my knowledge. I also certify that this application is being made with the full knowledge and consent of all owners of the affected
property.
1/ /2015
(LANDOWNER OR AUTHORIZED REPRESENTATIVE SIGNATURE) (DATE)
FOR OFFICE USE ONLY
SMALL_ MEDIUM LARGE_ REDEVELOPMENT Stormwater Site Plan: Yes No
stormwater talc worksheet—REV.10/20/2014 2