HomeMy WebLinkAbout004DEPARTMENT OF COMMUNITY DEVE
621 Slrcddan Strcct, l\rrt'l'ownscrrrl, W,\ 983(18
'l'cl: 360.i79.4450 | Irax: 360.i19.1151
Wclr: www.co.ic [[crsort.wa.us,/cr rnrnunirydcvclr lPmcrrt
l,l-rnail: dcd(rl).co.icffcrs<xr.wa.us
itSUPPLEMENTAL APPLICATI ON
FOR SOURCE WATER REVIEW
nt Name a.)l t lia
Er't
Nntr tt tl r0$
t,Eprcnsorv
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and subsequent permit
Date: lt ^tr'2018,
iI
Pleose complete this document and submit the associdted documents in order to sotisly 1CC78,40.530(1)(b) which requires that utilities
be identified for the projed including woter source. This submittol must not be confused with an opprovol to withdrow woter for
beneficiol use. The beneficiol use ol woter intended lor irrigotion must meet the requirement ol Woter Right Laws, either be o permit
exempt source or hove o valid woter right and where opplicoble. The source must olso meet oll of the provisions as specified in the
Quilcene Snow Woter Resources Monogement Progrom Chopter 773-577. t initiol inlormotion submitted is not odequote for consistency
review ond odditionol inlormation or work is needed, an hourly rate will be chorged occordingly.
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
issuance.
of the to enter upon the for visits related to this application
Signature
Owner Name:
Site Address:
r \
Type of Structure/Project:
Parcel No. (nOll O ls txl
o-
CE
!o:
3_.t
+t
Water Source Existing Proposed Attach Copies of:
(please check one of the applicable lines below and follow the corresponding instructions in the same box to the right)
Private well nffil Water Well Report or Well Log
(if no report on file, a t hr stabilization test may be substituted.)
2-Party Well .il .fl
Item above AND recorded Operations & Maintenance
agreement and recorded Easement.
Alternative System rnR
Provide justification and design per Jefferson County
Environmental Health policy 97-01
www.ieffersoncountvoublichealth.orqlpdflPolicv 97-01 Rainwater Collection.pdf
Spring or Surface Water E -n Attach copy of Valid Department of Ecology (ECY) Water Right
or contact ECY.
Public Water E EN
Name of Water Provider:
-Submit Water Availability Notification form on back to be
completed by you water purveyor.
NOTE: lf 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.
FOR OFFICE USE ONLY .Z
ln Compliance Yes _ No _ WRIA 17 Subbasin
SIPZ -Coastal/ Moderate / High
Based upon information provided by the applicant, it appears that the potable water supply:
Meets Conditionally Meets Does not Meet
Yes No
Yes No
3) lndividual Well
Meets Water Quality Standards?
1) Water Right Permit #
2) Public Water Supply WS lD#
DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Shcridan Strcct, l)ort'l ownscnd, W,\ 9836t1
' l'cl: 36O.319.4450 | lrax: 360.379.4451
Vcb: www.co.icffcrson.wl.us/comrnurritydcvck rpmcnt
I')-rnail: dcd(i)co.icf-fcrson.wa.us
WATER AVAII-ABILITY NOTIFI CATI ON
PUBLIC WATER SYSTEM
TO: Jefferson County Environmental Health Department
FROM:(Water System Name)
System Operator:
State lD Number:
Total connections for which system is approved:
Number of service connections existing (in use):
Number of service connections committed:
Date and results of most recent water bacteriological analysis:
The water system is
capable of and will supply potable water to the following location:
Assessol's Parcel lD#:
Legal Description:
Site Address:
Operator Signature:
Date: I l-
EXPIRATION DATE OF THIS SERVICE COMMITMENTI
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