Lewis County Community Development
FILL AND GRADE PERMIT
F
OR OFFICIAL USE ONLY: Plans approved by: ________________________________ Date: _________________
Signature: _________________________________
Date: __________
Check one: Owner
Authorized Agent
Self-Built: Name: ____________________________________________ Phone: ______________________________
Contractor’s Name: __________________________________________ Phone: ______________________________
License #: ____________________________ Expiration Date: ___________________
Address: ______________________________________________________________
2025 NE Kresky Ave, Chehalis, WA 98532 ● Phone: (360) 740-1146
Applicant Information (if different):
Owner
Name: __________________________________________________________ Phone Number: _______________________
Mailing Address: __________________________________________________ Email: _______________________________
Project Information:
Contact when permit is ready or more information is required:
Applicant
Owner
Existing Contours
Final Grade Contours
Location of Drainage and Stream Courses
Design of Any Soil Retention Structures
Areas and Volumes of Cut and Fill Erosion
Control Plan for Construction Phase Soils
Report (Retaining Walls)
Acknowledgment and Permission to Enter
I understand that County regulations require owner permission for County personnel to enter private property to conduct permit processing, review, and
inspections. I also understand that my failure to grant permission to enter may result in denial or withdrawal of a permit or approval. By my signature below,
permission is granted for representatives of the Community Development, Environmental Services, and Public Works Department to enter and remain on
and about the property for the sole purpose of processing such permits and performing required inspections or reviews.
Prior notification of the date of inspections will take place is: Required Not Required
(________) ___________________ (Must provide phone number where applicant/representative can be reached)
I/We certify that all plans, specifications and other submissions required in support of this application conform to the requirements of all federal, state, and
local codes and applicable laws and ordinances; and I certify that I am either the current legal owner of this property or their authorized representative.
With this document, I take full responsibility for the lawful action that this document allows.
I certify that I have read and understand the limitations and conditions of Lewis County Code and agree to comply with all conditions of approval. I
understand that any permits issued by Lewis County, consistent with the attached site plan, are valid ONLY if construction is in according to this plan and all
other conditions of the permit are followed. By my signature below, I affirm that all the information and documents provided with this application are true and
accurate to the best of my knowledge.
Map Requirements (in additional to the site plan requirements handout):
_____
Property Information:
Tax Parcel Number: ________________________ Site Address: ________________________________________________
Owner’s Name: __________________________________________________ Phone Number: _______________________
Owner’s Mailing Address: ____________________
___________________________ Email: ________________________________
Permit Number: ______________
Master Site Review: ___________
Date submitted: ______________
Permit Technician: _____________
Fees Due: ___________
Contractor Other: ______________
Residential Commercial
Please select one:
Project Description:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Cubic yards of fill: ________ Cubic yards of cut/grade: _________
The State Environmental Policy Act (SEPA) Checklist is required for any projects involving over 500 cubic yards of material or if the project crosses water
S:\COMMUNITY DEVELOPMENT\Forms\2018
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