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Home My WebLink AboutBLD2021-00089 - 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 l d g P e r m i t # 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 PUD #1 Lainie L. Ritter 821355066 365 Alpine Ct, Port Ludlow, Wa 98365 10-20-2020 Jerry Schmuck 4 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: ______________________________ 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: Assessor’s Parcel ID#: _____________________________________________________ Legal Description: ________________________________________________________ _________________________________________________________________________ Site Address: _____________________________________________________________ _________________________________________________________________________ Operator Signature: _______________________________________________________ Date: ____/____/____ EXPIRATION DATE OF THIS SERVICE COMMITMENT: ____/___/____ PUD #1 PUD #1 LOT 4 OF WHITE ROCK COVE DIVISION 4, LARGE LOT SUBDIVISION, AS PER PLAT RECORDED IN VOLUME 1 OF LARGE LOT SUBDIVISIONS, PAGE 17, RECORDS OF JEFFERSON COUNTY, WASHINGTON TOGETHER WITH EASEMENTS FOR INGRESS, EGRESS AND UTILITIES AS DELINEATED ON THE FACE OF SURVEYS RECORDED IN VOLUME 10 OF SURVEYS, PAGE 134 (BRIDGE VIEW TREACTS DIVISION 3) VOLUME 10 OF SURVEYS, PAGE 54 (BRIDGE VIEW ESTATE TRACTS) AND VOLUME 10 OF SURVEYS, PAGE 105 (WHITE ROCK COVE TRACTS DIVISION 2) ALL EING RECORDS OF JEFFERSON COUNTY, WASHINGTON 821355066 365 Alpine Ct., Port Ludlow, Wa PUP fefferson County Public trtility District Board of Commissioners Jeff Randall, District 1 Kenneth Collins, District 2 Dan Toepper, District 3 Kevin Streeft, General Manager To: Jefferson County Environmental Health Department From: Bywater Bay Vl/bter System System Operator(s): Doug Reeder State lD Number: O2U3P Number of existing connections: 251 (Estimated) Number of permitted connections 300 Number of committed connections This water system is capable of; and will supply potable water to the following location: Assessofs Parcel lD# 821 355 066 "' Water connection is available once all fees andror charges have been paid '** Site address: 365 ALPINE CT PORT LUDLOW WA 98365 Signature: Maureen Vvhippy Date 11 10.2020 THIS IS A NON.BINDING STATEMENT OF WATER AVAILABILITY. IT PROVIDES THAT AT THE TIME OF REQUEST, WATER IS AVAILABLE WTHIN THIS SYSTEM. THIS NOTIFICATION IS GOOD FOR ONE YEAR. PH (360) 3E5-5800 Fx (360) 385-5945/P.O. Box 929, Port Hadloch wA 9E339 qls!9Eqsrryllqfig&ld.alg 310 Four CorrErs Road- Porr Townsen4 WA 9t368 Leoal DescriDtion V![-llTE ROCK COVE DIV lV LOT 4 W-S/EASE Title: CUSTOMERSERVICE Parcel Number 82 1355066 Owner Mailing Address: JERRY M SCHMUCK PO BOX 386 KINGSTON Site Address: 365 ALPINE CT PORT LUDLOW 1r/10t2020 98346-0386 98365 Section: 35 Qtr Section: NE1/4 Township:28N Range: 1E Sewer: Bank: View 2: Zoning 2: Sub Division: Assessor's Land Use Code: 9 100 - Vacant Land Property Description: t'flITE R(rK COVE DIv MOT 4 I{-SIEASE School District: Chimacum (49) Fire District: Port Ludlow (3) Tax Status: Taxable Thx Code: 0231 Planning Area: Paradise Bay (8) Drainage: View l: Znn;ng l: RR-5 - Rural Residential Zofing3:.