HomeMy WebLinkAboutBLD2004-00623 1
` .„ Jefferson County Department of Community Development
621 Sheridan St, Port Townsend WA 98368, (360) 379-4450
OCT - 1 2004
APPLICATION FOR
DETERMINATION OF ADEQUATE POTABLE WATER SUPPLY
Resolution #99-90 requires building permit applicants to provide evidence of an adequate potable water supply.
Name 1- ,�....- ...?., -•.- `.\.s :..1"'∎ Phone 3€ s" c) G .5"
Mailing Address I1 0 7 'mot-tom',-., ,k--. cic ...--z-\`ate 'J 4,-- < Zip Code ?c d3 La c,)
Parcel ID# c , `3\6 Subdiv. Block Lot(s)
Site Address k,b(-,h \ '~ ,4 Zip Code .2j
Type of Structure
Type of Evidence (check one)
Valid Water Right Permit (attach copy)
Approved Public Water (Submit the attached Water Availability Notification form completed by your water
purveyor stating the system is capable of and will supply water.)
Individual Well--attach copy of:
1) Well logs or pump test result.
2) Lab analysis for water quality parameters:
-Total coliform
-Nitrate-N
-Chloride and/or Sodium
3) Plot plan showing location of well with respect to 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 against 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 it's 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 by "ness boirrri.
Signature 40-' X� /. -�" , Date ()( 7 - C' a
H:AHOME\PLNC - NFOHLTH\WATEAREV1/00
, t.ftvl 5-71
FOR OFFICE USE ONLY
1) Water Right Permit# �/
2) Public Water Supply `�. .t -i 7 1
Washington State ID# 'l R
• U/
5
In Compliance Yes S. No
3) Individual Well -•'
Driller Name Date Drilled r 1
Depth Production cr-
Meets Water Quality Standards Yes No
Based upon in#ormation provided by the applicant, it appears that the potable water supply: V v
meets :tots does not meet
the conditions of RCW 19.27.097 and th nes Is re - %nom• Water Availability fo Ne :u7dings.
A lication Reviewed by Id � Date 11 I 0
Date !O (" Fee g —2"'ry Receipt # (:1775- Check #3'LZ1 Case # BLD C-1 4'` 10L
41e'°
III
i.-1,5d)02/12/03-RML
Public Utility District #1
Of Jefferson County
Board of Commissioners
WATER AVAILABILITY NOTIFICATION Dana Roberts,District 1
David W. Sullivan, District 2
PUBLIC WATER SYSTEM Wayne G. King, District 3
James G. Parker, Manager
To: Jefferson County Environmental Health Department
From: Water System: TRI AREA
System-Operator: Eric Selberg or Eric Storey WDM 2 & WD 3
State ID Number: 05783U
id `
Number of existing connections: 1700 Approx. l ; i OCT - 1 2004
l
Number of permitted connections: 2200 DEPT.OF j C T O MEtPtii`UdNlll' c UE l 'YLOP h
Y
This water system is capable of, and will supply potable water to the following location:
Assessor's Parcel ID #: 62()l g 30/
Legal Description:
Owners: Te r /,9 e e
Water is available provided all fees and Charges have been paid.
Site Address: /
2 3`3
Port Kacl:13ack, WA 98.33-9
k
Signature:
Title: Manager Date: 4/-6--03
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 Chi:: acum Road/PO. Box 929, Poi Hadiock,WA 98339 (360) 395-5800 FAX (3501 385-5945
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