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Critical Areas Checklist CA File No: Tj 0
Site Information (soils/ topography/ hydrology/ vegetation)
1. Site Address/ Location: 61-5— /C�;_ Ir ;0,- 1
2. Property Tax Account Number: 4410 tDc) tgQ 0 1 D 5
3. Approximate Site Size (acres or square feet):
4. Is this site currently developed?ZL.— yes; _
no.
If yes; how is site developed? NOU 54��
5. Describe the general site topography. Check all that apply.
/Ir Flat: less than 5-feet elevation change over entire site.
4"'
Rolling: slopes on site generally less than 15% (a vertical rise of 10-feet over a horizontal
distance of 66-feet).
Hilly: slopes present on site of more than 15% and less than 30% (a vertical rise of 10-feet
over a horizontal distance of 33 to 66-feet).
Steep: grades of greater than 30% present on site (a vertical rise of 10-feet over a horizontal
distance of less than 33-feet).
Other (please describe):
6. Site contains areas of year-round standing water: Approx. Depth:
7. Site contains areas of seasonal standing water: Approx. Depth:
What season(s) of the year?
8. Site is in the floodway — floodplain — of a water course. 11/0
9. Site contains a creek or an area where water flows across the grounds surface? Flows are year-round?
Flows are seasonal? (What time of year?
10. Site is primarily: forested ; meadow. ;shrubs mixed
urban landscaped (lawn, shrubs etc)
11. Obvious wetland is present on site:
------ —For City Staff Use Only
1. Plan Check Number, if applicable?
2. Site is Zoned? tg
3. SCS mapped soil type(s)? 17 -
4. Critical Areas inventory or C.A. map indicates Critical Area on site?
5. Site within designated earth subsidence landslide hazard area?
DETERMINATION
—STUDY REQUIRED WArVER
Reviewed bv: Datp! 9,/) 8�0-�
Critical Arcas Checklist.doc/4.22.2003
*k' �, T, �� I, .
oe
The Critical Areas Checklist contained on this form is to
be filled out by any person preparing a Development,
Permit Application for the City of Edmonds prior to
his/her submittal of the application to the City.
The purpose of the Checklist is to enable City staff to;'
determine whether any potential Critical Areas are,* or
may be, present on the subject property. The information
needed to complete the' Checklist should be. easily
available from observations of the site or data available at
City , Hall (Critical areas inventories, maps, or soil
surveys).
A pr6o6fty'owne'r, or his/her � authorized repreientative,-
inust fill out the checklist,. . si gn and date it, and Isubmit it
to' the City. The City wiff review" the checklist
make a
precur . sory site'visit, eindihiake'a determinati6n-of the
subsequent. steps necessary.to complete a development
permit application.
Please.submit a vicinity map, along with the signed copy
of this form to assist City siaff in finding and lo�ating the
specific piece' of property, described on this form. In
addition, the applicant shal I include other pertinent
information (e.g. site, plan, topography map, etc.) or
studies in conjunction with this Checklist to assistant staff
in completing their prelimiharyassessine4it of the site.
The undersigned applicant, and his/her/its heirs, an�'assigns', 'in* consideration' on'thi processing bf the a pplication agrees
i
to release, indemnify, defend and hold the City�of Edin6n&"harmless from,any and all dama s,,Jficluding reasonable
I . ge ,
based in whole or part upon false, misleading, inaccurate or
attorney's fees, arising from any action or infraction
incomplete information ' furnished by the applicant, his/her/its agents or employees.
By my signature, I certify that the information and exhibits herewith submitted are true and correct to the best of my
knowledge and that I am authorized to file this application on the behalf of the� owner a's listed below.
SIGNATURE OF
C
DATE � — �-- C-)
Prooerty Owner's Authorization
By my signature, I cer* that I have authorizedthe above Applicant/Agent to'apply for the subject land use 4pplication,
and grant my permission for the public officials and the staff of the City of Ed�iWnds to enter the subject property for the
purposes of inspection and posting atten4antto this application.
9,IGNATURE OF OWNER
Owner/A lic nt*
pp a .
/; �/- � Da
Name 7
615— -0- - rf—,
Street Address
el /
city State zip,
Telephone: 7 7 63
Email address (optional):'
Applicant Re I presentative:
412 44-
Name
41
Street Address,
city State zip
Telephone:
Email Address (optional):
Critical Areas Checklist.doc/4.22.2003
The City of Edmonds
Side Sewer Drawing
EASEMENT NO - ------- - ----------
CONSTRUCTION E] REPAIRS LID NO. - ---------------- ASMT. NO - ---------------- -
OWNER------ R-.--G ...... 13ZT.TS ---- ------------------------------------------------------ CONTRACTOR ---------------------------------------- ------------------------------------------- PERMIT NO - ----------------
JOB ADDRESS ---- -61-5 ST-PAFX, T --------------------------------------- LEGAL DESCRIPTION: LOT NO - -----------------
------------- ------- BLOCK NO - -----------------------------
------------ I ......... - -------------------------------------------------- ------------------------------ -----------------------------------
NAME OF ADDITION
4(4e
4tZ'N"-
DYE TESTED ON SEWER
Approved:
PWW-0001 -11175 (REV. 11/78) DATE -------------------- ....................... By ----------------- ................. -----------------------