HomeMy WebLinkAboutCWSP USR Cover 2016 QR CodeDEPARTMENT 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
CERTIFICATE OF WATER SUPPLY
UTILITY SERVICE FOR JEFFERSON COUNTY
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, Development
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 County's approval of the
water system design.
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 system or connection to an existing system.
Triggering applications include the following:
-subdivisions,
-zoning,
-well site inspections,
-building permits,
-onsite sewage system permits
The DRD will determine 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 will 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.
Application No._________
Page 1 of 5
CERTIFICATE OF
WATER SUPPLY UTILITY SERVICE
JEFFERSON COUNTY
APPLICANT TO COMPLETE
Applicant Name __________________________________________________________________________
Proposed Project__________________________________________________________________________
Project Location __________________________________________________________________________
Project Preliminary Plan:
Indicate the number of units of each category:
Residential _____ Multi-Family _____ Commercial _____
Industrial _____ Agricultural _____ Other _____________
I, the undersigned, certify that I, or my appointed representative have discussed this proposed project and its impacts with the Water
Utility shown above. I acknowledge that this proposed project may require improvements to the water system shown above which
would incur my financial obligation. Prior to Final Plat approval, or approval of the Water System Plan or the Engineer's Report, it is
understood that a legal contract between myself and the Water Utility must be submitted to Jefferson County which specifies the
terms of the water service, operational responsibility, and financial obligation. Furthermore, I acknowledge that I have read and
understand the following material.
By signing the application form, the applicant/owner attests that the information provided herein is true and correct to the best of
their knowledge. Any material falsehood or any omission of a material fact made by the applicant/owner with respect to thi s
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 th e
purpose of application review and any required later inspections. Access and right of entry to the applicant’s property or
structure shall be requested and shall occur during regular business hours.
_________________________________________________________________________________________
Signature of Applicant Date
OFFICIAL USE ONLY DO NOT WRITE IN THIS SPACE
__________________________________________________________________________________________
Application Number Project Name
__________________________________________________________________________________________
Approved Water Plan Water Utility Assigned By Date
__________________________________________________________________________________________
Water Utility
__________________________________________________________________________________________
PUD/SMA Date
Application No._________
Page 2 of 5
UTILITY SERVICE REVIEW PROCEDURE (USRP)
If an individual well is proposed, then the Procedure (USRP) is not required at this time. Individual
well proposal is forwarded to the County Health Department for review and approval.
Priority 1: 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. If the utility declines service, a letter
stating 'Justification of Denial' will be required.
If the purveyor declines service, then go to Priority 2.
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.
Priority 3: 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.
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 determined, Jefferson County will sign off on the Certificate for Water Supply
Utility Service and adjust service area maps as necessary. Sign off will occur only after
consultation with the DOH to determine whether the proposed system is adequate to serve.
Application No._________
Page 3 of 5
TO BE COMPLETED BY THE WATER UTILITY
A. Please circle the appropriate action(s) and/or fill in the appropriate blanks.
1. The proposal is/is not within our approved water service area.
2. The ____________________________________ water utility does/does not desire
to serve this development at this time/ever.
3. 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.
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.
4. The proposed development is/is not consistent with our approved water system plan.
5. Water service can be made available to this development immediately/by
_____/_____/_____.
6. Indicate estimated peak hour, peak day, and annual average water supply needed in
gallons per minute (GPM).
Peak Hour Peak Day Annual Avg.
Required fire flow N/A N/A__
Estimated domestic __________________________________________
Total requirements __________________________________________
7. Number of fire hydrants required __________________________________________
8. The ____________________________________________ water system has been
approved for _______ service connections and currently has _______ active
connections and _______ service commitments.
9. Will the project require extension of water mains or adjustments to service area
boundaries? Yes/No If yes, please describe:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Application No._________
Page 4 of 5
10. Significant facilities improvements other than waterline extension would/would not be
required. List improvements:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
11. The entire water system capable of serving the ultimate development density will/will
not be installed initially prior to final plat approval. If staged development is proposed,
specify what form and the method of surety which will be provided to guarantee
ultimate installation of water system facilities.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
12. List the flows that could be provided to the development with a minimum pressure of
30 psi and 20 psi.
_______________________________________________________ GPM at 30 psi
_______________________________________________________ GPM at 20 psi
13. Indicate size of main required for hookup: ___________________________ inches.
14. Indicate distance from existing main to project: _______________________ feet.
15. Design and installation of the proposed water system will/will not be reviewed and
inspected by our agency.
16. A satisfactory contract has/has not been made with the applicant to serve this
proposal. Comments:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
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 capacity in installed
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 system
plan.
___________________________________________ _________________
WATER UTILITY REPRESENTATIVE DATE
Application No._________
Page 5 of 5
TO BE COMPLETED BY APPROPRIATE REVIEW AGENCY
B. Please circle the appropriate action(s) and/or fill in blanks.
1. Jefferson County Health Department (Individual Wells)
The Jefferson County Health Department has reviewed the proposed method of water supply
and hereby offers conceptual approval/ 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 Date
2. 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:________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
_______________________________________ _______________
Development Review Division Signature Date
3. Washington State Department of Health
Reviews applications where there is a disagreement of terms of water service or formation 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:
_________________________________________________________________________.
The Water Utility Coordinating Committee did/did not make recommendations applicable to
this case which are/are not attached.
Comments:________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
______________________________________ ___________________
Washington State Department of Health Date