HomeMy WebLinkAboutBLD2021-00493 - 04 Potable WaterDEPARTMENT OF COMMI.JNITY DEVEI-TOPMENT
621 Sheridan Strcet, Poft To*'nsmd, WA 983(ru
'lel: 3(t0.379.4450 | tszx: 36{1.379.4457
\X'cb: w.co.icffcson.wa.us/communiq'development
E-mail: dsl@co.icffcs()n.wa.us
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
of RCW 19.27.097 andthe Guidelines for Determining Woter 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/a8ent 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. ApplicantmayrequestnoticeoftheCounty'sintenttoenteruponthepropertyforvisitsrelatedtothisapplication
and subsequent permit issuance.
n"^., /n //u .t/ E'. /,!1 r.,,,, D,o.t q/// c7/2 /
o0-t-No.
L
Site Address: {
Owner Name:
Water Source Attach of:
@
o-
oE
!o
3B'{t
1) Well Logs
(if no log report on file, a t hr stabilization test may be substituted.)
2) Lab analysis tested within 3 years of application.
-Total Coliform, Nitrate-N, Chloride
Private well
2-Party Well Items above AND recorded Operations & Maintenance
and recorded Easement.
Alternative
System:
Provide justification and design per Jefferson County
Environmental Health policy 97-01
M.jefferencountypublichealth.or&/pdflPolicy_97-01_Rainwater_Collection.pdf
r water
Public Water:
Lab Analysis as required under private well above.
-Submit Water Availability Notification form completed by
Name of Water Provider:
General to attach
Valid Water Right
Permit:
NOTE: lf any of the above utilities need to be installed and disturbance will occur in a public maintained or
unmaintained Cou road and/or lication will be needed.easement, then a
FOR OFFICE USE ONIY
1) Water Right Permit #
2) Public Water Supply WS lD#
ln Compliance Yes No
3l lndividualWell
Meets Water Quality Standards?
WRIA 17 Subbasin
Yes
Yes
No
NoSlPZ -Coastal / Moderate / High
Based upon information provided by the applicant, it appears that the potable water supply:
Meets Conditlonally Meets Does not Meet
I
Spectra Labs - Kitsap, LLC (Poulsbo) received samples from Alan Babboni on Tuesday, April 13, 2021 at
10:20 am. 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.
SPECTRA Laboratories - Kitsap
...Whc ra axp er iance ddtte rs
Description
Private
Private
Spectra Labs - Kitsap, LLC (Poulsbo)
262'16Twelve Trees Ln NW Ste. C
Poulsbo, WA 98370
Phone: (360) 779-5141
www.spectralab.com
Sample No.
207490-01
207490-02
Location
2381 Cape George Rd Port Townsend
2381 Cape George Rd Port Townsend
Sampled
O4l13l202l 8:30
0411312021 8:30
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.
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
360443-7845 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 witten approval by Spectra laboratories.
04t20/2021 Page I of I
26276TwelveTrees Ln NW Ste. C
Poulsbo, WA 98370
(360) 779-s141
System ID No:
SPECTRA Laboratories - Kitsap
...Where experience matters
Drinking Water
System Group Type: Private
Smple Number: 01049002 System Name:Private
Smple hcation: 2381 Cape George Rd Pon Townsend County:Jefferson
Sampler:Alar J. Babboni
Source Number(s):Sampler Phone No:
Sample Purpose: Othsr Date Collected:4fi3tzozr
Sample Composition: Single Source Date Received:4n3t202t
Smple Type:Untreated: DW Date Reported: 4l2Ol2O21
Send Report to:
Alan Babboni
2381 Cape George Rd
Port Townsend, WA 98368
Bill to:
Alan Babboni
2381 Cape Gmrge Rd
Port Townsend, WA 98368
Analyte Exceeds Method
EPA 300.0
0.5
SampleNumber: 207490-02
lnclude he original lab number, sample number, and colledjon date oforuinal sample in either lsb or samplel comments section.
(State Deteclion Repoding Limit) Ihe minimum reportable detedion of an analy{e as esbblished by f'1e department..
DOH drinking water response level. Systems wih compounds detecbd at concenfaliofls in excess ot Utb hvel may be required to take
additional samples or monitor more fiequenuy. Please mntad your DOH drinkng water regional offce br fudler intomation.
(Maximum Contaminant Level) tl the contaminant amount exceeds fie MCL, please conbc{ your regional DOH ofrce to determine follow-up actions.
(Not Analyzed) ln $e results column, indicates his mmpound was not included in he cunent analysis.
(Nol Detected) ln the results column, indicates fiis compound was analfzed and not detected at a level glealer han or equal to the SDRL.
The compound was not delecled in he sample at or above he concenualon indicated (usuallyfte lab method reporting limit)-
milligrams per literor parts per million.
nephebmeuk turbidity units (a rnoasure olwater darity).
Micm ohms per centirneter (a measure of the ability of the water to conduct ebcficity). One micto ohm pel centimeter is equivalent to one micro
siernen per centimeter (us/cm).
No exisling triggeror MCL value.
Secondary MCL (Eslablished lor aeshetic purposes, not heallh based).
PQL Analysis
Date
4t20t2021
SZ 4114t2021
ilCL
30.9
ND
NOTES:
'Confirmation
SDRL:
Trigger Level:
xtcL:
NA:
ND:
< (0.0011:
mg/L:
NTU:
pmhos/cm:
Lab Qualifiers Comments:
,l:
'/,14
Approved By
Angela Kaelin
[:b Supervisor/ QA Manager
This report is issued solcly for the ur of the person or compmy to whom it is addressed. Any use, copying or disclmure other thff by the intended rciPient is
unauthorized. If you have rrceived this report in mor, plw notify the sender imediately at 36G.t143-7845 md destrcy this report promptly.
These results relate only to th€ it€ru tested and the mple(s) il meived by the labomtory. This repon shall not be rcproduc€d except in full, without prior express uitten
approval by Spectra liboratories.
DOH #
002 1
0020
AnalystREsults
SZ
Qual.Units
20mg/L
SDRL
4.00
MCL
250
0.1
Trigger
10 EPA 300.0mg/L
207490-OZ Page I of I
_Jt_
SPECTRA Laboratories - Kitsap
26276 lwelve Trcs Lane, Suite C, Pulsbo. WA 98370
(360) 779-sl4l
COLTFORM BACTERIA ANALYSIS
llate
/
uJrn
Sample Collectedt/3t 2/
Day \ba,
Iime Sample Collected County
{f*rrsoq
trPM
f-
Type of Water System (check only one box)
E croupA E Group B K*fr,rA
Group A and Group B SystBms - Provide hom Water Facilities lnlEntory (WFl):
Cell Phone:
rD#
System llhme:
Gontacl Person:
Day Phone:
Fax( )Ew. Phone: 5A-.r, e_-
Email Address:
Send rssulls afld inwkes tf?rint
--ZkrZ*23g( Coo-4.a4,- B=1
ao ress rfo il
/336(
code)./Jtull mme ,Ba
-
23€/lmtion
<
or commnts;
TyIc ol Sad[le (must ciec* only m bu ol t1 $rowh ,5lEl€{t b€low}
1. E Bouthe DlstihrtlonSlmple
Chlorinaled: Yes- * --t/
Chlorire Resilual: Tohl
-
Free.'
Unsatistactory routine colhct dde:
_l_t_
Clrlorimted: Yes _
-llo -Chlorin€ B€srirual: Total- Hee
-
Unsatisfactory routine lab numhr:
3. G]ound Walcr Rlle Source Sampl?
tr Trigoered (An)
E Assessment (ly'P)
2. Repoit Sample (A/P)
(irom dinributbn system afrn uHt
{. E Sutu! or 61It Rrr Sures frbr Slmdc (Enumedion)
E f.coli E fecat Filtec{, Yes- ilo--lsl I I
kivdte Resideme
5.
Constructim otB-
LAB USE ONLY DBIIIKI}IG WATER BESUTIS LAB USE ONLY
fi s.tu.arrr0 Uns*traaorytotal Colitorm Pcsetrt sld
O E coti prff'ent A E. coliabscnt
R.plrc!mcot Sallulc Ra[!6tcd/Fls0ged:
El Sample too old (>30 hours) 0 TIITC
Bacterhl thnsity ResufB: Total Colirorm
-
/l fixnl. Ecori- nmml.
Fecal Colitorm
-
/100m1. HPC /.1 ml-
Lab Reterence
tvnte - DOH (Irrq*r 8rD - bboEto.y GlM - llAB S4Cq Gd - DOH R.(ind
l"l I I
Yff.its, fi)t.
Ilatellim ln lmrSelorul t:,1:r
iiietaod Code
92238
tldBfiime Oul lrutrtorultult r
Feceipt Temp C" (Bil Wator)
tx)]] LaFsam0le,
o1G 3 1Co I
Remarks:
l. System ID No:2. System Name:3, Group (circle)
A B
4. Sample Location: fo r 6>14t A'i,5.Collected:Number:Iabwe aly
C o L
6. Sample 7 Sampler Phone 8.(Circle one)
at,Treated Unknown
9. County: (clrcle one)
Kibry Clallam
Masoa Pierce
Island King
Other
C6f"r*=\
Thurston
Grays Haftor
I0. Semple Purpose:
tr Routine Compliance,
Reportedto DOH
\Orlo, Investigative
l,l-Sample Comporifion
S, Singte Sourced st*d.d
tr Coryosite
n Distrbution
Source No (s):
14. Phone No.:sbz g<<va?
15. Fax No.:
16. Email:
17. Special Instructions:
Analysis
Requested
ElGroup A I(rc (complete)
(SbAsrB.,Be,Cd,Cr,CN-,f ,E&NiSe,T!
NOTN,NOT-N,Cr'FeM&Ag,SO+2tr$i,
hrrd,snqturb,olor. Pb,Cu)
[JGroup B IOC (complete)
(srme$GrcupA mhurPbcu)
ENitrate only
ElKitsap 5 (rvo.x, re M, cr,conrl)
EPierce County IOC
(St3arrpe,C4Cr,CT{,F,EgNr,Se,Tl,
NOr{r,NOrN,FcMnJY!, trrtPlr,Cr)
fr "n"r*o coutrty G{orN, <r)
trPrimary IOC
(su31n rBqC4cr,cNf,
HgJrLSe,Tl,NOrN, NOrN'
Nr,Turb,Pb,Cu)
Cteck a
group
or circle
individual
tests below
Eother (circle
individual
below)
EPA
R.EGTJLATEI)EPA REGULATED EPA REGI'LATED
(Secondrn)
STATE
REGTJLATED UNREGULATED
Antimony (Sb)Nitrate-N (Nq-N)Chloride (CI)Sodium (Na)Alkalinity
Ars€rdc (As)Nirite-N(NO2-N)kon (Fe)Ilardness Calcium (Ca)
Barftm @a)Total Nitrat€n{itrite Manganese (Mn)Con&ctivity Magpesium (Mg)
Beryllium @e)Nickel (Ni)Silver (Ag)Turbidity Potassium (K)
Cadmiun (Cd)Selenium (Se)Sulfate (SOr-2)Color pH
Chromium (Cr)Thallium (Tl)Zitc (7a\Other: (list)Chlorine Resi&ral (circlc)
Free aodlor Total
Cyanide (CN)STATE
[,NREGI,'LATT,D
Total Organic Carton
(TOC)
Orthophosphate-P
{POa-P)
Fluoride (F)Lead (Pb)Total Dissolved Solids Sulfr& (H2S)
Mercury (Hg)Copper (Cu)Bromate @rOr-)Tannin
SPECTRA Laboratories - Kitsap,LLC
DRTTIKING WATER SAMPLE rNT'ORMATTON (WSD FOR
INORGAIYIC CIIEMICAL ANALYSIS
See Sampling Instructions on back of page
Smple
Rdinqdrhed By:
SiBmtrre I)ite /fime:
SamplcRcived
By:
Siguture
A5
Drtc/TIrc:
Vhth,l0 Lo
Condition and
:'r*'"*""
Rftcipt:
Qoo
262T6TwelveTrecsLane,SuiteCAPoulsbo.WA9E3T0A(360)779-5l4lAFax:(360)779-5150A www.SpectraJab.com
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