HomeMy WebLinkAbout20230329 - CONST COMPLETION REPORT FORM.pdf()Henltlr CONSTRUCTION COMPLETION REPORT FORM
In accordance with WAC 246-290- t20 (5), a Constuction Completion Report is required for all approved construction projects.
Operators must submit a Construction Completion Report to us within sixty (60) days ofcompletion and before use ofany 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:
CITY OF RENTON DOH System ID No 718501
Name of Waler System
GEORGE STAHL DOH Project No.
Name of Pu.veyor (Owner or System Contaco
3555 NE 2ND STREET
Mailing Address
RENTON 98056 (lfapplicable)
City State Zip
PROJECT NAME AND DESCRIPTI\TE TITLE: WEATHERLY INN . MEMORY CARE FACILIry
CHECK ONE:tfntire Project Completed. ! Description of Portions Completed.
PROFESSIONAL ENGINEER'S ACKNOWLEDGMENT Gonptere irer,r beto* Attach additionat sheets as needed)
The undersigned professional engineer (PE), or their authorized agent, has iffpected the above-described project which, as to
layout, size and type ofpipe, valves and materials, reservoir and other designed physical facilities, has been constructed and is
substantially completed in accordance with construction documens reviewed by the purveyor's engineer or approved by the
Department of Health. ln 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 procedu.., t'Or"rrur" ,"st resutts t'and resuls of the bacteriotogical test(s) ffir this project
and certiry that they comply with the requilemeots of the construction standards/specifications approved by the Depanment of
Health. (Check all boxes that apply that are consistent with the nature ofthe project.)
(ifapplicable)
Date Construction Documents
Approved by DOH
This project changes the physical cap39i[y ofthe system to serve consu'ners. The system is now able to serve
equivalent residential units (ERUs.) UINot applicable
O3l23tZO23
Date Signed
LDC, lnc
Name of Engineering Firm
Ross Jarvis?I Name of PE Acknowl(lging Construction
141 1 State Ave NE, Suite 200
4,Mailing Address
Olympia WA 98506
Zip
Engineer's
Statey'Federal Funding Tfpe (if any)
Plesse retutn codpleted fo l to yout rcgioLql olJice checked below.
I NWRO Drinking water
Deprrtment of Health
20425 72"d Ave. s, ste 310
Kent, WA 98032-2388
2s3-39'.6750
E SWRO Drlnkiog water
Department of Health
PO Bor 47823
Olympia, WA 98504-7823
360-2363030
tr ERO Drinking Wat€r
Department of Health
16201 E. lndiana Ave, Suite 1500
Spokare Valley, WA 99216
509-329-2100
For people with disabilities, this document is available on request in other formats. To submit a request, please call l-800-525-0127
GDDI|TY call 7l I ).
The operutor ust uttach a completed Woter Ftcilities ltve ory (WFI) form in accordaace with WAC 246-290-120(6), dapplicable
Contact your regional olJice for lfFI forms ot additional Constructio| Co,npletion Repod Iorms.
DOH Forn 331-121-F (01/10)
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