HomeMy WebLinkAboutDOH Construction Completion.pdf CONSTRUCTION COMPLETION REPORT FORM
In accordance with WAC 246-290-120 (5), a Construction Completion Report is required for all approved construction projects.
Operators must submit a Construction Completion Report to us within sixty (60) days of completion and before use of any 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:
DOH System ID No.:
Name of Water System
DOH Project No.:
Name of Purveyor (Owner or System Contact) (if applicable)
Date Construction Documents
Mailing Address Approved by DOH
(If applicable)
City State Zip
PROJECT NAME AND DESCRIPTIVE TITLE:
CHECK ONE: Entire Project Completed. Description of Portions Completed.
PROFESSIONAL ENGINEER’S ACKNOWLEDGMENT (Complete items below–Attach additional sheets as needed)
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
Department of Health. 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 Department of
Health. (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 ________________________________________________ Date Signed
________________________________________________ Name of Engineering Firm
________________________________________________ Name of PE Acknowledging Construction
________________________________________________ Mailing Address
________________________________________________ City State Zip
______________________________________________________ Engineer’s Signature
State/Federal Funding Type (if any)
Please return completed form to your regional office checked below.
NWRO Drinking Water SWRO Drinking Water ERO Drinking Water Department of Health Department of Health Department of Health
20425 72nd Ave. S, Ste 310 PO Box 47823 16201 E. Indiana Ave, Suite 1500 Kent, WA 98032-2388 Olympia, WA 98504-7823 Spokane Valley, WA 99216
253-395-6750 360-236-3030 509-329-2100
For people with disabilities, this document is available on request in other formats. To submit a request, please call 1-800-525-0127 (TDD/TTY call 711).
The operator must attach a completed Water Facilities Inventory (WFI) form in accordance with WAC 246-290-120(6), if applicable. Contact your regional office for WFI forms or additional Construction Completion Report forms.
P.E.’s Seal
DOH Form 331-121-F (01/10)
AHBL
2215 N 30th St Ste 300,
Tacoma, WA, 98403
WALKER RENTON MAZDA DEALERSHIP -
WATER MAIN EXTENSION
06/02/2021
06/02/2021
J. Matthew Weber