HomeMy WebLinkAboutExhibit 19_Water Availability LetterSupplemental Potable Water 1
DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street, Port Townsend, WA 98368
Tel: 360.379.4450 | Fax: 360.379.4451
Web: www.co.jefferson.wa.us/communitydevelopment
E-mail: dcd@co.jefferson.wa.us
SUPPLEMENTAL APPLICATION
DETERMINATION OF ADEQUATE POTABLE WATER
Owner Name: Parcel No.
Site Address:
Water Source Existing Attach Copies of:
Private well
1)Well Logs
(if no log report on file, a 1 hr stabilization test may be substituted.)
2) Lab analysis tested within 3 years of application.
-Total Coliform, Nitrate-N, Chloride
2-Party Well Items above AND recorded Operations & Maintenance
agreement and recorded Easement.
Alternative
System:
Provide justification and design per Jefferson County Environmental
Health policy 97-01
www.jeffersoncountypublichealth.org/pdf/Policy_97-01_Rainwater_Collection.pdf
Valid Water Right
Permit:
Lab Analysis as required under private well above. Generally applies to
springs, attach copy.
Public Water:Name of Water Provider:
-Submit Water Availability Notification form completed by
your water purveyor.
NOTE: If any of the above utilities need to be installed and disturbance will occur in a public maintained or
unmaintained County road and/or Right-of-Way easement, then a Right-of-Way application will be needed.
Resolution #99-90 requires building permit applications to provide evidence of an adequate potable water supply per the conditions
of RCW 19.27.097 and the Guidelines for Determining Water Availability for New Buildings.
By signing this application form, the owner/agent attests that the information provided herein, and in any attachments, is true
and correct to the best of his, her or its knowledge. Any material falsehood or any omission of a material fact made by the
owner/agent with respect to this application packet may result in making any issued permit null and void.
I further agree to that all activities I intend to undertake or complete associated with this application will be performed in
compliance with all applicable federal, state and county laws and regulations and I agree to provide access and right of entry to
Jefferson County and its employees, representatives or agents for the sole purpose of application review and any required later
inspections. Applicant may request notice of the County’s intent to enter upon the property for visits related to this application
and subsequent permit issuance.
Signature: Print Name: Date:
FOR OFFICE USE ONLY
1) Water Right Permit #3) Individual Well
2) Public Water Supply WS ID#Meets Water Quality Standards?Yes No
In Compliance Yes No WRIA 17 Subbasin
SIPZ -Coastal / Moderate / High Yes No
Based upon information provided by the applicant, it appears that the potable water supply:
Meets Conditionally Meets Does not Meet
Bart Brynestad 11/19/2025
Supplemental Potable Water 2
DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street, Port Townsend, WA 98368
Tel: 360.379.4450 | Fax: 360.379.4451
Web: www.co.jefferson.wa.us/communitydevelopment
E-mail: dcd@co.jefferson.wa.us
WATER AVAILABILITY NOTIFICATION
PUBLIC WATER SYSTEM
TO: Jefferson County Environmental Health Department
FROM: _____________________________________________ (Water System Name)
System Operator: ________________________________________________________
State ID Number: _________________________________________________________
Total connections for which system is approved: ______________________________
The_____ __________________________ watersystem is capable of and willsupply potablewater to the following location:
Assessor’s Parcel ID#: _____________________________________________________
Legal Description: ________________________________________________________
_________________________________________________________________________
Site Address:_____________________________________________________________
_________________________________________________________________________
Operator Signature: _____________________________
Date: ___/___/____
EXPIRATION DATE OF THIS SERVICECOMMITMENT: ____/___/____
Number of serviceconnections existing(inuse):
Numberof serviceconnections committed: ___________________________________
Date and results of mostrecent water bacteriological analysis: _____/_____/_____
_________________________________________________________________________
_________________________________________________________________________