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    Construction Completion Report Form: Please Type or Print Legibly in Ink

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    Nyi Nandarsheinn
    This document is a construction completion report form that water system operators must submit to the Department of Health within 60 days of completing any approved construction project. The form requires information about the water system and project, acknowledgment from a professional engineer inspecting the project, and certification that disinfection and testing procedures were completed according to state regulations. It also indicates whether the project changed the system's capacity to serve more users. Operators must submit this form before using any new or updated facilities.

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    Construction Completion Report Form: Please Type or Print Legibly in Ink

    Uploaded by

    Nyi Nandarsheinn
    7 views1 page
    This document is a construction completion report form that water system operators must submit to the Department of Health within 60 days of completing any approved construction project. The form requires information about the water system and project, acknowledgment from a professional engineer inspecting the project, and certification that disinfection and testing procedures were completed according to state regulations. It also indicates whether the project changed the system's capacity to serve more users. Operators must submit this form before using any new or updated facilities.

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    331-121-F

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    This document is a construction completion report form that water system operators must submit to the Department of Health within 60 days of completing any approved construction project. The form requires information about the water system and project, acknowledgment from a professional engineer inspecting the project, and certification that disinfection and testing procedures were completed according to state regulations. It also indicates whether the project changed the system's capacity to serve more users. Operators must submit this form before using any new or updated facilities.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    7 views1 page

    Construction Completion Report Form: Please Type or Print Legibly in Ink

    Uploaded by

    Nyi Nandarsheinn
    This document is a construction completion report form that water system operators must submit to the Department of Health within 60 days of completing any approved construction project. The form requires information about the water system and project, acknowledgment from a professional engineer inspecting the project, and certification that disinfection and testing procedures were completed according to state regulations. It also indicates whether the project changed the system's capacity to serve more users. Operators must submit this form before using any new or updated facilities.

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    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
    P.E.’s Seal
    __________________________________________________
    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.

    DOH Form 331-121-F (01/10)

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