HomeMy WebLinkAboutBLD2021-00069-04- POTABLE WATERDEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street, Port Townsend' WA 98368
TeI 360.379.4450 | Fax: 360.379'4451
Web: www"co.ieffersou.wa,us/ communirydevelopment
E-mail: dcd@gr,iclfr.tnsulcss
SUPPLEMENTAL APPLICATION
DETERMINATION OF ADEQUATE POTABLE WATER
Resolution #99-90 requires building permit applications to provide evidence of an adequate potable water supply per the conditions
and subsequent
Signatu nt Name
(\_]rl,R.,Datet f '- eJ- A{-
of RCW 19.27.097 and the Guidelines for Determining Water Availobility for New Buildings.
By signing this application form, the owner/agent attests that the information provided herein, and in any attachments, is true
a,iA lo..ect to tirb best of his, 'her or its knoilledge. Any material falsehood or any omission. of a material fact made by the
o*n"il"i"nt with respect to this application packet may iesult in making any issued permit null and void.
I further agree to that all activities I intend to undertake or complete associated with this app.lication will be performed in
;;;li;ffi;ittt iti jppftute ieoerat, state and county laws and r6gulations and I agree to provide access and right of entry to
dff&; cdntv ana'iit irproy""l, representatives oiagents for ttie sole purpose of application,review and any.required later
inipeaioni.
-
Ajplicant miy?e,iresi notice of the Counqls intent to enter upon the property for visits related to this application
(hrner Name:
Site Address:Y\.SrG
,", Q...' A-err Parcel No.
WaterSource of:Attach
!g
CL@To
3
1*
1) WellLogs
(if no log report on file, a t hr stabilization test may be substituted.)
2) Lab analysis tested within 3 years of application.
Private well
2-Party Well
agreeme nt and recorded Easement.
-Total Coliform, Nitrate-N, Chloride
Items above AND recorded Operations & Maintenance
Alternative
System:
Provide justification and design perJefferson County
Environmental Health policy 974L
wwwjeffersonmuntypublicheahh.org/pdf/Policy-97-01-Rainwater-Collection'pdf
3/
-Submit Water Availability Notification form com pleted by
Lab Analysis as required under private well above.
attachato
o{Name of Water Provider:
your water purveyor.
Public Water:
Valid Water Right
Permit:
NOTE: lf any of the above utilities need to be installed and disturbance willoccur in a public maintained or
willbe needed.then aunmaintained Co aeasemeroad
FOR OFFICE USE O]{tY
1) Water Right Permit#
2) Public Water Supply WS lD#
ln Compliance
3) lndividual Well
Meets Water Quality Standards?
WRIA lTSubbasin
SIPZ -Coastal / Moderate / High
Based upon information provided bythe applicant, it appearsthatthe potable water supply:
Meets
-
Conditionally Meets Do€s not Meet
Yes No
Yes No
Yes No
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ON
N G
DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street, Port Townsend, WA 98368
^fel: 360,379.4450 | Fax: 360.379.4451
Web: www.co.ie fferson.wa.us /communitydevelopment
E-mail: dcd@co.iefFerson.wa.us
WATE R AVAILAB ILITY NOTIFI CATI ON
PUBLIC \TATER SYSTEM
TO: Jefferson County Environmental Health Department
ulo f L,r
{WaterSystem NamelFROM:
The
System Operator:
State lD Number:
Total connections for which system is approved:
Number of service connections existing (in use!:
Number of setvice connections committed:
Date and results of most recent water bacteriological analysisz I I
water system is capable
of and will supply potable water to the following location:
Assessol's Parcel lD#:111 os Trro 3
Legal Description:
Site Address:6 Zq Co'Ava tr-\AJ-.
Operator Signature:
Date: I I
EXHRAflON DATEOFTHISSERVICECOMMITMENI:' I I
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