13107483 BS 10900 Bald Hills Rd SE . . � r . .� k ;.:a, ; i.4^z���4�'9Ck.�fHK<�is'�v 5rb`iF� 3r .'�YAf'�iti�,��4;'�}?'� i°,-P�,
�'����� Thurston County Permit Assistance Center
2000 Lakeridge Dr. SW,Olympia,WA 98502
�.; °`�'"� °�' �,��� Q � 2(�j� (360)786-5490 / (360)754-2939(Fax)
" � ���i -�: � TDD Line(360)754-2933
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-- -�-�,�';s;;�� .�.� �� Email:permit(a�co.thurston.wa.us
— -�._.. _____.---
,, www.cathurston.wa.us/permitting
THL R�T(3N �C7UI'�1T'� 'a=-----____
"��,�s: Creati►zg Solutions for Our Future
MASTER APPLICATION
STAFF USE O1VI.Y DATE STAMP
13 107483 BS T�{��STON COUNTY
Permit Type: Site Application ���F����
Sub Tyoe: Residential Lot:B �,AY �� �n��
site: 10900 BALD HILL RD SE YELM WA 98597 °� ��
Assessor Property ID: 22729310700 �
Applicant: BALD HILL ROAD LLC ����`��� ��S`��~�4�� ������
Owner: BALD HILL ROAD LLC
�...�' I � �� ��� t �
�
Intake by:
The Master AFplication is required for all projects and shall accompany a project-specific supplemental
application(s). The Master Application may not be submitted alone. Check the appropriate box for each
supplemental application being submitted with this Master Application.
T e of Pro�eCt(check all that apply):
BUILDING PLANNING
❑Residential(�orm SAOOZ) ❑Administrative Variance(form SA021)
❑Non-Residential(form SAO02) ❑Binding Site Plan(�orm SA022)
❑Non-Residential Hood&Duct({orm SA003) ❑Boundary Line Adjustment/I,ot Consolidation(jorm SA023)
❑Non-Residential Sign (form SAO04) ❑Critical Area Review(�orm SA024)
❑Manufactured Home Placement(form SAOOS) ❑Design Review(�orm SAO25)
n Minor Permit Iform SA006) �Division of Land(�orm SA026)
(Mechanical/Plumbing/Fire/Re-roof/Re-siding/Demo) ❑Division of Land Final Map(�orm SA026a)
❑Adult Family Home Inspection (}'orm SA0o7) ❑Environmental Checklist(SEPA)(�orrn SAO27)
❑Fire Code Permit(form SA008-SA012) ❑Forest Practice Activities((orm SA028)
❑Innocent Purchaser(�orm SA029)
ROADS ❑Joint Aquatic Resources Permit Application (JARPA)
❑Encroachment Permit(�orm SAO13) (form SA030)
�Construction Permit(form SA014) ❑Legal L.ot Determination (form SA031)
❑Variance(�orm SA015) ❑Other Administrative Actions(�orm SA032)
❑Scoping Review Request(�orm SAO15a) ❑Presubmission Conference(�orm SA033)
❑ACCeSS POtlllit(form SA0156) ❑Reasonable Use Exception (jorm SA034)
❑Release of Moratorium(�orm SAO35)
ENVIRONMENTAL HEALTH ❑Rezone,Comp Plan Amendment,Open Space(�orm SA036)
�On-Site Sewage System(�orm SA016) ❑Shoreline Administrative Variance(�orm SA03�)
❑On-Site Sewage System Abandonment(�orm SAO1�) ❑Site Plan Review(�orm SA038) j��i CE�v
�On-Site Sewage Evaluation (form SA018) ❑Special Use Permit (form SA039)
❑Water System Design(Group B or 2 Party)(�orra �Variance—Hearing Examiner(�orra SAO o) ��N 21 2013
SA019) SCAN N E D
❑Well Slte(form SA020)
R�v�s�d 3-„ JUN 2 4 2013 Form Na MA001
Thurston County Permit Assistance Center
Master Application
Page 2 of 3
Property Tax Parcel Number(s): 22729310700
Zoning: RRl/5 Acreage: 10.5
Subdivision Name(if applicable): BLA04104565TC Lot#: B
Property Address: 10900 BALD HILL RD SE City: YELM State: WA Zip Code: 98597
Directions to the Property:
GOING SOUTH ON HWY 507 THROUGH YELM TO RIGHT AT TRAFFIC LIGHT ONTO BALD HILL RD SE TO SITE ON
LEFT.
Property Access Issues(locked gate,code required,dogs or other animals): �No Q Yes
If yes,Describe: LOCKED GATE-LOCK BOX ON LEFT SIDE OF GATE,CODE:3-6-0
OWiV�L+It iS�ESt��i�1SI$I.�FJ�vE�:.J.R.IN���I�4T S B�+FOAE SITE VISIT.
Type or Print: Additional property owner sheet can be obtained onli�ze at www.co.thurston.wa.us/nermittinQ or copy obtained
from the Permit Assistant Center.
Property Owner(s): BALD HILL ROAD LLC CHAD HALTERMAN
Mailing Address: 15705 92ND CRT SE
City: YELM State: WA Zip Code: 98597
Phone#: (253)380-2954 Ext. Fax#:
Cell#: E-mail:
Signature:* Date:
Applicant(if different than owner):
Mailing Address:
City: State: Zip Code:
� Phone#: Ext. Fax#:
Cell#: E-mail:
Signature:* Date:
Point of Contact: JIM HENRY DESIGN SERVICES INC
Mailing Address: PO BOX 14531
City: TUMWATER State: WA Zip Code: 98511
Phone#: 956-7242 Ext. Fax#: 956-7242
Cell#: 507-1267 E-mail: HENRYJIM@COMCAST.NET
Signature:* �._., Date: � —z�/
Revised 7-I1 Form No. MA001
,�`� Thurston County Environmental Health
_.v--"�': � 2000 Lakeridge Dr. SW Olympia,WA 98502
� � �'` (360)867-2673/(360)867-2660(Fax)
���� TDD Line(360)754-2933
TI-I[. E2^�Iti'�'� C�,�;��-,� � �,�_��_1���.,
r:ra�rr��ar�r,�
Supplemental Application
ONSITE SEWAGE SYSTEM
STAFF U5E ONLY DATE STAMP
13 107484 HD _
Permit Type: On 5ite Sewage Systems
r�°����'�T(.�N CQt'JN�`Y
Sub Type: On Site Sewage System Lot:B ��'�''�i���
site: 1 Q900 BALD HILL RD SE YELM WA 98597 MAY 2 9 2Q13
Assessor PropertylD: 22729310700
Applicant: BALD HILL ROAD LLC ����'�E�QS����'�,(�(�� ��{;. ;_
Owner: BALD HILL ROAD LLC 4 ` r���
%�.1°a.�
�� f � � C�� G C C c��
Intake b : `��
This application cannot be submitted alone.In addition to this form,a complete package includes:
`�p U Ce°t SUBMTTTAL CHECKI,IST StOnl se
QX Master Application. ❑
� For new septic systems requiring a design: �
a. Site plan(5 copies—11"X 1 T'maximum size), 1"=20'or 1"=30' scale.(See attached checklist)
b. On-site sew e se tic s stem desi 3 co ies
� For replacement of existing septic systems requiri.ng a design:On-site sewage(septic)system design �
3 co ies .
� For submittals not requiring a design: (�amples: sand filter and/or mound rebuild using e�sting �
design,septic tank or pump chamber replacement,septic tank placement):Site plan(3 copies—11"X
17"maximum size .
� For onsite sewage system projects within a city jurisdiction,the application must be taken to the city �
� for review and comment prior to submitting an application with Thurston County. If unable to obtain
comments rrom the city,Environmental Heatth wili route the appucaiion to the cify. The project will
be laced on hold until comments from the ci have been received.
� Applicable processing fees.Refer to current fee schedules. Depending on the adopted fee �
structure, additional ees m occur i base hours/ees at intake are exhausted.
SEPTIC DESIGNER:
Name: JIM HENRY Company Name: JIM HENRY DESIGN SERVICES INC
Mailing Address: PO BOX 14531 Ciiy: 'I'LTMWATER State: WA Zip: 98511
Phone#: 956-7242 Ext. Cell Phone# 507-1267 Fa�c#: 956-7242
E-mail Address: HENRYJIM@COMCAST.NET
Revised 5-9-11 Form No. SA016
Thurston County Environmental Health
Supplemental Application for Onsite Sewage System
Page 2 of 3
JURISDICTION: �����' �
0 Thurston County ❑City of Select City from List
CTTY JURISDICTION REVIEW AND COMIVVI�NT: ❑Approved ❑Disapproved
I - , ,: � , � ,
Comments: ' }-�.. � �=. , , �; , ��,C� tt;� _� ' " �-�.' C( �-�1
, '
Signature: � <,', ,,� / 7,��-�. -- .Title, j�`:"•a'! �1�+�' � 1'�.�����t .a" Date: � ,�; / �
TYPE OF PROJECT:
0 Onsite Sewage System with Residential Site Plan Review
(Project includes a new structure or addition/remodel to e�sting structure)
�Qnsite Se���.ge System only(HD) (no cl�ange to structure that septic will serve)
0 Residenrial Single Family ❑ Residential-Multifamily #Units �on-Residenrial
TYPE OF PERMIT:
�On Site Sewage System ❑Tank Only ❑Sand Filter and/or Mound Rebuild or Replace
❑Community Drainfield
WORK TYPE:
Ox New ❑Repair of a Failure ❑Modification Upgrade Number of Bedrooms: 6
WATER SUPPLY: ❑Existing �Proposed
❑X Single Family well ❑Two Party well ❑Group A ❑Group B
System
Name of Community system ID#
ACCESS:
�Existing Access ❑Proposed Access ❑x Private Driveway ❑Shared Driveway
❑Private Road (list name of road,if applicable)
x�Public Road BALD HILL RD (list name of road,if applicablel
PROPERTY INFO:
Water on or within 300' of property: ❑None ❑Salt �River/Creek/Flood Zone ❑Lake/Pond ❑Wetland�Ditch
Name of body of water: FLOOD ZONE ACROSS ROAD WITHIN 200 FT OF SW PROP CORNER
Has the property ever flooded? ❑No ODo not know ❑Yes,when?
Ilf i'�.'�. �lir„e ierCtt v,i silc'G%[tlt,
Slopes greater than 20%? ❑No ❑Yes
APPEAL: A�person aggrieved by a decision,an inspection,or notice made by the Health Officer shall have the right to appeal
the matter as specified in Article 1 of the Thurston County Sanitary Code.
EXPIRATTON:
Sewage System applications e�ire one year from date of application per Thurston County's Sanitary Cod,Article N, Section
9. This period may be eartended for a single one-year period without cbarge,if specifically requested by the applicant prior to
the expiration date.
Revised 5-9-I1
Form No. SA016
Thurston County Permit Assistance Center
Master Application
Page 3 of 3
BRIEF DESCRIPTION OF PROJECT PROPOSAL
NEW CONSTRUCTION FOR PRIMARY MOBILE HOME AND FUTURE FMU
BILLING INVOICES
The base application fee charged at the time of application covers base hours listed on the fee schedule. When the base
hours by a Department are used, a monthly billing invoice will be generated for additional hours at the hourly rate listed
on the fee schedule. Should review of the project exceed the base hours allotted,billing invoices shall be mailed to:
Q Owner ❑Applicant ❑Point of Contact
*Application is hereby made for a permit or permits to authorize the activities described herein. I certify that I am familiar
with the information contained in the application and that to the best of my knowledge and belief,such information is true,
complete,and accurate. I further certify that I possess the authority to undertake the proposed activities. I hereby b ant to the
agencies to which this application is made or forwarded,the right to enter the above-described location to inspect the proposed,
in-progress or completed work. I ab ee to start work only after all necessary permits/approvals have been received.
Revised 3-11 Form No.MA001
Thurston County Environmental Health Division
�`�_ - 2000 Lakeridge Dr. SW,Olympia,WA 98502
5 f`�ti�;��� (360)867-2673/(360)867-2660(Fax)
�-��;.�g� �„ ;, TDD Line(360)867-2603
`��UR��i't�� C;C)UNT'�` l�ttp://www.co.thurston.wa.us/health/ehadm
��u'r.t.ny:
WATER SYSTEM PRIORITY OF SERVICE
❑ Owner/Applicant �'Applicant Only Date Received --
Name ��,�L -� � I/ -�� LL� — � �-'� � Phone#�- J,� ��c4'j.� _� `t 5��
c, y,� , . �� .��'-�-�F' ,�.�-�
Mailing Address 1 � 7� I ���� � `1 f � �^'i ��� ( �� '� ��]
Property Address ��� � ��(1 ��'Z 1� � � ( �C� �S �_ Parcel#���c���,� �u �O �'i
(attach location map)
-�
Project Description (Plat, short plat, etc) : 11 L <r - �-.-
' IM J���_�
Primary Source Area Utility_�
Priority I-Area Utility
Yes, the applicant will be provided with terms of service
Yes, via area utility satellite service
�No (Go to Priority Level II)
Signature of Utility Representative Date
Priority II-Neighboring Utility
Yes, the applicant will be provided with terms of service
Yes, via neighboring utility satellite service
�No (Go to Priority Level III)
Signature of Utility Representative � � �'� � - Date'�
Priority III-Other Approved Satellite Service Company
Yes
� _ No (Go to Priority Level IV)
Signature of Utility Representative Date
Priority IV-Water Supply Developed by Applicant
Date
Signature of Thurston County Environmental Health Representative
Approval of Service
Date
Signature of Thurston County Environmentai Health Representative
To obtain a list of approved utilities, and the name of your primary area utility, contact the Thurston County Environmental
Health Representative.
UPDATED 12/29/09
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