HomeMy WebLinkAboutBLD1999-00578 efferson County Permit Center • Date
621 Sheridan Street Fee
Port Townsend WA 98368 Rec #
CRITICAL AREAS QUESTIONNAIRE Ck #
Case #
Applicant Name &04-iex eicii-AmAte„-
Building Application Land Use Application Shoreline Application
On-site Sewage Application _ Subdivision Application _ Other:
1 . Is there any standing or running water on the surface of the YES / >NO
property or on any nearby property at any time during the year?
If YES, please describe:
2. Has any portion of the property or any nearby property ever been YES X NO
identified as a wetland or swamp?
If YES, please describe:
3. Are any willows, skunk cabbage, alders, or cottonwoods present YES x NO
on your property or adjacent properties?
If YES, please describe:
4. Are there any indications on any portion of the property or on any YES X NO
nearby property of rockslides, earthflows, mudflows, or landslides?
If YES, please describe:
5. Please indicate which line best represents the steepest slope found
on your property. (Check appropriate box)
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6. Does the site have steep slopes with little to no vegetation? YES X_NO
If YES, please describe:
7. Does the site contain high percentages of silt and/or very fine YES >(NO
sand?
If YES, please describe:
8. Does the site contain ground water seepage or springs near the YES XNO
surface of the ground?
If YES, please describe:
The applicant hereby certifies that all of the above statements and the information contained in any other
transmittals made herewith are true, and the applicant acknowledges that any action taken by Jefferson
County based in whole or in part on this application may be reversed if it develops that any such statement
or other information contained herein is false.
Signature t9r d4,646,1-eDate " / (,
FOR OFFICE USE ONLY
O Wetlands 0 Seismic
CRITICAL AREAS ON OR 0 Aquifer Recharge Area (zone ) ❑ Fish & Wildlife Area 1
IMMEDIATELYADJACENTTO SITE: ❑ Frequently Flooded Area 0 Fish & Wildlife Area 2
O Erosion
❑ Landslide
Zone:
Parcel Size: Status:
Comprehensive Plan Land Use Designation: Reviewed by:
Community Plan: Date:
���N �o Jefferson County Permit Center * Department of Community Development
NN 4, , , , 621 Sheridan Street.Port Townsend WA 08368(360]379 4450
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Till eu tie jal10w4,9 &tm¢d ad eo a eetel4y as sa e:
Project Description: ,
9 Digit Parcel Identification Number (from your tax statement): 5 `7 06 ,5-01
Site Address
911#: Road Name:. i g ,' Zi Code: p3 :J
Legal Description
Subdivision Name: 6p`m�4�,ie&-E*f` I Block: sj Lot(s):
Section: 1 Township: R<nge:
Parcel Size (acres or square footage): O , - o _5 ,, e htr sum it000,
7, ,..,
Property Owner: Phone:
Mailing Address: /'
/7 � _3
r5 � m j vs , at, 9,,,ikO6 kr 3vr- 32?
Applicant/Occupant: Phone:
(if different from owner) ifi tfit'
Mailing Address:
Authorized Rep: Phone:
Mailing Address:
General Contractor: . y
Or Manufactured Home Installer: Ae7riviti z i L bed� Phone: 3 ,�= / 9
Mailing Address: - /
t:?t it_
1i � rIwwi s 4t't fre/,r
Contractor's State License Number: 3 i Expiration Date:
Septic Designer: Phone:
Mailing Address:
Architect:/Engineer: Phone:
Mailing Address:
Loan Lender/General 4mmm 4,7°, 0,iri ifver 5v,,gib Phone:
Contractor's Bond Holder: 346—sag- 99//
Mailing Address:
FOR Oi~I--ICE USE ONLY
Fire District: Planning Area: >-* School District u Zone: 1
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