20120188 DOH Approval Ltr 10092012 � ��r�,STATE o� .
04 Q
Y
W x
,P �?
� .
�y'�1889��y
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
SOUTHWEST DRINKING WATER REGIONAL OPERATIONS
PO Box 47823,Olympia,Washington 98504-7823
TDD Relay 1-800-833-6388
October 9, 2012
Edward Smith
; Yelm, City of
� 105 Yelm Avenue West
Yelm, Washington 98597
Subject: Yelm, City of Water System, ID #99350, Thurston County; Palisades Booster
� Pump Station, ODW Project#12-0814
Dear Edward Smith:
The design approval documents for the above project received by the Office of Drinking Water
(ODW) August 28, 2012, have been reviewed and in accordance with the provisions of WAC
246-290 are APPROVED. The approval issued herein is based on conformance with current
standards outlined in WAC 246-290, revised effective Apri130, 2012. Future changes in the
rules may be more stringent and require facility modification or corrective action.
This project has been reviewed as a Group A water system project submittal in accordance with
WAC 246-290.
As required by WAC 246-290-120—within sixty days following the completion of and prior to use
of this project or portions thereof,the following must be completed and submitted to ODW:
• A Construction Completion Report form signed and stamped by a professional engineer
licensed in the state of Washington.
• An updated Water Facilities Inventory(WFI)report form reflecting the changes or additions
resulting from this project.
Based on information provided in this project,the number of approved service connections remain
at 3,540.
WAC 246-290-120 (8)provides that this approval is in effect for two years, unless ODW
determines a need to withdraw the approval. An extension of the approval may be obtained by
L��1
.
Edward Smith
October 9, 2012
Page 2
submitting a status report and a written schedule for completion. Extensions may be subject to
additional terms and conditions imposed by ODW.
Regulations established a schedule of fees for review of planning, engineering, and construction
documents (WAC 246-290-990). The total cost is $377.40. An itemized invoice showing the
amount due of$377.40 is enclosed.
Sincerely,
��( �-��,,�-�.�-�-.
Jozsef Bezovics, P.E.
�
Office of Drinking Water, Regional Engineer
Enclosures
cc: Thurston County Health Department
Construction Completion Report
In accordance with WAC 24Cr290-120(5),a Construction Completion Report is required for all approved construction
projects. Purveyors must submit a Construction Completion Report to the Department of Health (DOH)within siNy(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 ar print legibly in ink:
YELM,CITY OF DOH System ID No.: 99350
Name of Water System
EDWARD SMITH DOH Project No.: 12-0814
Name of Purveyor(Owner or System Contact) (if applicable)
105 YELM AVE W Date Construction Documents
Mailing Address Approved by DOH
YELM,WA 98597 (If applicable)
City State Zip
Project Name and Descriptive Title: PALISADES WEST BOOSTER PUMP STATION
Check one:
❑ Entire Project Completed. ❑ Description of Portions Completed.
Comp[ete(Attach additional sheets as needed):
Professional Engineer's Acknowledgment
The undersigned professional engineer(PE),or their autha�ized agent,has inspected the abov�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 cbcuments 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 reguhtions and principles of standard engineering practice.
I have reviewed the disinfection procedures❑ ,pressure test results 0 , and results of the bacteriological test(s)0 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 consuners. The system is now able to serve
equivalent residential units(ERUs.) ❑Not applicable
Date Signed
Name of Engineering Firm
P.E.'s
Seal Name of PE Acknowledging Construction
Mailing Address
City State Zip
Engineer's Signature
State/Federal Funding Type(if any)
Please return comp[eted farm to DOH regiona!o/'fce checked below.
❑ NWRO Drinking Water �SWRO Drinking Water ❑ ERO Drinking Water
Department of Health,K17-12 Department of Health Department of Health
20435 72nd Ave S,Suite,200 PO Box 47823 16201 E Indiana Ave,Suite 1500
Kent,WA 98032 Olympia,WA 985047823 Spokane Valley,WA 99216
(253)395-6750 (360)236-3030 (509)329-2100
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 additiona!Construction Completion Report forms.
DOH 331-121 (3/00)
WATER FACILITIES INVENTORY (WFI) FORM Quarter:1
w�8+�su7fe��t�f Updated:03/09/2012
����e���'� ONE FORM PER SYSTEM Printed:10/09/2012
WFI Printed For:On-demand
L p i i .1 f.''r. r �",?!f}<�:?I?r
� t � � >r�=;. . 1 = Submission Reason:Source Update
RETURN T0: Southwest Re ional Office PO Box 47823 01 m ia WA 98504
1. SYSTEM ID N0. 2. SYSTEM NAME 3. COUNTY ` 4. GROUP 5. TYPE
' 99350 J YELM, CITY OF THURSTON A Comm
6. PRIMARY CONTACT NAME&MAILING A[3�3RESS 7.OWNER NAME&MAtLtNG ADDRESS $,pwner Number Q06806
EDWARD B. SMITH [OPERATOR] YELM, CITY OF
105 YELM AVE W TIMOTHY M. PETERSON Tir�E:PUBLIC WORKS DIREC
YELM,WA 98597 105 YELM AVE W
YELM,WA 98597
STREET ADDRESS IF QtFFERENT FROM ABaVE' STREET ADDRE3S IF DIFFERENT FRON[ABOVE
ATTN ATTN
ADDRESS 204 2ND ST SE ADDRESS
CITY YELM STATE WA ziP 98597 CITY STATE ZIP
9. 24 HOUR PRIMARY CONTACT INFORMATION 1 O. OWNER CONTACT INFORMATION
Primary Contact Daytime Phone: (360�458-3244 Owner Daytime Phone: (360�458-8499
Primary Contact MobilelCell Phone: Owner MobilelCell Phone: �36Q�45$-$4Q6
Primary Contact Evening Phone: (360�446-7278 Owner Evening Phone: (360)894-2698
Fax:(360)458-8417 E•ma�i: smitty@ci.yelm.wa.us FaX: (360)458-8417 E-ma�i: timp@ci.yelm.wa.us
�i i •� � � �• . . � � � �-
11. SATELLITE MANAGEMENT AGENCY-5MA(check`only one)
� Not applicable(Skip to#12)
❑ Owned and Managed SMA NAME: SMA Number:
❑ Managed Onty
❑ Owned Only
12. WATER SYSTEM CHARACTERISTICS(mark ALL that apply)
�Agriculturat �( Hospital/Clinic �Residential
�Commercial/Business � Industrial �School
�S(Day Care � Licensed Residential Facility ❑Temporary Farm Worker
�Food Service/Food Permit � Lodging �S(Other(church,fire station,etc.):
❑1,000 or more person event for 2 or more days per year �( Recreational/RV Park
13. WATER SYSTEM OWNERSHIP(mark only o�e) 14. ST�FWGE CApAC17Y�gallonS}
�Association ❑ Counry ❑ Investor ❑SpecialDistrict
�City/Town ❑ Federal ❑ Private �State �,���,���
15 16 17 18 19 2 21 22 23 24
SOURCE NAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION
LIST UTIUTY'S NAME FOR SOURCE
AND WELL TAG ID NUMBER. o a r w �, Z
r..r� � w W o W o
ti' �y � r u. � w
'z Example: WELL#1 XYZ456 INTERTIE � z W a � > � ? � Z Z w
d SYSTEM W � a a LL "' o o "' a � o �
o IF SOURCE IS PURCHASEO aR INTERTIED, ID W ¢ LL z w w Z w Q Z � Q p Q � � � v w � z a
N Z V > Z Z w W ? � O Q � H a d y Z S
LIST SELLER'S NAME NUMBER � J J ? z z 3 LL z w � r°n � � w o ag �o ° w w ? a � ° z �
Example: SEATTLE w w w a a a u� � � � w u� � o o i � � � � � � �' w 3 Z
3 3 3 cn rn rn rn rn o a v> w �n z c� �Z W � o �n � a
S01 WELL#1 AAA943 X X Y X X 57 275 SW SW 19 17N 02E
S02 WELL#2 AAA944 X X Y X X 61 1700 SW SW 19 17N 02E
S03 InAct 10/21/1999 WELL#3 AAA945 GWI X X X 40 500 SW SW 20 17N 02E
SO4 WELL#4 3A GWI AGP800 X X Y X 40 400 SW SW 20 17N 02E
S05 WELL#1A ALG255 X X Y X X 57 1700 SWSW 19 17N 02E
DOH 331-011 (Rev.06/03) Sentry DOH Page: 1
i
WATER FACILITIES INVENTORY (WFI) FORM - Continued
'I. SYSTEM ID N0. 2. SYSTEM NAME 3. COUNTY 4. GROUP 5, TYPE
99350 J YELM, CITY OF THURSTON A Comm
ACTNE SERVICE DOH USE ONLY! DOH USE ONLY!
CONNECTIONS CAICUTATED APPROVED
ACTIVE ONNECTION
25. SINGLE FAMILY RESIDENCES(How many of the following do you have?) 0 2824 3540
A. Full Time Single Family Residences(Occupied 180 days or more per year) 2313
B. Parl Time Single Family Residences(Occupied less than 180 days per year) Q
26. MULTI-FAMILY RESIDENTIAL BUILDINGS(How many of the fol;owing do you have?)
A. Apartment Buildings,condos,duplexes,barracks,dorms z�
B. Full Time Residenlial Units in ihe Apariments,Condos,Duplexes,Dorms that are occupied more than 180 days/year 5�1
C. Parl Time Residential Units in the Aparlments,Condos,Duplexes,Dorms thaf are occupied less than 1 BO dayslyear �
27. NON-RE5IDENTIAL CONNECTIONS(How many of the following do you have?)
A.Recreational Services and/or Transient Accommodations(Campsites,RV sites,hotellmotellovernight units) 67 67 �
B. Institutional,CommerciallBusiness,School,Day Care,Industrial Services,etc. 326 326 Q
28. TQTAL SERVICE GONN��7`IONS 3217 3540
29. FULL-TIME RESIDENTIAL POPULATION'
A. How many residents are served by this system 180 or more days per yea(? 5815
30. PART-TIME RESIDENTIAL POPULATION �AN FEB' MAR APR MAY JUN JUL AUG SEP' OCT NOV DEC
A. How many part-time residents are present each month?
B. How many days per month are they present?
31. TEMPORARY&TRANSIENT USERS JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
A. How many total visitors,attentlees,travelers,campers, 60000 60000 60000 60000 60000 60000 60000 60000 60000 60000 60000 60000
patients or customers have access to the water system
each month?
B. How many days per month is water accessible to the 30 30 30 30 30 30 30 30 30 30 30 30
public?
32. REGULAR NON-RESIDENTIAL USERS JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
A. If you have schools,daycares,or businesses connected 3400 3400 3400 3400 3400 3400 1243 1243 3400 3400 3400 3400
to your water system,how many students daycare
chldren and/or employees are present each month?
B. How many days per month are they present? 20 20 20 20 20 20 20 20 20 20 20 20
33. ROUTINE COLIFORM SCHEDULE JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
10 10 10 10 10 10 10 10 10 10 10 10
35. Reason for Submitting WFI:
❑Update-Change ❑Update-No Change ❑Inactivate ❑Re-Activate ❑Name Change ❑New System ❑Other
36. I certify that the information stated on this WFI form is correct to the best of my knowledge.
SIGNATURE: DATE:
PRINT NAME: TITLE:
DOH 331-011 (Rev.06103) Sentry DOH Page: 2