DDW-2025-007380

^tf^SlJSm&l*^
"'Cental PfO^*
July 23, 1997
BEAR RIVER HEALTH DEPARTMENT
655 East 1300 North • Logan, Utah 84341
Phone:[phone]
Fax:[phone]
A^ r?,
(^/c,
Bob Foote
Willard Bay State Park So.
900 West 650 North #A
Willard, UT 84340
Re: Sanitary Survey
Dear Mr. Foote:
Enclosed is the Sanitary Survey for the Willard Bay State Park
Water Systein conducted July 11, 1997 by yourself and Grant Koford
of Bear River Health Department. I appreciate your cooperation and
assistance in conducting the survey.
The Utah Public Drinking Water Rules now include a system of rating
public water utilities called the Improvement Priority System. All
non-community water systems will receive a rating from 0 to 100
points based on violations of the Drinking Water Rules. Any system
receiving 100 points or more will be rated "Not Approved" if
corrections are not made. Points accumulated during a sanitary
survey will only become part of your total if corrections are not
made on or before the date that has been set next to each item.
When corrections are made, please document the changes and submit
a letter to our office and the Division of Drinking Water or
contact our office for a follow-up inspection.
The Willard Bay State Park Water System received 14 points on this
sanitary survey.
Conclusions and Recommendations:
1. The air relief valve on the discharge piping must be down
turned and screened with a #14 mesh screen. (R309-106-5(7) (e)
2. The chlorinator feed vent must have the end covered with a #14
mesh screen. (R309-107-5(2)
3. A means to measure the volume of water that has been treated
with chlorine must be provided. (R309-107-5(2))
4. The air vent on the wet well must be screened with a new #14
mesh screen.
8)7 West 950 South
Brigham City, Uiah 84302
Phone:[phone]
Fax: [phone]
125 South FiRt West
Tremonton, Urah 84337
Phone: [phone]
Fax: [phone]
Courthouse
Randolph, Utah 84064
Phone; 793-2445
Fax: [phone]
If you have any questions, please contact our office
Sine
Gr^ntr Ko:
Division of' Environmental Health
cc: David F. Hansen, M.P.H,
Division of Drinking Water
UTAH DIVISION
PUBLIC WATER SUPPLY INFORMATION StSTEM
03/26/96
HATER STSTEM NUMBER: 02030
NAME: WILLARD BAY STATE PARK SO
OWNER: STATE PARKS & RECREATION
ADDRESS: 900 y 650 N #A
UILLARD UT 84340
AREA: SO UILLARD
COUNTY: BOX ELDER
TYPE: STATE PARKS 6 REC.
MANGR.: ROLAN BRINGHURST
PHONE: [phone]
OPER.: BOB FOOTE
PHONE: [phone]
RATING:
RATING ASSIGNED:
INVENTORY REVIEWED:
INVENTORIED BY:
LAST SURVEYED:
SURVEYED BY:
LAST PLAN APPR.;
SYSTEM ENGINEER;
BEGIN OPERATION:
END OPERATION:
/ /
07/20/95
SCANLAN
09/01/93
KOFORD
/ /
PARKS AND
05/15
09/30
POPULATION: 700
RESIDENTIAL CONN,:
OTHER CONNECTIONS: ^ U>
TOTAL NO. CONNECTIONS; 8
TYPE OTHER CONN: NO CLASSIFICATION
OUTSIDE USE PERMITTED: YES
CALC PEAK DEHAND (GPD):
GPD/1440 = DEHAND (GPM):
PEAK HOURLY DEHAND:
-BACTERIOLOGIC QUALITY-
SAMPLES REQ/QUAR.: 1
GUAR. INSUF. SAMPLS: 2
GUAR. UNSAT RESULT: 0
RECORD SATIS.: NO
12 nos END.: ^ 10/31/95
STORAGE-
NUMBER OF UNITS:
HATERlAL
CAPACITY
ADEQUATE
CONCRETE
5,300
YES
TREATHENT
TYPE: CHLORINATION
PUNT:
CAPACITY (MGD): .00
INSTALLED: 1986
DISTRIBUTION -
PUMP/GRAVITY:
FIRE HYDRANTS:
PRESSURE ADEQ.:
PCT HETERED:
MASTER HETER;
PUMPED
YES
YES
YES
NO.
01
SOURCE
TYPE
WELL
SOURCE NAME
4" WELL
- - WELL - -
TYPE DIA
4
YIELD
(GPM)
100
SOURCE
PROT.
CONCUR TYPE OF TREATHENT
CHLORINATION
SOURCE LOCATION
-UTITUDE - -LONGITUDE-
DEG HIN SEC DEG KIN SEC
SYSTEH VIOLATION: BEGINNING DATE OF VIOUTION: 07/01/95
DATE SYSTEH ADVISED: 10/30/95
DATE PUBLIC NOTIFIED: / /
TYPE OF VIOUTIONS: FAILURE TO MONITOR (BACTI)
SYSTEM VIOLATION; BEGINNING DATE OF VIOUTION; 04/01/95
DATE SYSTEH ADVISED: 07/20/95
DATE PUBLIC NOTIFIED: / /
TYPE OF VIOUTIONS: FAILURE TO MONITOR (BACTI)
SYSTEH VIOLATION BEGINNING DATE OF VIOUTION: 09/01/93
DATE SYSTEH ADVISED: 11/03/93
DATE PUBLIC NOTIFIED: / /
TYPE OF VIOUTIONS: FAILURE TO TAKE REPEAT BACTI
SYSTEH VIOLATION BEGINNING DATE OF VIOLATION; 05/01/93
DATE SYSTEH ADVISED: 06/29/93
DATE PUBLIC NOTIFIED: / /
TYPE OF VIOUTIONS: FAILURE TO TAKE REPEAT BACTI
STAFF COHHENTS SOURCE #1, WELL IS ARTESIAN ft
IT FLOWS 10 TO 20 GPM 3 5 TO 9
PSI. IT ALSO HAS SUBMERSIBLE
DATE: 05/12/93 INITIALS: CSB
Date of Survey j ^ l\* 7 /
DRINKING WATER FACILITY EVALUATION
1. Administrative Issues
(Office Interview)
System Name wiliard BRV SI-.HI-P PR-TV <;n. Number snsn^
Name of Surveyor Gtu^^\ ^N/IV^KA
Water System Representative,(s)/Others accompanying survey:
fc-iU PiAe. (c^Ai\A (^^.M.4^) Phone 'J^f-9^'i^
Phone
Phone
10 points will be credited to a water system with a current Emergency Response Program.
0 or 10 Points
ao points will be credited to a water system which has a written Financial Management Plan;
including an appropriate rate structure, infra-structure repair/replacement plan, master plan.
0 or 10 Points
Total Points Credited cD,
Service Data
Have there been any customer complaints received and validated during the last three (3) years
dealing with any of the following list of categories?
** (Indicate the number of complaints received in each category) **
Turbidity Pressure Taste and Odor LU
Sickness [Water System suspected) " Waterbome Disease Outbreak •
Interruptions in Service or Water Outages'
Comments:
0 to 100 Points O
B/96 revision
Date of Survey 7 "// ' ^\
Source Monitoring
5 points will be assessed to a water system which does not have an adequate bacteriological
sampling site plan.
To be fisted by / / 0 or 5 Points <9
10 points will be assessed to a water system which does not have an adequate Lead/Copper
sampling site plan. (Not applicable to Non-Community water systems.)
To be fixed by / / 0 or 10 Points <g)
Cross Connection
.50 points total OR 10 points per element will be assessed to a water system that does not have
any of the below listed components of a cross connection control program,
A water system which only has some of the components of a cross connection
control program shall be assessed the following number of points.
lO points will be assessed to a water system which does not have local authority to enforce a
cross connection program {i.e., ordinances^ bylaws or policies).
To be fixed by / / 0 or 10 Points O
10 points will be assessed to a water system which does not provide public education or
awareness material presentations on an annual basis.
To be fixed by / / 0 or 10 Points Q ,
10 points will be assessed to a water system which does not have an operator with training in
the area of cross connection.
To be fixed by / / 0 or 10 Points O
10 points will be assessed to a water system with no written records of cross connection
activities, such as, backflow assembly inventories, hazard assessments, and/or test history.
To be fixed by / / 0 or 10 Points O
10 points will be assessed to a water system which does not have an on-going enforcement
activity plan. -i^
To be fixed by J / 0 or 10 Points
Comments regarding the above notations
Total Administrative Issue Points O
8/96 revision
Date of Survey I ' jl ~ 1 I
DRINKING WATER FACILITY EVALUATION
2. Wells
(Field Interview/Inspection)
system Name Ld.(faM ^y <;|o4p Kv^|< ^n . Number ^StO^O
Source Nuinber 0\ Source Name ^ ** (L'^II
Location fAlvMla^ci Bcxy S4L Y-^^' ^^ i^h)y,a
Period of Use ^LAKMP.b-S^ Latitude Longitude
A. Was Plan Approval received for this Well? Yes [ ] No [ ] Unknown
B. Well Seal fkei iv C'7.*<jo,ie oii/e f>0>fe ^'"^ 'AX? Oj^f/
50 points will be assessed for any well that does not have a sanitary seal or has
unsealed openings in the top of the well that could allow contamination to enter
the well.
A properly installed and maintained pitless adapter will meet this criteria if it has
been approved hy the Division of Drinking Water for the specific installation.
To be fixed by / / 0 or 50 Points O
'C. Proper Lubrication Oil
25 points will be assessed for any well that requires oil lubrication if the oil used
is not a mineral grade suitable for human consumption.
To be fixed by / / 0 or 2 5 Points O
D. Elevation of Top of Well Casing
1 to 20 points will be assessed for any casing that does not extend at least 12",above
the concrete floor or IB" above the ground, or five feet above the highest flood level.
No points will be assessed if a properly installed and approved pitless adapter is used.
Range of points will be determined by degree of exposure to flooding, drainage, condition
of floor and other factors which may jeopardize the integrity of the wellhead. If
insufficient height above floor or ground, identify any conditions or factors which
could jeopardize the well's sanitary integrity.
To be fixed by / / 0 to 20 Points d)
Explanation of assigned points
E. Screening of Well Casing Vent
5 points will be assessed for a well casing vent that is not properly covered with a
number 14 mesh screen.
To be fixed by / / 0 or 5 Points O
F. Well Discharge Piping Equipment
1 point assessed for each of the following items which are not present or serviceable
on the discharge piping: (1) a smooth nosed sampling tap {2} a check valve (3) a
pressure gauge (4) a flow measuring device and/or (5) a shut off valve. CIRCLE ITEMS
NOT FOUND OR NOT SERVICEABLE, AND IDENTIFY IF THEY ARE NOT IN THE ORDER LISTED.
To be fixed by / / 0 to 5 Points ^
ExvlauaLi'iSr;!;f1y>iyn«3-pe4«4^ T/U (jid( Lry< p^ aN^Jry.A -rfooJ ; T/X? fr^iTcM'f
f M9fP- r^AJ-AAK 4itfi feiWp 4 Pt>f<^jJ^ JA 1^ //V<S - //Ui^r ^V caM&leX ftitf <n
6 revision
r
Date of Survey 7" //" 7 /
G. Discharge Piping Air Vent
1 to 5 points assessed for each well that does not have an air relief valve on the
discharge piping. Relief Valve piping must be turned down and properly screened
with number 14 mesh screen. Integrity of scre^ must be determined.
To be fixed by ^ / / / ?/ 0 to 5 Points S
Explanation of assigned points \Jm-^ iWil^J- j^ Of^dJA hi/^^P^ *f ^f^&Pf\Pc\
H. Well House Floor Drain
1 to 5 points assessed for well houses that do not have a drain to daylight floor
drain that is fully serviceable, where does the drain end up?
To be fixed by / / 0 to 5 Points O
Explanation of assigned points
Total Points Assessed -5^
ADDITIONAL REQUIRED INFORMATION (no points assessed)
is this source covered in a source protection plan? Yes [ ] No [^
Is a current well log available for this well? Yes {^i-^No [ ]
Current flow rate (determined during survey) gpm Size of Well Casing ' inches
Type of Pump: Verticle turbine Submersible ^""""^
Size of discharge piping o( -^ ^ inches. Brand of pump f/uK*<Quf*^ Model .
Motor Information
li<^^ Brand _ UnVU^W^A. Model
Horsepower Voltage
Is there a pump to waste line with an adequate air gap (twice pipe diameter)? Yes [ ] No [ T"^
If there is a Pump House, is it secure? Yes [ <'3^No [ )
Does it have adequate heating? Yes [^y^^ [ ]
Does it have adequate lighting? Yes ^^.^T^ [ )
Does it have adequate ventilation? Yes E^S^^'NO 1 ]
Is the floor elevation at least 6 inches
above the surrounding ground elevation? Yes [^^''''"'^No [ )
OTHER OBSERVATIONS OR COMMENTS
s/96 revision
Date of Survey 7' ll'ff
DRINKING WATER FACILITY EVALUATION
8. Source Protection
(Field Interview/Inspection)
NOTE: Attach this to each source worksheet for wells and springs.
System Name iJ,7(aM Qnw dviitg ro/K C\ . Nuinber O^o'^C
Source Number 0\ Source Name V Cj^tf
Location
on
Period of Use '^^j&ixr, I __. Latitude . Longitude
^5=^e K^':&^ \^ ^UvL^u ^r AIQM • Gv«*iurt.'L System Populati
NOTE: Non-community sources constructed prior to 7/26/93 are not required to have a source
protection plan.
However, the system will be eligible for incentive points if a source protection plan
is implemented.
A. Is a source protection plan required for this Source according to the table/schedule on
the back of this page?
Yes [ ] No [ ]
B. 5 points will be assessed to a water system that has not delineated a protection area of
its groundwater sources in accordance with the required time frame. Points shall remain
until the source is properly delineated and the plan has been concurred with by Division
personnel.
To be fixed by / / 0 or 5 Points
C. 5 points will be assessed to a water system that has not inventoried potential sources
of contamination for its ground water sources.
To be fixed by / / 0 or 5 Points
D. 5 points will be assessed to a water system that has not developed a management program
for pre-existing potential contamination sources.
To be fixed by / / 0 or 5 Points
E. 5 points will be assessed to a water system that has not developed a management program
program for future potential contamination sources.
To be fixed by / / 0 or 5 Points •__
Total Points Assessed
20, CREDIT points will be awarded to a water system that has completed all of its
source protection plans before the required due date. (SEE BACK)
Credit 0 or 20 Points •
8/96 revision
Date of Survey ^/^•^;
OTHER OBSERVATIONS OR COMMENTS
The following schedule'indicates the required completion dates for source protection plans.
Population Served by PWS:
Over 10,000
Over 10,000
y,30D - 10,000
Less than 3,300
Springs and Other Sources
Percent of Sources
50% of wells
100% of wells
100% of wells
100% of wells-
100%
DWSP Plans Due By:
December 31, 1995
December 31, 1996
December 31, 1997
December 31, 1998
December 31, 1999
Please fill out the required information on the worksheet as completely as possible. The
issuance of monitoring waivers is determined by this worksheet. Many water systems have^
already been issued waivers for different monitoring requirements. These waivers will not
renewed without the field verification from surveyors using this worksheet.
S/96 revision
Date of Survey 1^11'^7
DRINKING WATER FACILITY EVALUATION
9. Waiver Verification
(Field Interview/Inspection)
NOTE: Attach this to each source worksheet for wells and springs.
System Name ^y)/7(aM Oou M-aTe bm ^. Number 0^530
Source Number QJ Source Name 4^'^ (0€(( ___^
Location
Period of Use ^zQS^An{ '___ Latitude Longitude -
NOTE: No points issued for any of the following information.
Is there a current source protection plan in place that covers this source? Vo^'-u^-kti^y
Yes [ ] ' No t ]
Are there any potential sources of contamination within 5,000 feet upgradient of the
• water levels in the spring source or 5,000 foot radius of a well?
Yes [ ] No U4^
NOTE: (If a source protection plan has been established for this source, then
the 5,000 feet distance shall be replaced by the delineated 3 year time of
travel distance.)
Describe any potential sources such as fuel storage, septic tanks, pesticide or ^
chemical storage tanks, industry, mining or feedlots? .,
Has the area within 5,000 feet upgradient of ,the water level in a spring or within
5,000 feet radius of a well been sprayed for insects or weed control in the last
10 years?
Yes [ ] No [t^
If yes, describe type and method of application of chemicals.
Is the source subject to any surface water intrusion or flooding at any time during
the year?
Yes t ] No f-t
Is there an adequate management plan in place to effectively eliminate the risk of
contaminant sites polluting the source?
Yes [iJ-^ No [ 3
8/96 revision
Date of Survey ^-((-i7
Does any of the source transmission lines or distribution system contain
asbestos/cement pipe? y
Yes [ ] No \1y
OTHER OBSERVATIONS OR COMMENTS
8/96 revision
Date of Survey 7' //^?7
DRINKING WATER FACILITY EVALUATION
4. Disinfection Facilities Gaseous Ciilorine
(Field Interview/Inspection)
System Name Jxllilfl^ R^ sf»W |^^f/ gn. Number nSjdlO
Disinfection Station Nuinber C){ Station Name c/a ^^l<^\\
Location l\k\c^ceA f^ f/,^ ^^ (,]e.({ .
Source (s) Treated <^j( — y" IM((
(include source numbers (s) and naj[ne(s))
A. Was Plan Approval received for this Chlorinator? Yes [*-}-^^o [. ] Unknown ( ]
B. Detectable Residual
10 points will he assessed to a chlorinated water system that does not maintain
a chlorine residual at all times.
To be fixed by / / 0 or 10 Points O
C. chlorine Building
. ' 2 points will be assessed for each chlorine building that is not properly
heated, lighted, and vented. Ventilation must include exhausting room air
at or near floor level. Heating may be unnecessary in warmer climates.
To be fixed by / / 0 or 2 Points ^
D. Chlorine Residual Test Kit
2 points will be assessed to a chlorinated water system that does not have a
functional chlorine residual test kit. ^-
To be fixed by / / 0 or 2 Points O
E. Cylinder Wrench on Yolk Valve
2 points will be assessed to a chlorinated water system that does not have a
chlorine cylinder wrench on the yoke valve. j.
To be fixed by / / 0 or 2 Points ^
F. Leak Detection and Repair Kit
15 points will be assessed for a water system that uses 1 TON CYLINDERS that
does not have proper chlorine leak detection equipment and a type B l ton
cylinder repair kit,
2 points will be assessed for a water system that uses ISO POUND CYLINDERS that
does not have proper chlorine leak detection equipment and a type A ISO pound
cylinder repair kit.
To be fixed by / / 0, 2, 15 or 17 Points Q
G. Restraint and Isolation of Chlorine Cylinders
2 points will be assessed to a water system that does not have chlorine cylinders
properly restrained and isolated from normal operating areas.
To be fixed by / / 0 or 2 Points O
H. Chlorinator Feed Vent
2 points will be assessed to a water system that does not have chlorinator feeder
vents properly vented and screened to outside oi the chlorine building. —
To be fixed by Y> I I / If 0 or 2 Points oL
8/96 revision • •
Date of Survey 1'ii'tt
I. Chlorine Feed Rate and Cylinder Usage
2 points will be assessed to a water system that does not have the equipment to
accurately measure the chlorine feed rate and the usage of the cylinder (scales)
To be fixed by / / 0 or 2 Points o
J. Self Contained Breathing Apparatus cklolStft^ GU4N%^ Fx'i^^ f^<i^K
5 points will be assessed to a water system using gaseous chlorine that does not
have access to a self contained breathing apparatus for chlorine emergencies.
5 points will be assessed to a system that stores the apparatus in the chlorine
room where getting to it would require exposure to chlorine gas.
To be fixed by / / 0 or 5 Points O
K. Measurement of Chlorinated Water
2 points will be assessed to a water system that does not have a means of measuring
the volume of water treated with chlorine. *_ -j
To be fixed by /^/ / / ^7 0 or 2 Points o^
Total Points Assessed I
ADDITIONAL REQUIRED INFORMATION [no points assessed)
Is the chlorination building secure? Yes [i^ No [ ]
What condition is the chlorine building in? Good [ (^.^'''''^Average [ ] Poor [ ]
Is a booster pump used for the chlorinator? Yes [iy^'^^No [ )
Pump Brand jDayrtA Model ^^^'feC ^3c9QQ
Size /4( nJ Capacity / jk
Brand of Injector £'i^M&iiX<;;f^ Capacity 7 \\^. /ikoK/
Are there spare parts on hand to repair the chlorinator? Yes [ ] No t ]
Does the chlorinator feed line have an in line screen or flush valve? Yes [ ] No tt"?"^
Are there exterior warnings signs on the chlorine building? Yes [ ] No XiY"^
Are the doors hinged to open outward and equipped with panic bars? Yes [ ] No [ ]
OTHER OBSERVATIONS OR COMMENTS
^ i(M t\&\^ Ccte^JA r^A t^{r (xyj( \JeA
^ ilatai (JrtLr- Sfitih^j^ jilt? ^A^Ai>:> LAJ/- t^AM)f., l<r fU. TS t^Prl ^ ^P <&X^^ .
8/96 revision
Date of Survey f' II' 1 I
DRINKING WATER FACILITY EVALUATION
5. Storage Reservoir
(Field Interview/Inspection)
System Name lAilL^j Lii ^o^9 fa^K $d. Number 69.0^0
Reservoir Number CJ\ Researvoir Name ^-r wp(f UGJMT
Location aM^t O^MA \A6a^€.
Volume in Gallons Dimensions
Material of Construction (^Cit^i-eJrP -
A. Was Plan Approval received for this Storage Unit? Yes [ ] No [ ] Unknown {L^-"^
B. Uncovered Finished Water Storage
A water system with an uncovered finished water storage reservoir shall
immediately be assessed a rating of NOT APPROVED.
Uncovered Reservoir? Yes [ ] No [^J-^^
C. Storage Reservoir Access
10 points shall be assessed for a water storage reservoir's access cover that is'
not an overlapping (shoe box) type lid, that is not locked and does not extend
at least 4 inches above the top of the tank or finished grade.
To be fixed by _/ / 0 or 10 Points G
Explanation of assigned points
D. Storage Reservoir Vents
5 points shall be assessed for storage reservoirs that are not properly vented
wich a downturned vent and screened with at least No. 14 mesh screen or finer
in good condition. ^,—-
To be fixed by _2_/__L/_2/ 0 to 5 Points G
E. Storage Reservoir Overflow Piping
Up to 15 points shall be assessed to a reservoir that has an overflow, that is
either l) unscreened with a minimum of no. 4 mesh screen, 2) inadequately sized,
3) improperly sloped, and/or 4) without at least 12 inches of free fall or an
adequate air gap if connected to the sewer. Number of points assigned shall be
determined by the number and severity of the above mentioned items.
To be fixed by / / 0 to 15 Points Q^
Explanation of assigned points
F, Storage Reservoir Drainage
2 points shall be assessed for a reservoir which does not have an adequate drain,
line that is properly screened with at least no. 4 mesh and 12 inches of free fall.
To be fixed by / / 0 or 2 Points tO
8/96 revision
Date of Survey 7" /|- ?/
G. Integrity of Roof and Sidewalls of Water Storage Reservoirs
Up to 50 points shall be assessed to a reservoir that has cracks and/or other unprotected
openings in the roof or sidewalls which are not water tight, or which may affect the
structural integrity of the reservoir. Points shall be determined by the severity of tne
problems and by the degree of possible contamination to the drinking water by surface
water, rodents, birds, and/or any other means permitted by the deficiency in the roof
or walls of the reservoir.
To be fixed by / / _ 0 to 5 0 Points Q
Explanation of assigned points
H, Access Ladders and Protective Railings
2 points shall be assessed for each storage reservoir that does not have a safe
and serviceable access ladder and/or protective railings where required.
To be fixed by / / 0 or 2 Points Q
I. Internal Coatings of Storage Reservoirs
3 0 points shall be assessed for each storage reservoir that has internal coatings
that are not in compliance with ANSl/NSP Standard 61.
To be fixed by / / 0 or 30 Points O
Total Points Assessed
ADDITIONAL REQUIRED INFORMATION [no points assessed)
When was this Storage Reservoir last cleaned? \\Pevt'\\J years ago
OTHER OBSERVATIONS OR COMMENTS
8/96 revision
Date of Survey 7* D'^f
DRINKING WATER FACILITY EVALUATION
5. Storage Reservoir
(Field Interview/Inspection)
System Name tdi^Hat^ bau gfafg, \r<yAK Number d3lf)7<S
Reservoir Number 6^ Reservoir Name fi<€S<^.tA-6 /aury
Location JTn ^in^ [ma^e _
Volume in Gallons /$^ Dimensions
Material of Construction SreBJ
A. Was Plan Approval received for this Storage Unit? Yes I ]• No I ] Unknown [^^—"''^
B. Uncovered Finished Water Storage
A water system with an uncovered finished water storage reservoir shall
immediately be assessed a rating of NOT APPROVED,
Uncovered Reservoir? Yes [ ] No [ 4"-
C. Storage Reservoir Access
10 points shall be assessed for a water storage reservoir's access cover, that is
not an overlapping (shoe box) type lid, that is not locked and does not extend
at least 4 inches above the top of the tank or finished grade.
To be fixed by / / 0 or 10 Points 0
Explanation of assigned points
D. Storage Reservoir Vents
5 points shall be assessed for storage reservoirs that are not properly vented
with a downturned vent and screened with at least No. 14 mesh screen or finer
in good condition.
To be fixed by / / 0 to 5 Points O
E. Storage Reservoir Overflow Piping
Up to 15 points shall be assessed to a reservoir that has an overflow that is
either 1) unscreened with a minimum of no. 4 mesh screen, 2) inadequately sized,
3) improperly sloped, and/or 4) without at least 12 inches of free fall or an
adequate air gap if connected to the sewer. Number of points assigned shall be
determined by the number and severity of the above mentioned items.
To be fixed by / / 0 to 15 Points ^
Explanation of assigned points
F. Storage Reservoir Drainage
2 points shall be assessed for a reservoir which does not have an adequate drain
line that is properly screened with at least no. 4 mesh and 12 inches of free fall.
To be fixed by / / 0 or 2 Points O
8/96 revision
Date of Survey '?~fM7
G. Integrity of Roof and Sidewalls of Water Storage Reservoirs
Up to 50 points shall be assessed to a reservoir that has cracks and/or other unprotected
openings in the roof or sidewalls which are not water tight, or which may affect the
structural integrity of the reservoir. Points shall be determined by the severity of tne
problems and by the degree of possible contamination to the drinking water by surface
water, rodents, birds, and/or any other means permitted by the deficiency in the roof
or walls of the reservoir.
To be fixed by J / 0 to 50 Points O
Explanation of assigned points
H. Access Ladders and Protective Railings
2 points shall be assessed for each storage reservoir that does not have a safe
and. serviceable access ladder and/or protective railings where required.
To be fixed by / / 0 or 2 Points O
I. Internal Coatings of Storage Reservoirs
30 points shall be assessed for each storage reservoir that has internal coatings
that are not in compliance with ANSI/NSF Standard 61.
To be fixed by / / 0 or 30 Points O
Total Points Assessed O
ADDITIONAL REQUIRED INFORMATION (no points assessed)
When was this Storage Reservoir last cleaned? V/6ftn^ years ago
OTHER OBSERVATIONS OR COMMENTS
8/96 revision
Date of Survey 7-H-f7
DRINKING WATER FACILITY EVALUATION
6. Distribution System
(Field Interview/Inspection)
System Name IxlHah^k PrMi ^0 kf\J Co. Number ogLCJO
A. Was Plan Approval received for this Distribution System? Yes [ ] No [ ] Unknown [ ^ "
B. System Pressures
50 points will be assessed to a water system which fails to provide at least
20 psi in all locations of the water system at all times, including peak
instantaneous flow conditions.
To be fixed by / / 0 or 50 Points /*)
C. Adequate System Source Capacity
5 to 50 points may be assessed to a system that does not have adequate source capacity
to meet peak daily and/or average yearly flow requirements. The number of points shall
be determined by the severity and frequency of shortages, outages or low pressure.
To be fixed by / / 0 to 50 Points /9
or DDW Calculate
D. Adequate System Storage Capacity
5 to 50 points may be assessed to a system that does not have adequate storage
capacity to meet average daily flow requirements. The number of points shall be
determined by the severity and frequency of shortages and/or water outages.
To be fixed by / / 0 to 50 Points O
t:iX DDW Calculate
E. Piping Materials
30 points will be assessed to a water system that uses unapproved pipe, fittings,
and material for conveyance of drinking water. Piping and fittings must be NSF .
approved and/or meet AWWA Standards or other appropriate approvals. Asbestos
Cement pipe that has successfully passed a distribution system asbestos
monitoring program according to the Drinking Water Rules shall not be assessed
any points.
To be fixed by / / 0 or 3 0 Points O
F. Clearance from Sewer Lines
30 points will be assessed to a water system that has improperly installed water
lines which do not have adequate clearance or separation from sewer lines.
To be fixed by / / 0 or 3 0 Points 0
G. Vent Piping on Air and Vacuum Release Valves
Up to 2 points shall be assessed each air and/or vacuum release valve that does
not have a properly turned down screen vent, for a maximum total of 2 0 points
possible.
To be fixed by / / 0 to 20 Points O
Explanation of assigned points
8/96 revision
Date of Survey 7- //'?/
H. Flooded Air and Vacuum Release Valves
20 points will be assessed to a water system for each air and/or vacuum release
valve chamber that is flooded or subject to flooding, where there is indication
that the vent is subject to submergence with a total possible of 50 points for
the system.
To be fixed by / / 0,20,40 or 50 Points O
Explanation of assigned points
Total Points Assessed .0
ADDITIONAL REQUIRED INFORMATION [no points assessed)
Does the water system provide fire protection? Yes { ] No U-^"""^
If yes, how many hydrants? C)
Does the water system have a periodic flushing program? Yes [ ] No [ ]
Does the flushing program include hydrant maintenance? Yes [ ] No [ ]
Does the water system have dead end water lines? Yes [ ] No t J
Does the water system have multiple pressure zones? Yes [ ] No I 1
If yes how many pressure zones? /
What are the pressure ranges throughout the system? (low) 7Q ..- i^" (high)
What are the ranges of the different pressure zones?
Pressure Zone Area psi range Controls
Automatic Manual Remote
HZ- fj
OTHER OBSERVATIONS OR COMMENTS
s/96 revision
Date of Survey ^ • H'^(
DRINKING WATER FACILITY EVALUATION
7. Pump Stations
(Field Interview/Inspection)
System NameaJTlLM CtXU ^ta^e RAK C^. Number (Pi^nlO
Name of Station P^oAp 9l4(^'A^ Location U\:{\a^S ^^ ^.i-fk ^/l^Ai\
Pump Station Is
V Used to fill storage reservoir
)*Cused to boost system pressure
Used to pressurize water out of a storage reservoir
NOTE: No points will be issued for any of the following information.
Are there multiple pumps such that with any one pump out of service the remaining pumps
can meet the peak instantaneous demand?
Yes [ ] No (/>—"
If yes, how many pumps? {
Horsepower Pipe Size GPM
Are the pumps accessible for service and repairs? Yes I^J-—-"^ No [ ]
Are there pressure controls on the suction line of the pump that will automatically shut
down the pump when the inlet pressure drops below 20 psi?
Yes [ ] No [ 4-
Are there serviceable pressure gauges on the discharge piping? Yes [t-^-"*^ No [ ]
on the suction piping? Yes [ ] No [^
Is there an air and vacuum release valve installed with a No, 14 mesh screened ventj
Yes i^^ No [ 3
Is there surge protection or a pressure relief valve installed to prevent water hammer?
. Yes [ ] No [J-
Is there a standby power source available in case of power outages or equipment breakdown?
Ye-s t ] No \L^
Is the pump station properly heated, lighted and ventilated? Yes ^^.^•"'^ ' No [ ]
Is pump station located in a below grade vault? Yes [ ] No
If yes, are proper safety measures exercised and electrical circuits properly protected?
Yes [ ] No [ ]
Is there a current station log book and a preventative maintenance schedule?
Yes [ '] No [/
8/96 revision
Date of Survey 1'lMl
OTHER OBSERVATIONS OR COMMENTS
n^ete. are 3. hi^^ ZK Ug, ^JAK^ UHJIS^ > r^JAf j\mu(^C uL ihe
8/96 revision
Date of Survey /-/l " T f
Work Sheet for Determining Source Capacity
To determine if the water system has adequate source and storage capacity, the following
information is needed: l) the number of residential connections, 2) the number of other
connections, 3} the source capacity in gallons per minute, 4) the storage capacity in
gallons. Since this information is contained on the Inventory printout, it should be
verified and if incorrect it should be corrected on the Inventory form.
INVENTORY FORM REVIEWED Yes i iX No [ ]
Ask if Water Rights are sufficient and perfected. If the water system person does not
know, have them contact the Utah Division of Water Rights at [phone].
Please describe, to the best of their knowledge, the monthly quantity of water used on
other connections such as Motels, RV Parks, Hospitals or large industry.
Please indicate the average lot size and the size of all large irrigated facilities such
cemeteries and parks.
AiSi ^
8/96 revision