Form Center Module

Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Temporary Easement & Hold Harmless Agreement

Sign in to Save Progress
  12. (if applicable)
  15. (Not valid for more than 500 cubic total unless an approved Storm water Management Permit is present on site.)
  17. (County Employee - Print Name)
  19. The undersigned hereby makes application to Jefferson County and certifies the information given in the application and supporting materials is correct. The undersigned, owner of the following described property, expressly agrees to grant Jefferson County a temporary easement to go on, over and across said property:
  23. For the purpose of disposing surplus fill material when available from road construction and routine road maintenance (ditch cleaning, chipping, etc.). Through the signing of this Agreement, applicant agrees he or she will indemnify, hold harmless and defend the State of Washington, FEMA, and Jefferson County and its agents and employees from all suits and actions, including reasonable attorneys' fees and all costs of litigation and judgment of every name and description against Jefferson County as a result of loss, damage or injury to person or property by reason of any action or omission by Jefferson County, its agents or employees for the above mentioned activities. By signing this document the Landowner has made express promises to Jefferson County, promises that can be legally enforced.

    It is further understood that the undersigned is responsible for obtaining any and all required permits related to this activity, and that the Jefferson County Unified Development Code or "UDC" (Section 6.6 and 6.7) requires environmental review and a Stormwater Management Permit for any grading or filling in or near environmentally sensitive areas (as defined by UDC Section 3.6.4) or for any grading or filling activity which will total more than 500 cubic yards over the lifetime of the activity. It is understood that all spreading and leveling of the material is to be accomplished by the owner in a manner consistent with the UDC unless other arrangements are specified above.

    No dumping shall take place within 200 feet of any lakes, streams, or tidal water, pursuant to the provisions of chapter 173-22 WAC and chapter 90.58 RCW. No dumping shall take place in wetlands or wetland buffer areas, natural drainage courses, or landslide hazard areas.
  25. Landowner acknowledges that he or she has voluntarily and knowingly signed this document below.
    29. Leave This Blank: