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Home My WebLink AboutBLD2021-00602 - 04 Potable WaterReceived by DCD 10/12/2021 Received by DCD 10/12/2021 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. 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 4 937-200-301Quilcene School District 4/27/2022Brian Ho corner of Old Railroad Grade Road, and East Rose St, Quilcene, WA April 18, 2022 Joseph Baisch Quilcene School District #48 3485 Dosewallips Road Brinnon, Washington 98320-9645 Subject: Quilcene School District #48 Water System, ID #19176, Jefferson County; Bus Barn Expansion, ODW Project #22-0318, APPROVAL Dear Joseph Baisch: The submittal we received on March 29, 2022, together with materials received on March 30 and April 15, 2022, are APPROVED in accordance with the provisions of WAC 246-290. Future changes in the rules may be more stringent and require facility modification or corrective action. The approved scope of work includes system expansion to serve a new bus barn and pumping system modifications. CAPACITY AND AREA SERVED The analysis presented in this document demonstrates that the water system has adequate capacity to serve the following: • Quilcene Elementary School (1 connection). • Quilcene Middle School (1 connection). • Quilcene High School (1 connection). • A bus barn (1 connection). • A gymnasium/kitchen (1 connection). The approval of this document establishes that this water system is able to serve a total of 5 connections. It is your responsibility to ensure that physical capacity and water rights are not exceeded. This system’s area served now includes parcels 937200103, 937201151, 937201150, 937200901, 937200201, and 937200301, as they are presently defined. Joseph Baisch April 18, 2022 Page 2 PROJECT COMPLETION As required by WAC 246-290-120–within sixty days after construction and prior to use of the approved facilities, submit the following by e-mail to swro.admin@doh.wa.gov: • A Construction Completion Report form, signed and stamped by a professional engineer, licensed in the state of Washington. • An updated Water Facilities Inventory (WFI) form reflecting the changes or additions resulting from this project. Please use the most current WFI form using our Sentry Internet database at https://fortress.wa.gov/doh/eh/portal/odw/si/Intro.aspx. We will update the treatment status on your Water Facilities Inventory (WFI) once we acknowledge the Construction Completion Report form. This approval is valid for two years unless we determine a need to withdraw the approval, WAC 246-290-120. If you need an extension, please send us a written schedule for completion. Extensions may be subject to additional terms and conditions. WATER RIGHTS Our approval of your water system design does not confer or guarantee any right to a specific quantity of water. The approved number of service connections is based on your representation of available water quantity. If the Department of Ecology, a local planning agency, or other authority responsible for determining water rights and water system adequacy, determines you have use of less water than you represented, the number of approved connections may be reduced commensurate with the actual amount of water and your legal right to use it. If you have any questions, please contact me at (360) 236-3018 or by e-mail at rscott.pollock@doh.wa.gov. Sincerely, R. Scott Pollock, P.E. Office of Drinking Water, Regional Engineer Enclosures cc: Raquel Callans, Davido Consulting Group, Inc. Emma Erickson, Jefferson County Public Health Construction Completion Report In accordance with WAC 246-290-120(5), a Construction Completion Report is required for all approved construction projects. Purveyors must submit a Construction Completion Report to the Department of Health (DOH) within sixty (60) days of completion and before use of any water system facility. This includes any source, water quality treatment, storage tanks, booster pump facilities, and distribution projects. Please type or print legibly in ink: QUILCENE SCHOOL DISTRICT 48 DOH System ID No.: 19176 Name of Water System JOSEPH BAISCH DOH Project No.: 22-0318 Name of Purveyor (Owner or System Contact) (if applicable) 3485 DOSEWALLIPS RD Date Construction Documents Mailing Address Approved by DOH BRINNON, WA 98320-9645 (If applicable) City State Zip Project Name and Descriptive Title: BUS BARN EXPANSION Check one: Entire Project Completed. Description of Portions Completed. Complete (Attach additional sheets as needed): Professional Engineer’s Acknowledgment The undersigned professional engineer (PE), or their authorized agent, has inspected the above-described project which, as to layout, size and type of pipe, valves and materials, reservoir and other designed physical facilities, has been constructed and is substantially completed in accordance with construction documents reviewed by the purveyor’s engineer or approved by the DOH. In the opinion of the undersigned engineer, the installation, physical testing procedures, water quality tests, and disinfection practices were carried out in accordance with state regulations and principles of standard engineering practice. I have reviewed the disinfection procedures , pressure test results , and results of the bacteriological test(s) for this project and certify that they comply with the requirements of the construction standards/specifications approved by the DOH. (Check all boxes that apply that are consistent with the nature of the project.) This project changes the physical capacity of the system to serve consumers. The system is now able to serve equivalent residential units (ERUs.) Not applicable ______________________________________ Date Signed ______________________________________ Name of Engineering Firm ______________________________________ Name of PE Acknowledging Construction ______________________________________ Mailing Address ______________________________________ _______________________________ City State Zip Engineer’s Signature __________________________________________ State/Federal Funding Type (if any) Please return completed form to DOH regional office checked below. NWRO Drinking Water SWRO Drinking Water ERO Drinking Water Department of Health, K17-12 Department of Health Department of Health 20435 72nd Ave S, Suite, 200 PO Box 47823 16201 E Indiana Ave, Suite 1500 Kent, WA 98032 Olympia, WA 98504-7823 Spokane Valley, WA 99216 (253) 395-6750 (360) 236-3030 (509) 329-2100 The purveyor must attach a completed Water Facilities Inventory (WFI) form in accordance with WAC 246-290-120(6), if applicable. Contact the regional office in your area for WFI forms or additional Construction Completion Report forms. P.E.’s Seal DOH 331-121 (3/00)