HomeMy WebLinkAboutBLD2021-00094 - 04 POTABLE WATERDEPARTMENT 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:
B
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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: 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
Supplemental Potable Water 1
Port Ludlow Associates Parcel No. 978802006
Homesite 6 Olympic Terrace 2, Port Ludlow WA
Cliff OBrien 2/12/2021
X OWSI Inc
Cliff OBrien Digitally signed by Cliff OBrien
DN: cn=Cliff OBrien, o, ou=Westharbor
Homes,
email=cobrien@westharborhomes.com, c=US
Date: 2021.02.12 10:31:01 -08'00'