HomeMy WebLinkAboutConstruction Completion Report Form for Submittal Exception Process_102120.pdfDOH Form 331-146 (Updated 08/10)
Construction Completion Report Form
for Submittal Exception Process
In accordance with WAC 246-290-120(5), a Construction Completion Report Form 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 storage
tank and booster pump facilities reviewed under the submittal exception process as provided by WAC 246-290-
125(3). Under the submittal exception process for other distribution-related facilities (including distribution main
projects), designed by a professional engineer but not submitted to DOH for approval, the report does not need to
be submitted. However, the purveyor must keep the Construction Completion Report on file and make it available
for review upon request by DOH in accordance with WAC 246-290-125 (2)(b) and WAC 246-290-125(3)(f).
Furthermore:
(1) The report form must bear the seal, date and signature of a professional engineer (PE) licensed in the
state of Washington;
(2) If project construction is being completed in stages, attach a description of the portion of the project being
completed as approved that is acknowledged by a PE on the date given below;
(3) As future portions of staged construction projects are completed, each must be acknowledged by a PE;
and
(4) Per WAC 246-290-120(5)(c), the amount of change in the physical capacity of a system must be
documented, if the project results in a change in physical capacity.
Please type or print legibly in ink:
_____________________________________ DOH System ID No.:__________________
Name of Water System
_____________________________________
Name of Purveyor (Owner or System Contact)
_____________________________________ Date WSP Approved by DOH___________
Mailing Address
_____________________________________
City State Zip
Type of Project (check all that apply):
(Project must be identified in the CIP of the Water System Plan)
Booster Pump Station(s) - If checked send form to DOH
Reservoir and Storage Tank(s) – If checked send form to DOH
Pressure Tank(s)
Internal Tank Coating
Transmission Main(s)
Other (specify):
For project reports and construction documents that have not been reviewed by DOH, provide name of PE who
completed Engineering Design Review Report Form (a departmental form):
______________________________________
Name of PE Shown as Review Engineer
city of renton 71850L
george stahl
3555 ne 2nd street
Renton WA 98056
9/19/2013
X
distribution main(s)
Sheri Murata, P.E.
DOH Form 331-146 (Updated 08/10)
Project Name and Descriptive Title:
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
_________________________________ Name of Engineering Firm**
_________________________________
Name of PE Acknowledging Construction
_________________________________ Mailing Address**
PE’s Seal
_________________________________
City State Zip**
____________________________________ **Complete if PE acknowledging construction
Engineer’s Signature Date completion is not employed directly by water
system.
Please return completed form to DOH regional office checked below if the project is for new
storage tanks or booster pump stations. For all other distribution related projects, please maintain
on file.
Northwest Drinking Water
Department of Health
2045 72nd Ave S, Suite
Kent, WA 98032-2358
Phone: (253) 395-6750
Fax: (253) 395-6760
Southwest Drinking Water
Department of Health
PO Box 47823
Olympia, WA 98504-7823
Phone: (360) 236-3030
Fax: (360) 664-8058
Eastern Drinking Water
Department of Health
16201 E Indiana Ave, Suite 1500
Spokane Valley, WA 99216
Phone: (509) 329-2100
Fax: (509) 329-2104
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.
,I\RXQHHGWKLVSXEOLFDWLRQLQDQDOWHUQDWHIRUPDWFDOO )RU77<7''FDOO
8 additional
Core Design, Inc.
Sheri Murata
19100 NE 195th St Suite 300
Bothell, WA 98011
10/20/2020
4
4