DOE BAY WATER USERS ASSOCIATION

Physical location: 3634 Pt. Lawrence Road

Mailing address: PO Box 28   Olga, WA  98279

Voice and Fax: (360) 376-4990

www.doebay.net

 

DBWUA Prospective Member Data Form

To be completed by the Prospective Member

Purpose

The purpose of this form is to assist in collecting essential membership data and to evaluate a property being considered for membership and/or a hookup in DBWUA so that:

  1. Service requirements are fully understood by DBWUA and the conditions of service can be determined and communicated to the applicant.
  2. The applicant fully understands the necessary actions that he/she will have to take to assure minimum service performance to the property in question.
  3. A staff recommendation for membership can be made to the Board of Directors.

Prospective Member Data

 

 

­­­­­­­­­­______________________________________________          _____________________________________________

Name in which the membership will be held              Physical address or location of the property to be served

                             (As it appears on the Tax Roll)

Legal description of the property:

 
 

 

 

 

 

 

 

 

 

 


___________________________________________________________________________________

Billing address

 

___________________________   ____________________________ _______________________         

                    Phone (day)                                              Phone (other)                         Tax Parcel Number (TPN)

 

 

Transferred from (if applicable): _____________________________    Number of living units: ______    

 

 

______________________________________________________________________________________

               Description of the use of the membership (e.g. single family house, guest house)

Property/Water Use Data

__The applicant must submit a site plan showing north, lot lines, lot line dimensions, elevation of house, distance of house from roadway, driveways, roadways, septic systems, utility trenches, TPN, building footprints, and major topographical features (e.g. streams, cliffs). This site plan can be hand-drawn but must be neat and at a legible scale.

 

__What is the applicantıs intended peak demand in gallons per minute (gpm) of the proposed use? For a typical single family house this is typically around 15 gpm but the applicant should also factor in continuous flows (e.g. fountains) or extraordinary periodic demands such as a large irrigation system. The applicantıs architect can provide useful information or DBWUA staff may be able to help.  Peak demand in gallons per minute: _____________gpm

 

 

 

___________________________________              _________________________________     _______

                     Submitted by (print)                                                   Submitted by (signature)                          Date

DBWUA Prospective Member Service Evaluation Form

To be completed by DBWUA

Membership Data

 

_________________________

Membership certificate number

 

___ Single family residential         ___ Guest house              Other: ______________________________

 

# of living units total on property: _____

Service Data

 

Is a main abutting the property? ____          Size? ______inch            Material? ______________

 

Tank supplying water? _________________             Tank bottom elevation? _____________ft.

 

Static pressure at ROW? _________ psi        Service connection loss at peak flow (use 25ı)? ________psi

 

Residual pressure at meter during peak flow? _______ psi      Distance from ROW to house? ________ft.

 

Peak flow as reported by applicant? _______gpm      Service line loss during peak flow? _________psi

 

Pressure available at house during peak flow? ________psi     Booster pump needed? ____________

 

Size of tap to be installed? ________ inch       Size of meter to be installed? ________ inch

 

Recommended size of service line? ________ inch    Backflow protection needed? __________________

 

Fire protection provided by? __________________________________    Main extension needed? _____

Information provided to applicant on (insert date)

Bylaws (v.5/18/03): ________________                                Conditions of Service (v.7/10/03): ________

 

Design & Construction Standards (v.7/10/03): ______              Easement form (v.11/99): __________

 

Prospective Member Info. Brochure (v.       ): ________           Application form (v. 11/23/03): _________

 

Booster Pump Agreement (v. 11/23/03): __________                Water Availability Form (SJC): __________

Financial Data

Annual Fee due as of /date: $___________/                         Summer Surcharge due as of /date): $___________ /     

 

Membership fee as of/date: $ __________/               Hookup fee as of/date:                       $___________/  

           

Transfer fee as of/date:        $__________/               Other (Cow Hill/Roehlıs Beach/Viereck Plat):$_______________

Recommendation to Board

 

Fees paid?: _________     Application form complete?: _________      Easement form complete?: ______

 

Hookup fee paid (if applicable)?: _________ Other?: ____________________________________

 

Staff recommendation:   __ Recommended        ___ Not Recommended (state reason): ______________­____________

 

Staff signature: ________________________________         Date: ________________

Special Terms and Conditions for Application Form