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CtiRTII'ICATION 01' INSPCCTION AND INSTALi.t1TI0N OF PUIILIC WATER SYSTEM PROJtiCTS <br />�. <br />Efl'ective January 16, 1971 die Pollowing Re�ulation shall apply: WAC 248-54-340 - Within <br />sixty days following tl�e completion of and prior to the use of any project or portions <br />thereof for wliicli plans and specitications have received tlie approval of the Secretary, n <br />cerl'ificntion shall be made to the Secretary and signed by a professional engineer that <br />tlie project was inspected by him or his auehorized agent and that it was constructed in <br />nccardance with [he plans and specifications approved by the Secretary, <br />Instructions: <br />(a) If n project is being completed in stage construction, attacl� a map and description <br />�f portion of project 6eing certified as completed as approved on da�e given below. <br />(b) As fu[ure portions of staged construction projects are completed, eacti must be <br />certified as required by WAC 248-54-340. <br />(c) Additional certification forms are availnble upon request from DSNS offices listed <br />below. <br />' EvereCt 4Jater Department <br />Name of �Aater System , <br />3102 Cedar <br />Mailing Address <br />Everett Washington 98201 <br />City State Zip <br />PROJECT NAME: • <br />Port of Everett <br />Newitt Ave, Terminal <br />Interstate 4latering Points <br />DSHS I.D. No. <br />24050 <br />Date Approved by Deparl•ment of <br />Social & Ilealth Services 3/17/72 <br />Date Project or Portions <br />Thereof CompleLed <br />I hereby certify that the above identified project was inspected by me or my autl�nrized agent <br />and that it was installed in accordance wilh Che plans and specifications approved by Llie <br />Secretary, Depar:ment of Social and Ne21th Services. �—�� <br />• i � <br />/ \ <br />! Engincers � <br />Professional Engineers Signal•ure 1 Seal � <br />� � <br />Date � <br />�� � <br />Please return complete<1 form to DSlIS officc cliccked below <br />� Seattle Re�ional Office �jOlympia Re�ional Office I iSpokane Rc�;ional OfLice <br />Divtsion of liealtli Division of Ile�lth Division of llealtli <br />Water Supply & ldasle Section Water Supply & 4laste Section Wnter Supply & WasCe Sec. <br />Snitl�'Powcr 6uildin� P.O. Isox 709 West 924 Si.nto Avenuc <br />Seatl•]c, Wasl�ingCon 98104 Olympia, ldanhington 98501 Spolcanc, k4�shin�ton 99201. <br />HEA-797 1/)1 <br />