Project Approval Application Form 0011~~H2Cllth Project Approval ApplieatioD Form
Please fill m all project description information and check all boxes that apply below. If you are submitting a Water System Plan, please
use the Water System Pla¢ Submiml Fotm DOH f331-040.
Forester Heiehts Booster Pum- Station
(pr jeac namq
City ofYelm Public Water System 993501
(wazer system name) PWS IDk
Cirv of Yelm
(rys¢m own«)
Intersection of Highway 507 and Forrester Heights Drive
(svee0
Yehn WA 98597
fc3rsj (s[au7 (vp god J
(960) 458-84] 0
(phone numbs)
Thwston
(county)
Nicholas D. Taylor
(desip~cngineer)
KPFF Consulting Engineers
(engivecring SrmJ
4200 6's Ave, Suite 309
(so-eet)
Lacey WA 98503
(oil ~s[J (vp uodc)
(360)292-7290
(phove number)
Steve Chamberlain (360)458-8410 (360)458-8410
(pmject covma ddidxeenv Nan above) (daytime phwenumber) (cveving phone number)
Forrester Heights, LLC (360)493-6002 (360)493-2476
(billing coumct namo--required if not the same as above) (billing phone vumber) (billing foe number)
4200 6a' Ave, Suite 301 Yelm WA 98597
(billing addass) (city) (staNVpJ
SYSTEM CLASS: ®Group A Community ^ Group A NTNC ^ Group A TNC ^ Group B
q SERVICE CONNECTIONS (for Group A systems only - k services after project compdetion):
^ Less than 100 ^ 100 - 500 ^ 501 - 999 ®1,000 - 9,999 ^ 10,000 or more
PROSECT DESCRIPTION: New Booster Pump Station to supply proposed develaoment
AREA SERVED (for distribution projects onlyname subdivision, site address, parcel numbers, etc.): Fortester Heights Subdivision
TYPE OF PROTEC7 (check all that apply): Reminder: Ifsubmitunga Water System Plan, ase Gm, f331-040.
1. ^ DWSRF Loan 2. ^ Enforcement
Application k Type
Loan # Docke['p
3. ^ New Group B desig¢ report (Workbook)
4. ^ New Water System (A completed Water Facilities Inventory Report Form (WFI) must be included with this submittal)
5. ®Project report: (Is a water system pla¢ required: ^ Y ®N If requved, is it current and approved: ^ Y ^ N)
Qs the project identiSed as part of the capital improvement plan: ^ Y ®A~
^ Filna[ion or other complex treatment
^ Chemical addition only (ion exchange, hypoehlorinatioq corosion control, or fluoridation)
^ Complete new water system
^ Major system modification
6. ^ Special reports or plans:
^ Corrosion Control Report
^ Corosian Control Study
^ Plan to Cover uncovered Reservoir
7. ^ Predesig¢ study
^ Uncovered reservou plan of operation
^ Tmcer study plan
^ Swface water or G WI treatment Cacility opea[ion plan
^ Filtration pilot study
DOH Form #331-149 (Updated 03/07) Page I oft
8. ^ Existing system approval
^ Sonexpanding; not detailed evaluation
^Son-expanding detailed evaluation
^ Expanding, not detailed evaluation
^ Expanding, detailed evaluation
® Construction documents:
^ FIlnation or other complex treatment
^ Chemical addition only
^ Complete new water system
^ Few source only
^ System modification
® System modification; denim standards used; PE prepazed
10.^ Waivers:
^ Inorganic chemical (iNtiap
^ Organic chemical (mitiap
^ Use
^ Area wide renewal
^ Inorganic chemical (renewal)
^ Organic chemical (renewal)
^ Use (renewal)
^ Colifirm (w/departmental inspection)
^ Cohfo® (w/ third-parry inspection)
l1. ^ Other
^ Well-site evaluator and approval
^ Regulatory monitoring plan
^ Unfiltered system annual report
^ Water system compliance report (loan letter)
^ Water righ[self-assessment (if applicable)
12. Other projects (describe)
P/ease return completed jarm to the Offrce of Drinking Water regional office checked below.
^ NWRO Drinking Water
Department of Health
20435 ]2n° Ave. S, Ste 200
Kevt, WA 98032-2358
(253) 395b]50
® SWRO Drinking Water
Department of Health
PO Baz 47823
Olympia, W'A 98504-]823
(360)236-3030
^ SRO Drinking Water
Department of Health
1500 W. Fourth Ave, Suite 305
Spokane, WA 99201
(509) 456-3115
For Depvtrnrnt use aNy.
OD W Pmjeci W Urifiat fei
Invoicek Fee
Approval Date:
Area served'
Prm~isions:
Daze canstmction report received:
# approved connecfions
For persons with disabilities, this document is available on request in other formats. To submit a request, please call 1-800-
525-0127 (TTY 1-800-833E388).
Date invoice mailed:
Review letters sent:
DOH Form #331-149 (Updated 03/07) Page 2 oft