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HomeMy WebLinkAboutBLD2004-00582 Jefferson County Department of Community Development < 621 Sheridan St, Port Townsend WA 98368,(360)379-4450 APPLICATION FOR DETERMINATION OF ADEQUATE POTABLE WATER SUPPLY Resolutions#99-90 requires building permit applicants to provide evidence of an adequate potable water supply.IN Name SIr�r .5c�P,-ce Phone 3 U/ -/ 7 V Mailing p Address '/ �Dop��lrn / °`-/ aG� . S°�,,1� IVI Zip Code ���� Parcel 11 / �C ID# 930 9,00 � ubdiv. iv / '�, /4-/-1,' v G / Block Lot(s) /� Site t / / (� Address �� N/D©���� via i�o/ .24,,,,,,7-54/ � 6 Zip Code Type of Structure /ff i.S �d s T�u C T�O/► ,L, j� Z' Check all that apply Note:Special conditions may apply within Seawater Intrusion Protection Zones. (SIPZ) Alternative system(provide justification and design per Jefferson County Environmental Health policy 97-01) Valid Water Right Permit(attach copy) Approved Public Water(Submit the attached Wafer Availability Notification form completed by your water purveyor stating the system is capable of and will supply water.) Individual We copy of: !!1 ! `'_, t :f�.` �_' ._ __. '" 1) Well logs (If no well log report is on file,a 1 hr stabilization test may be substituted) 2) Lab analysis for water quality parameters tested within 3 years of application: S E P 1 4 2004 i '{ -Total coliform i -. -Nitrate-N f -Chloride -= 3) Plot plan showing location of well with distances from proposed sewage system buildings, driveways and surrounding properties. Two-party Well—items above AND recorded Operation&Maintenance agreement and recorded Easement. By signing the application form,the applicant/owner attests that the information provided herein is true and correct to the best of their knowledge. Any material falsehood or any omission of a material fact made by the applicant/owner with respect to this application packet may result in this permit being null and void. I further agree to save, indemnify and hold. harmless Jefferson County against all liabilities,judgments, court costs, reasonable attorney's fees and expenses which may in any way accrue aganst Jefferson County as a result of or in consequence of the granting of this permit. I further agree to provide access and right of entry to Jefferson County and its employees, representatives or agents for the purpose of application review and any required later inspections. Access and right of entry to the applicant's property or structure shall be requested and shall occur during regular business hours. Slgnatu -� j c Date 9-vv-62 c .. n m z .1 ue a L: s ,z i n i,T i� :e 't �,.',„,,,7,14,,y.,^','''d -` r N D le �r_ I ,] m` nd� :L 4�` v�°�a�� does n 1@ a �w a 7an k 8 t t°t : ' litti Date Fee 4. t �. r l'APEVISED 02/11/03-RML Public Utility District #1 Of Jefferson County Board of Commissioners WATER AVAILABILITY NOTIFICATION Dana Roberts, District 1 PUBLIC WATER SYSTEM David W. Sullivan, District 2 Wayne G. King, District 3 James G. Parker, Manager To: Jefferson County Environmental Health Department From: Water System: Glen Cove South . System Operator: Mike McClure or Dous Reeder WDM's n EL J!i'i [1, tl tt: 11,-,:\ State ID Number: 025164 DI ' / 4 I L SEP 1 4 2004 ;,°-1, Number of existing connections: 1-O0-- Approx. Number of permitted connections: 179 _ELE_ car c���F,r, ���L�" �:r ,r,9 ±/*y r This water system is capable of, and will supply potable water to the following location: Assessor's Parcel ID #: 93 ' yb o bP - Legal Description: 1--0 T (7 f (..Vet./-Ax;,i .4cAL4. / r,i c_41- Owner: 1°C/ =d i--e-4'r- Provided all fees and charges have been paid Site Address: `-d'1(& Port Townsend, WA 98368 Signature: 111_44.-u___ LQi\__-. Title: A GG; 47 t)-XL�t- Date: ('- / 114 ".Y ** THIS IS NON-BINDING STATEMENT OF WATER AVAILABILITY. IT PROVIDES ONLY THAT AT THE TIME OF REQUEST WATER IS AVAILABLE WITHIN THIS SYSTEM. THE NOTIFICATION IS GOOD FOR ONE YEAR. 230 Chimacum Road J PG. Box 929, Port Hadlock, WA 98339 (360) 385-5800 FAX(360) 385-5945 • , , . 4 ,, , ____________... r_____ 3 ,, 0 0 cb cn 1 I " p r 1 • 2 —" '01 " f-i.:, , 1 1:: at 4 V m E IP 1 i ED n . 2 m 0 PO "a, rr. ° n r S Ca; **, , > (-) z , .., PS'. ° ' "' # c m Z � .1 `4 —.. ., .< 174.2 , ,. ,..'.--Ize.;(-7-/--,- 1� ..4 - ,i -vF . . 1 .x _., , u.,.:=__----_,..37 , . . ,..,--„, ,. , iN 2filk M Tit/i0 a'DVd GOO DO JA o W T hb6LELISE 5t: vi)-0z/1-[/k:°ct -..�,J 10/10 'd 8908179909£ 'ON XV.d lal,VM ONIXNIHa ISHMHIf OS Wd 2: 1 1 NOW 1700Z-0�-dHS