Fillable TOP SOIL REMOVAL PERMIT APPLICATION (City of Lacey)

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TOP SOIL REMOVAL PERMIT APPLICATION (City of Lacey)

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FORM: TSR-1
PAGE 1
CITY OF LACEY
Community & Economic Development Department
420 College Street SE
Lacey, WA 98503
(360) 491-5642
TOP SOIL REMOVAL PERMIT
APPLICATION
DATE:
DATE:
DATE:
DATE:
SIGNATURE(S)
I (We), the above-signed, do hereby affirm and certify, under penalty of perjury, that I/we am/are one (or more) of
the owner(s) under contract of the below described property and that the following statements and answers are in all
respects, true and correct on my information and belief as to those matters.
OWNER NAME:
MAILING ADDRESS:
CITY, STATE, ZIP:
TELEPHONE:
APPLICANT NAME:
MAILING ADDRESS:
CITY, STATE, ZIP:
TELEPHONE:
SIGNATURE: DATE:
ENGINEER/ARCHITECT NAME:
MAILING ADDRESS:
CITY, STATE, ZIP:
TELEPHONE:
SIGNATURE: DATE:
OFFICIAL USE ONLY
Case Number: ___________
Date Received: __________
By: ___________________
Related Case Numbers:
_______________________
_______________________
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FORM: TSR-1
PAGE 2
PROPERTY LOCATION
[ ]North [ ]South [ ]East [ ]West Side of between
(ROAD NAME)
and
(ROAD NAME)
Property Address:
Section: Township: Range: Assessor’s Parcel Number:
Full legal description of subject property:
(ATTACH SEPARATE SHEET IF NECESSARY)
AUTHORIZED REPRESENTATIVE:
MAILING ADDRESS:
CITY, STATE, ZIP:
TELEPHONE:
SIGNATURE: DATE:
NAME OF PROJECT:
SUMMARY OF REQUEST (List Type of Uses):
UTILITIES
Water Supply (Name Of Utility, If Applicable
):
Existing: Proposed:
Sewage Disposal (Name Of Utility, If Applicable):
Existing: Proposed:
Access (Name Of Road Or Street From Which Access Is Or Will Be Gained):
Existing: Proposed:
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FORM: TSR-1
PAGE 3
Total acreage in site:
Total square footage in paved or covered surfaces:
Estimated amount of topsoil to be removed each calendar year for the next five years:
Year #1: Amount: Year #2: Amount:
Year #3: Amount: Year #4: Amount:
Year #5: Amount:
ALL APPLICANTS MUST SUBMIT THE FOLLOWING INFORMATION
NOTE: The site plan must be at a scale of not less than 20 feet to an inch and not more than
100
feet to an inch.
1. Twelve (12) copies of the site plan drawing and application shall be submitted which must
include ALL of the following:
a. The boundaries of the property proposed for top soil removal.
b. All means of vehicular ingress and egress to and from the site and the size and location of
access points.
c. An illustration of the areas of said property where top soil is proposed to be removed and the
soil berm, fence or landscape screening to be used to screen the soil removal operation from
adjoining properties or public facilities.
d. The location of all existing and proposed structures, including, but not limited to, buildings,
fences, culverts, bridges, roads and streets. Include setbacks from property lines.
2. An engineering study showing the grade of the top soil both prior to and after the proposed
removal, and engineering documentation and explanation of the effect of said top soil removal
upon the future installation of sewerage or septic tank facilities, the effect upon future drainage,
and the effect upon the water table located under said property.
3. Drawing and descriptive narrative showing the removal sequence and the means proposed to be
taken to ensure the continuity of natural site drainage flow without undue or uncontrolled
ponding in retention areas.
4. Proposed actions to control dust and noise during the removal operation.
5. A proposed plan, including time sequence, for restoration of the land area after the removal of
top soil.
6. A listing of the names and addresses of all adjoining landowners.
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TOP SOIL REMOVAL PERMIT APPLICATION (City of Lacey)

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Completed 4 August 2020

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