HomeMy WebLinkAbout08_Supplemental Application - Certificate of Water Supply_Revised_2024-0325ERSON
KiSHINO TON
DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Strect, Port 'l'ownsend, WA 98368
"Tek 360.379.4450 | l'ax: 360.379.4451
Web: www.co,jcfferson.wA.JS/comnunitydevelopment
E-mail: dçd@cojcferson.wa.us
-subdivisions,
The Jefferson County Coordinated Water System Plan establishes the Utility Service Review Procedure. The
purpose of the procedure is to assure that water system development is coordinated between existing water
service providers, the Jefferson County PUD and the Jefferson County Planning Department, Developmet
Review Division (DRD). The Certificate of Water Supply Utility Service form must be completed prior to
developing a new public water supply system, expanding an existing system, or changing the standard of service
(e.g., change from residential service to commercial service). The Certificate should be completed before
significant engineering and design have begun since the completed form documents the Couty's approval of the
water system design.
-Zoning,
The utility service review procedure is initiated by the Development Review Division upon submission of a
triggering application that indicates creation of a new water systemn or connection to an existing system.
Triggering applications include the following:
SUPPLEMENTAL APPLICATION
CERTIFICATE OF WATER SUPPLY
UTILIIY SERVICE FOR JEFFERSON COUNTY
-well site inspections,
-building permits,
-onsite sewage system pemits
The DRD will detemine if the proposal is within an existing service area and, if so, direct the applicant to the
appropriate utility for service review. If there is not a service area, then the applicant wil be directed to the PUD.
If a water system is being proposed independent of a triggering application, the applicant will need to prepare a
conceptual water system design and submit it to DRD to initiate the procedure. The design should include a map
showing the proposed service area boundaries, proposed source location, preliminary distribution system layout
and the number and types of service connections.
In all cases, the DRD will evaluate the proposal for consistency with land use policies and will make written
findings to that effect.
Exhibit 08
|Application Number
OFFICIAL USE ONLY DO NOT WRITE IN THIS SPACE
|Approved Water Plan
|Water Utility
|PUD/SMA
Applicant Name
WATER SUPPLY UTILITY SERVICE
JEFFERSON COUNTY
Project Preliminary Plan:
Project Name
CERTIFICATE OF
Water Utility
Statesmdn GC, LTD
Industrial
Proposed Project Ihe Hamlet at Pleasant Harbor
APPLICANT TO COMPLETE
Indicate the number of units of each category:
Residential 810 ERU Multi-Family
Project Location_O Black PL Rel Brinnon, wA.
c
Signatufe of Applicat
Assigned By
Agricultural
Date
Date
Other
Application No.
Page 1 of 5
Commercial 56,b 0 SafT MAX
, the undersigned, certify that I, or my appointed representative have discussed this proposed project and its impacts with the Water
Utility shown above. I acknowiedge that this proposed project may require improvemerts to the water system shown above which
wouid incur my financial obligation. Prior to Final Plat approval, or approval of the Water System Plan or the Engineers Repot, it is understood that a legal contract between myself and the Water Utlity must be submitted to Jefferson County which specifies the
tems of the water service, gperational responsibility, and financial obligation. Furthemore, I acknowledge that I have read and
understand the following material.
9832o
By signing the application form, the applicant/owner attests that the information provided herein is true and corect to the best of
their knowledge. Any material falsehood or any omission of a material fact made by the applicant/owner with respect to this
application packet may result in this permit being null and void.
I further agree to save, indemnify and hold harmless Jefferson County against all liabilities, judgments, court costs, reasonable
attorney's fees and expenses which may in any way accrue against Jefferson County as a result of or in consequence of the
granting of this permit.
I further agree to provide access and right of entry to Jefferson County and it's employees, representatives or agents for the
purpose of application review and any sequired later inspections. Access and right of entry to the applicant's property or
structure shall þe requested and shall fcur during regular business hours.
bate
3/14/2024
Exhibit 08
Priority 1:
If an individual well is proposed, then the Procedure (USRP) is not required at this time. Individual
well proposal is forvwarded to the County Health Department for review and approval.
Priority 2:
Priority 3:
Priority 4:
UTILITY SERVICE REVIEWN PROCEDURE (USRP)
Within Service Area
Jefferson County will determine whose service area water supply the request is
located in, and will then direct the applicant to that purveyor or water utility with a
Certificate of Water Supply Utility Service in hand. f the utility declines service, a letter
stating 'Justificatiorn of Denial' will be required.
If the purveyor declines service, then go to Priority 2.
Satellite System Management Agency (SSMA)
The designated SSMA for the County will be allowed to respond to the service request
and provide conditions of service to the applicant. If the SSMA declines service, a
letter stating 'Justification of Denial' will be required.
If the SSMA declines service, then go to Priority 3.
Application No.
Adjacent utility
The applicant must approach adjacent utilities to determine if service can be provided.
If the adjacent utility declines service, a letter stating Justification of Denial will be
required.
If adjacent utility declines service, then go to Priority 4.
Create new Public Water System (PwS)
After the first 3 priorities are ruled out, a new PWS may be considered through the
required State review process. The applicant will be directed to have an engineer
contact the DOH Regional Engineer for specific requirements (Water System Plan,
project report, construction documents, etc.).
Note: Once service is detemined, Jefferson County will sign off on the Certificate for Water Supply
Utility Service and adjust service area maps as necessary. Sign off will ccur only after
consultation with the DOH to determine whether the proposed system is adequate to serve.
Page 2 of 5
Exhibit 08
A.
1
Please circle the appropriate action(s) and/or fill in the appropriate blanks.
2
3.
5
6.
7.
8.
TO BE COMPLETED BY THE WATER UTILITY
The
9.
The proposal is/is not within our approved water service area.
If you (the utility) are not going to manage the supply of water for this development, please
proceed to number 16 and attach a letter explaining the 'Justification of Denial'. The County
will be unable to proceed without this 'Justification of Denial'. In all other cases, continue with
the questionnaire.
to serve this development at this timelever.
4. The proposed development is/is not consistent with our approved water system plan.
The water utility is/is not willing to assume interim satellite operational management
responsibility for the proposed water system until a connection to our system is
possible.
Water service can be made available to this development immediately/by
Required fire flow
Application No.
Indicate estimated peak hour, peak day, and annual average water supply needed in
gallons per minute (GPM).
Estimated domestic
Total requirements
Number of fire hydrants required
The
water utility does/does not desire
approved for
Peak Hour
connections and
Page 3 of 5
Peak Day
NIA
service connections and curenty has
service commitments.
Annual Avg.
NJA
water system has been
active
Will the project require extension of water mains or adjustments to service area
boundaries? Yes/No If yes, please describe:
Exhibit 08
10.
11.
12.
13.
14.
15.
Signicant facities improvements other than waterüine extension wouldwould not be
required. List improvements:
16.
The entre water system capable of serving the utimate devekopment density williwill
not be installed initially prior to final plat approval. f staged development is propOsed.
specfty what fom and the method of surety which wil be provided to guarantee
ultimate installation of water system facilties.
List the flows that coukd be provided to the development with a minimum pressure of
30 psi and 20 psi.
Indicate size of main required for hookup:
Application No.
Indicate distance from existing main to project
WATER UTILITY REPRESENTATIVE
GPM at 30 psi
Page 4 of 5
GPM at 20 psi
Design and installation of the proposed water system willwill not be reviewed and
inspected by our agency.
inches.
A satisfactory contract has/has not been made with the apphcant to serve this
proposal. Comments:
DATE
feet.
I, the undersigned, certify that I, or another authorized representative of the utility, have
discussed this proposed project and its imparts with the applicant. I acknowledge that the
water system has the capacty in instaled
facilities and water rights to serve the proposed development with the improvements identified
above and that the service to the proposed project is consistent with this utility's water systerm
plan.
Exhibit 08
B. Please circle the appropriate action(s) and/or fill in blanks.
1. Jefferson County Health Department (individual Wells)
TO BE COMPLETED BY APPROPRIATE REVIEW AGENCY
The Jefferson County Health Department has reviewed the proposed method of water supply
and hereby offers conceptual approvalW disapproval for the proposal. Final approval will be
reserved until a suitable well site is approved and until it is demonstrated that applicable
separation distances and health regulations are attainable.
Comments:
County Health Department Official
2.
3.
Development Review Division Signature
Jefferson County Development Review Division (Reviews for consistency with
County land use policies.)
The Development Review Division has reviewed the proposed method of water supply and
hereby offers conceptual approval/disapproval for the proposed supply.
Comments:
Washington State Department of Health
Application No.
this case which arelare not attached.
Date
Reviews applications where there isa disagreement of terms of water service or fomation of a
new water supply utility. Due either to a disagreement on terms of water service or to the
formation of a new water supply utility, the DOH has made a decision on water service. This
decision is presented in the attached letter dated and signed by:
Comments:
The Water Utility Coordinating Committee did/did not make recommendations applicable to
Washington State Department of Health
Page 5 of 5
Date
Date
Exhibit 08