HomeMy WebLinkAboutBLD2021-00294 - 04 Potable WaterSupplemental 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.
B
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P
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#
Site Address:
Water Source Existing Proposed 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 tr ue
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 entr y 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
CAMERON DENNING 801-022-012
1464 EGG AND I RD CHIMACUM WA, 98325
X
CAMERON DENNING 4-20-21
XXX
May 06 2021
May 06 2021
Spectra Labs - Kitsap, LLC (Poulsbo)
26276 Twelve Trees Ln NW Ste. C
Poulsbo, WA 98370
Phone: (360) 779-5141
www.spectra-lab.com
Sample No. Description Location Sampled
Spectra Labs - Kitsap, LLC (Poulsbo) received samples from Laurie McKenzie on Friday, February 26,
2021 at 3:42 pm. Unless otherwise noted, all samples were received in good condition and were tested in
accordance with the laboratory's quality control procedures. A summary of the samples received are
outlined below.
206275-01 McKenzie-Denning Home 02/26/2021 9:371464 Egg & I Rd Chimacum- Kitchen
This report package contains laboratory sample results and any attachments listed below. If you have any
questions please call (360) 779-5141 or email us at www.spectra-lab.com.
03/01/2021 Page 1 of 1
This report is issued solely for the use of the person or company to whom it is addressed. Any use, copying or disclosure other
than by the intended recipient is unauthorized. If you have received this report in error, please notify the sender immediately at
360-443-7845 and destroy this report promptly.
These results relate only to the items tested and the sample(s) as received by the laboratory. This report shall not be reproduced
except in full, without prior express written approval by Spectra Laboratories.
May 06 2021
System ID No:
Date Received:2/26/2021
System Name:McKenzie-Denning Home
Source Number(s):
Sample Purpose:Other
Date Reported:3/1/2021
County:Jefferson
System Group Type:Private
Send Report to:
Laurie McKenzie
1464 Egg & I Rd
Chimacum, WA 98325
Bill to:
Laurie McKenzie
1464 Egg & I Rd
Chimacum, WA 98325
Drinking Water
Date Collected:
Sample Number:
2/26/2021
010-27501
Sample Location:1464 Egg & I Rd Chimacum- Kitchen
Sample Composition:Single Source
Sample Type:Untreated: DW
Sampler: laurie McKenzie
Sampler Phone No:
26276 Twelve Trees Ln NW Ste. C
Poulsbo, WA 98370
(360) 779-5141
TriggerSDRLDOH #MCL MethodAnalyteResultsUnitsExceeds
MCL
Analyst Analysis
Date
Qual.PQL
SZ 2/26/2021EPA 300.020mg/LNDChloride0021---250---1.00
SZ 2/26/2021EPA 300.00.5mg/LNDNitrate-N0020 ---10---0.1
Include the original lab number, sample number, and collection date of original sample in either lab or sampler comments section.
(State Detection Reporting Limitl) The minimum reportable detection of an analyte as established by the department..
DOH drinking water response level. Systems with compounds detected at concentrations in excess of this level may be required to take
additional samples or monitor more frequently. Please contact your DOH drinking water regional office for further information.
(Maximum Contaminant Level) If the contaminant amount exceeds the MCL, please contact your regional DOH office to determine follow-up actions.
(Not Analyzed) In the results column, indicates this compound was not included in the current analysis.
(Not Detected) In the results column, indicates this compound was analyzed and not detected at a level greater than or equal to the SDRL.
The compound was not detected in the sample at or above the concentration indicated (usually the lab method reporting limit).
milligrams per liter or parts per million.
nephelometric turbidity units (a measure of water clarity).
Micro ohms per centimeter (a measure of the ability of the water to conduct electricity). One micro ohm per centimeter is equivalent to one micro
siemen per centimeter (uS/cm).
No existing trigger or MCL value.
Secondary MCL (Established for aesthetic purposes, not health based).
*Confirmation
SDRL:
Trigger Level:
MCL:
NA:
ND:
< (0.00x):
mg/L:
NTU:
mhos/cm:
--:
1:
NOTES:
Lab Qualifiers Comments:
Sample Number:206275-01
Approved By
Angela Kaelin
Lab Supervisor/ QA Manager
This report is issued solely for the use of the person or company to whom it is addressed. Any use, copying or disclosure other than by the intended recipient is
unauthorized. If you have received this report in error, please notify the sender immediately at 360-443-7845 and destroy this report promptly.
These results relate only to the items tested and the sample(s) as received by the laboratory. This report shall not be reproduced except in full, without prior express written
approval by Spectra Laboratories.
Page 1 of 1206275-01
May 06 2021
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May 06 2021