HomeMy WebLinkAbout01- Land Use ApplicationDEPARTMENT OF COMMUNITY DEVELOPMEN'
021 .` htrldan `street, Fort'1 ownscnd, VA 98368
Tel:.360.i_'9.4r150 I ,ix: 360.37f .4451
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PERMIT APPLfCATION
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 350-379-4450.
-This is not a standalone application; it must be accompanied by a project specific supplemental app`lczj-don.
-Fees will be collected at intake. Additional fees may apply after review and payment is required befor-L ;permit is issuec'.
For Department Use Only
Related Appkation #s:
_._.__ _ -
, Site: lafo -mation
Assessor Tax Parcel Number:
Site Address and/or Directions to Property: y(tV.�rs�•
Access (name of street(s)) from which access will be gained:,,
Present use of property:
Description of Work (include proposed uses): ( -r__ ' �E
W8stewAt r _ swage D!sposat' t
This property is served by Port Townsend or Port Ludlow sewer system? NO
IV -
If not served by sewer identified above, identify type of septic system below
Type of Sewage System Serving Property:
K Septic Septic Permit #: c'
Community Septic Name of System: Case #:
Are other residences connected to the septic system? ef-Iv
Additions or repairs to sewage system: 1.tJ67 _
Is it a complete or partial system installation: Complete Partial
Has a reserve drainfield been designated? Yes )C No
Date of Last Operations & Maintenance check: _ 4-,c��
i "-G 2c: Attach last report to applica',
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 Count;r i
/ e-mail requests and information about the application to the authorized agent/representative and will copy (cc) the owner r:ct_s
below. The authorized agent/representative is responsible for communicating the information to all parties involved with the
application. It is the responsibility of the authorized agent/representative and owner to ensure their mailbox accepts County email
County email is not blocked or sent to "junk mail").
Information
Property Owner: j
Name: ��c i� b 5
Address: S ----
Phone #: 360 --& >C -2c?33 EFinail Address:
Please contt Auth zed Agent/Representative with project info. (select only one).
Property Owner Signature: / (/ ri Date: J5 J �-
Note: For projects with multiple owners, attach a separate sheet with each owner(s) information and sienatures.
Name:
Address:
Phone #:
Engineer
Name:
Address:
Phone #:
Engineer
Name:
Address:
Phone #:
Engineer
Name:
Address:
Phone #:
Architect Sar;, eyro
Architect
Surveyor
Architects veVor
fear' c
E-mail Address:
ent !ivE. :�ojeet?
Lunt,, -actor
License #
E-mail Address:
Contractor
License #
E-mail Address:
By signing this application form, the owner/agent attests that the information provided herein, and in any attachments, is true an,
correct to the best of his or her knowledge. Any material falsehood or any omission of a material fact made by the owner/agent witi-i
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 perfoi med in co« iia is t;
all applicable federal, state and county laws and regulations and I agree to provide access and right of entry to jefferson { oun"y
employees, representatives or agents for the sole purpose of application review and any required later inspections. Appli!:zl,
request notice oft ounty's intent to enter upon the property for visits related to this application and subsequent permit issuan -z:.
Signature:J C;ntE 0 Print Name: t
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