05/30/2017
SOUTH BEND OFFICE
P.O. Box 68
South Bend, WA 98586
(360) 875-9356 FAX (360) 875-9304
OWNER/APPLICANT INFORMATION
OFFICE USE ONLY
Land Use Planning Permit Applicaon
Pacic County Department of Community Development
Internet Address: www.co.pacic.wa.us
Owner:
Applicant:
Contractor:
LONG BEACH OFFICE
7013 Sandridge Road
Long Beach, WA 98631
(360) 642-9382 FAX (360) 642-9387
PLANNING INFORMATION - Failure to provide complete informaon will lead to a rejecon of your permit applicaon.
PROJECT/PROPERTY INFORMATION
Tax Parcel ID #:
Project Value:
1. List exisng improvements and structures:
2. Is the proposed development one phase of a larger project or larger development?
If yes, describe the enre project in detail:
3. Is there any surface water body on or in the immediate vicinity of the proposed site (including year-round and seasonal streams,
saltwater, lakes, ponds, wetlands)?: YES NO
4. Name of water and/or wetlands within which development is proposed:
5. Does the property have an exisng driveway?: YES NO
6. Will ll material be placed near or within a drainage way (ditch, swale, channel, etc.)?: YES NO
7. Are acvies adjacent to unstable soils or slopes?: YES NO
8. Will acvies alter man-made or natural drainage features?: YES NO
9. Indicate amount of new impervious areas (areas covered by buildings, pavement, concrete, rock, etc.):
10. Does the project involve any clearing, lling, grading, paving, surfacing and/or dredging?: YES NO
If Yes, answer the following. If No, go to number 11.
A. If acvies include clearing and grading greater than 5,000 sq. . Indicate SF:
B. If acvies include new landscaping, yard maintenance, or gardening greater than 7,500 sq. . Indicate SF:
C. Will acvies involve placing ll materials? YES NO
1. If ll materials exceed 1 foot in depth. Indicate Depth:
2. If ll materials exceed 50 cubic yards. Indicate Cubic Yards:
D. If acvies involve earth removal exceeding 2 feet in depth (Excluding foundaon excavaons). Indicate FT:
E. If acvies add more than 10, 000 sq. . of impervious area (Road projects only). Indicate SF:
F. If acvies add 5,000 sq. . of impervious area (All other projects). Indicate SF:
11. Proposed site must be agged/staked at me of applicaon submial. Completed
