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Home My WebLink AboutBLD2021-00362-04- 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. Bl d g P er mi 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 932200701BeckettPointFishermen's Club, John & Terri Zagula PUD - Quimper Water 1220 Beckett Point Road, Port Townsend, WA 98368 4 4 Supplemental 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. 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 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. 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 Jun 17 2021 PH (360) 385-5800 FX (360) 385-5945 /P.O. Box 929, Port Hadlock, WA 98339 customerservice@jeffpud.org 310 Four Corners Road, Port Townsend, WA 98368 To: Jefferson County Environmental Health Department From: Quimper Water System System Operator(s): Eric Storey State ID Number: 05783U Number of existing connections: 3462 (Estimated) Number of permitted connections: Unspecified Number of committed connections: 3462 This water system is capable of; and will supply potable water to the following location: Assessor’s Parcel ID# 932200701 Legal Description BECKETT POINT FISHERMAN'S CLUB ASSESSOR'S PLAT SOUTH BEACH ANNEX LOTS 1 & 1A Water connection is available once all fees and/or charges have been paid *** Site address: 1220 Beckett Point Rd, Port Townsend, WA 98368 ____________________ Signature: April Owen ___________________________________ Date 06.17.2021 Title: Jefferson County PUD CSR _________________________________________________ THIS IS A NON-BINDING STATEMENT OF WATER AVAILABILITY. IT PROVIDES THAT AT THE TIME OF REQUEST, WATER IS AVAILABLE WITHIN THIS SYSTEM. THIS NOTIFICATION IS GOOD FOR ONE YEAR. Board of Commissioners Jeff Randall, District 1 Kenneth Collins, District 2 Dan Toepper, District 3 Kevin Streett, General Manager