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Home My WebLink About709 S Valley St - Building4 pORT s NGELES P �h W A S H I N G T O N U S A Public Works Utilities Department City of Port Angeles P O Box 1150 321 East 5 Street Port Angeles, WA 98362 RE. Port Angeles Landfill Transfer Waste Disposal Application, WDA 07 -37 Building demolition at 709 South Valley Street We have received your application for disposal of building demolition debris from the referenced site and reviewed the testing results for asbestos and lead content. Based on the testing results the debris appears to be acceptable for disposal at the transfer station. A copy of your approved application is attached. This approved application must be shown to the transfer station scale attendant at the time of disposal. Please be advised that this disposal application is only for the materials and quantities listed in the application. Materials not listed or in excess of the quantities noted may require separate applications and approval. Please call if you have questions Very truly yours, uL, Stephen Sperr P.E. City Engineer Encl. WDA 07 -37 Copy Claudia Stromski Bldg file 8' Street Bridge project N:\PWKS \ENGINEER \WDAPPLIC\07 37 File: Landfill Solid Waste Disposal Applications Phone 360- 417 -4805 Fax 360- 417 -4542 Website www cityofpa.us Email publicworks @cityofpa.us 321 East Fifth Street P 0 Box 1150 Port Angeles, WA 98362 -0217 Wed,10 /4/2006 0:4 PM To City of Port Angeles City Engineer 321 E Fifth Street P O Box 1150 Port Angeles Washington 98362 NOTE. All questions must be answered for waste to be approved. 1 Generator Information Company Name Mailing Address Phone PORT ANGELES LANDFILL WASTE DISPOSAL APPLICATION Cry Aivr 4-444.44 Sal &04-r tz'otti p D. 4o iiso Pet 4 t‹cg.c. 10,44. Project Name l_ I- 6A &Aiwa -60-J Project Location )of .5. IJ444✓ cepzae 2 Other Contacts (if applicable) °4 c-. x 74 4 4a 4 4 at) krdi Consulting Firm. Contact: Phone Contractor Name Contact: Phone Laboratory Contact: Phone AM— (ftig 644 7' 0 4.4.4 A 14 ai1 77 24.9 76G 5 016t) Phone (360) 417 -4803 FAX. (360) 417 -4709 LvbP- CI- City of Port Angeles Landfill Waste Disposal Application Page 1 Wed,10/4/2006 0:4 PM 3 Source of Waste Check the appropriate box below and briefly describe the project, process and /or cleanup that will or has produced the waste requiring disposal Include the gasoline service station number (if applicable) CERCLA/MTCA Remediation Agency Contact: Independent Remedial Action UST Removal Unused Chemical Product Spill K Other Source AVM- 4 Waste Material Composition (check all that apply and include percent of total) Soil Concrete /Asphalt Preserved Wood Coal Ash Wood Ash NOTE. Total must equal 100% Gasoline Solvents Unknown 5 Waste Material Contaminants (check all that apply) Unused Motor Oil !C Other *66 i (44 A s (lea) <s S 14/4 0 iDoex. Foundry Slag Dredge Sediments k Debris Other (list) Metals Heating Oil Used Motor OiI/Waste Oil Other Petroleum Product NOTE. Supply any MSDS information with application if available Diesel PCBs City of Port Angeles Landfill Waste Disposal Application Page 2 Wed,10 /4/2006 0'4 PM 6 Estimated Quantity of Waste for Disposal 2c Cubic yards Tons (estimate both) Drums Other NOTE Estimated quantity for disposal must be within 20% of the quantity actually disposed (10% for projects over 7 500 tons or 5 000 cubic yards.) 7 Frequency of Disposal kG One time 8 Waste Sampling Proper characterization of the waste for disposal requires the collection of representative samples. The methods and equipment necessary for obtaining representative samples of a waste and the frequency of sampling will vary with the type and form of the waste Check the appropriate box and briefly describe how and where the waste was sampled Include site maps with sampling locations if possible Number of COMPOSITE samples 1 number of discrete samples per composite Number of DISCRETE samples 16 S:4.1.P 4 ,144#/...4.4..,-11 k o,Ni (dc x., r." 4404 61/4-60 i 14.11./Ap 0/14Att 4GtAI lain.>> NOTE 1 NOTE 2. Monthly Unless prior approval has been granted by Port Angeles the following sampling frequency will be used 0 25 25 100 101 500 501 1000 1001 2000 >2000 cubic yards cubic yards cubic yards cubic yards cubic yards cubic yards One composite sample shall discrete samples Tons (estimate both) Annual Other 1 composite sample 3 composite samples 5 composite samples 7 composite samples 10 composite samples 10 plus one sample for each additional 500 cubic yards contain a minimum of three /maximum of five City of Port Angeles Landfill Waste Disposal Application Page 3 Wed,10 /4/2006 0:4 PM 9 Waste Analysis The `Dangerous Waste Regulations (WAC 173 -303) shall be utilized to determine the appropriate analytical requirements for waste characterization Ecology Publication #91 -30 (Revised April 1994) `Guidance for Remediation of Petroleum Contaminated Soils shall also be used to characterize petroleum contaminated soils from UST releases Submit all laboratory analytical results QA/QC data and Chain of Custody sheets along with this application (NOTE The laboratory must be accredited by the Washington State Department of Ecology a) List all analytical test methods used 1SA)131 t b) Provide a narrative as to why the above analytical methods were selected yo 4A eA S -ig€+tc t. IS IL Igio e 1 NOTE. Additional sheets attached kG YES NO 10 Soil Classification *FOR PETROLEUM CONTAMINATED SOILS ONLY**) Based on the analytical data and Ecology Publication #91 -30 the soil classification is (check one) Class 1 Class 2 Calculated Hazard Index 11 Dangerous Waste Affidavit: Class 3 Class 4 Based on a review of the analytical test results, site history and the applicable regulations this waste is classified as (check one) Neither Dangerous Waste (DW) nor Extremely Hazardous Waste (EHW) Dangerous Waste (DW) and Waste Code Extremely Hazardous Waste (EHW) and Waste Code City of Port Angeles Landfill Waste Disposal Application Page 4 Wed,10/4/2006 0'4 PM 12. Certification We THE UNDERSIGNED certify that this application is true to the best of our knowledge All information provided rrect and the enclosed analytical results represent the proposediovaste m ?terial t best of our abilities Waste Generator SigKature Printed Name 2 vLAc. Asf4)4 Company 7/V.7 (p-7 Date City of Port geles Approve ND City Engine c�J 7 Date 1 QC 31, �o p 7- Approval Expiration Date City of Port Angeles Landfill Waste Disposal Application Page 5 ,JUL 25 2007- 9 26AM NVL LABORATORIES INC NVL Laboratories, Inc. 4708 Aurora Ave. N., Seattle, WA 98103 Tel. 206.547.0100, Fax: 206.634 1936 www.nvllabs.com Lab ID Client Zenovic Associates Inc. Address: 301 E. 6th St. Suite 1 Port Angeles, WA 98Z.62 Attention' Mr Tracy Gudgel Project Location: 709 S Valley St. 27073291 07159A Client Sample Sampled by Client Analyzed by Ahmed Izzat Date Analyzed: 07/25/2007 RL mg/L 0.4 NO.1444 —P 2 eft WA DOE C1765 D ui ORATORYY AIWA IH 101861 Analysis Report Toxicity 6aracteristic Leaching Procedure Lead (Pb) Results in ma1L 2.1 mg/ L Milligrams per liter ppm parts per million Note Method QC results are acceptatle unless stated otherwise. Unless otherwise indicated, the lcondition of all samples was acceptable at time of receipt. Batch 2710979.00 Matrix: Bulk Method: EPA 1311/7000B Client Project 07159 Date Received: 07/23/2007 Samples Received: 1 Samples Analyzed: 1 DRAFT Results in ppm 2.1 RL Reporting Limit 1 4' Below the reporting Limit NV{_ Laboratories, Inc. 4708 Aurora Ave N. Seattle. Wft 88103.. Tel 208 547 0100E Pager. 206 344 1878 )tang. 1.888.NVL.LABS (885.5227) Client Zenovic Associates, Inc. Street 3O\ C (a""` Sk-Ce.te -k Port Angeles Project Manager 4C eV -4U". Project Location '709 s t/.4414Y S?. i JUL 25 2007 9 26AM NVL LABORATORIES INC CHAIN of CUSTOM SAMPLE LOG NVL Batch Number Client Job Number Total Samosa Turn Around rune Na 1444 3 jr) lit44 9 00 1 1-Hr 4-Mrs 4 Days 2-Hrs 1 Days 5 Days ys 0 4-H Dll I TA le a than 6 to 2 Ns Days Please Emati address 5icYti tlre,rt/KY Phone: (360) 417 0501 Fax: (360)1417 ICI Asbestos Air I PCM (NIOSH 7401) TEM (NIOSH 7402) G TEM CAMERA) D TEM (EPA t eves il) Q Other ID Asbestos Bulk D PLM (EP/ 0/R-93 /116) D PLM (EPA Point Count) 0 PLM (EPA Gravimetry) TEM Bulk METALS Dot. Limit Matrix RCRA Metals D All 8 D t they All Mi 3 ss 0 Total Metals Cl.P (my) El Air Pilfer D Paint Chips CI Arsenic (As) p tread (Pb) p b GFAA) a Dnnlung water Q Paint Chips (Area) D Barium (Ba) Mercury (119) D COPPer (CU PP U Dust/wipe 0 Waste Water Cadmium (Cd) Selenium (se) 7Jnc In} i) 0 Soil Chromium (Cr) 0 Silver (Am 0 Other Types D Mercian ergiass D Nuisance Duet 0 Rotometer Calibration Other (specify) of Analysis I Silica D Respirable DU)st Mold/Fungus Condition of Paclage: Good 0 Damaged (no lipTtage) Severe damage, (spi1I ge) Seq. #1 Lab ID 1 Client Sample Number 1 Commends I AIR 1 I d i t `76L4° 2 1 a 1 I I I q 8 7 a 9 10 11 12 13 14 15 I Pei Below Sampled by u Rt. Relinquished by Received by i Analyzed try 1(�T�►f Results Called by I Results Faxed by I Si Bel QY .�,iicltc .token; X Date Special Instructions. Unless requested in wr ting. all samples will be disposed of two (2) weeks after analysis. p ./.434, Amp Resafl Op pORT M,O CITY OF PORT ANGELES DEPARTMENT OF COMMUNITY DEVELOPMENT BUILDING DIVISION 321 EAST 5TH STREET PORT ANGELES, WA 98362 41 .1kc ,n00 Application Number 07 00000840 Date 7/17/07 Application pin number 470920 Property Address 709 S VALLEY ST ASSESSOR PARCEL NUMBER 06 30 00 0 2 3445 0000 Tenant nbr name CITY OF PORT ANGELES Application type description DEMOLITION Subdivision Name Property Use Property Zoning PUBLIC BUILDINGS PARKS Application valuation 100 Owner Contractor CITY OF PORT ANGELES PARSONS RCI INC ATTN YVONNE PO BOX 1730 PO BOX 1150 SUMNER WA 98390 PORT ANGELES WA 98362 (360) 452 5991 (360) Structure Information 000 000 DEMO HOUSE Permit DEMOLITION Additional desc DEMO HOUSE Permit pin number 107300 Permit Fee 50 00 Plan Check Fee 00 Issue Date 7/17/07 Valuation 0 Expiration Date 1/13/08 Qty Unit Charge Per Extension BASE FEE 50 00 Fee summary Charged Paid Credited Due Permit Fee Total 50 00 50 00 00 00 Plan Check Total 00 00 00 00 Grand Total 50 00 50 00 00 00 1ture of Contractor or Authorized Agent Date T Policies \1102_15 building permit inspection record05 wpd [1/4 /2005] Separate Permits are required for electrical work, SEPA, Shoreline, ESA, utilities, private and public improvements. This permit becomes null and void if work or construction authorized is not commenced within 180 days if construction or work is suspended or abandoned for a period of 180 days after the work as commenced or if required inspections have not been requested within 180 days from the last inspection I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this type of work will be complied with whether specified herein or not. The granting of a permit does not presume to give authority to violate or cancel the provisions of any state or local law regulating construction or the performance of construction. Signature of Owner (if owner is builder) Date CALL 417 -4815 FOR BUILDING INSPECTIONS. CALL 417 -4735 FOR ELECTRICAL INSPECTIONS CALL 417 -4807 FOR PUBLIC WORKS UTILITIES PLEASE PROVIDE A MINIMUM 24 HOUR NOTICE. IT IS UNLAWFUL TO COVER, INSULATE OR CONCEAL 4N)' WORK BEFORE INSPECTED AND ACCEPTED. POST PERMIT IN A CONSPICUOUS LOCATION KEEP PERMIT CARD AND APPROVED PLANS AT JOB SITE. INSPECTION TYPE DATE FOUNDATION: FOOTINGS SHEAR WALLS WALLS FOUNDATION DRAINAGE DOWN SPOUTS PIERS POST HOLES (POLE BLDGS.) PLUMBING UNDER FLOOR SLAB ROUGH -IN WATER LINE (METER TO BLDG) GAS LINE BACK FLOW WATER AIR SEAL WALLS CEILING FRAMING JOISTS GIRDERS SHEAR WALL /HOLD DOWNS WALLS ROOF CEILING DRYWALL (INTERIOR BRACED PANEL ONLY) T -BAR INSULATION SLAB WALL FLOOR CEILING MECHANICAL ROUGH -IN HEAT PUMP /FURNACE /DUCTS GAS LINE WOOD STOVE PELLET CHIMNEY ELECTRICAL LIGHT DEPT FIRE 417 -4653 PLANNING DEPT 417 -4750 BUILDING PERMIT INSPECTION RECORD YES 1 1 1,i 1 1 1 1I IM Il ACCEPTED BUILDING 417 -4815 I /8 I if I I T' \Policies11102 15 building permit inspection recoid05.wpd [174/20051 NO 1 FINAL MANUFACTURED HOMES FOOTING SLAB BLOCKING &HOLD DOWNS SKIRTING PLANNING DEPT SEPARATE PERMIT #1's SEPA. PARKING /LIGHTING ESA. LANDSCAPING SHORELINE: FINAL INSPECTIONS REQUIRED PRIOR TO OCCUPANCY/USE RESIDENTIAL DATE YES NO COMMERCIAL 417 -4735 ELECTRICAL LIGHT DEPT CONSTRUCTION R.W /PW/ CONSTRUCTION R.W ENGINEERING 417 -4807 PW /ENGINEERING FINAL DATE ACCEPTED BY. I FIRE DEPT PLANNING DEPT I BUILDING COMMENTS DATE ACCEPTED BY. DATE ACCEPTED YES I NO 1 1 1 1 1 I 1 I I I BUILDING PERMIT APPLICATION Fill out COMPLETELI and in INK. Your application and site plan MUST BE COMPLETE to be accepted for review If you have any questions, call PERMITS (360) 417 -4815 FAX(360)417 -4711 Applicant or Agent: PP l ce n t rdr/ L a Owner Of PO h Yl of j-e S Phone. Address: City Zip Architect/Engineer Phone: Contractor pa r.soh S State License f 4g S or l55 J S Exp q/30/0 Phone: (360 ¥S2-sy/ I Address: City PROJECT ADDRESS 7C)/ S- V a Item S+ LEGAL DESCRIPTION Lot: Block: CLALLAM COUNTY PARCEL NUMBER. d 6 3a no() 2 39 c) 000 kvo 4s w/ s; /'h os ivM w/ )?J7 ir, Fuv Lead 4470/ Qa &Star TYPE OF WORK. Residential New Coast Multi- family Addition Commercial Remodel Repair Sign BRIEF DESCRIPTION OF THE PROJECT PLANNING USE ONLY Re -roof Stove Move n Garage d emolition Deck Other No of Stones: Lot Size: Existing Sq Ft. Tota lot coverage r Geol. 02- is FCT'a ST '•ar S4 ilnAhlr/w. S Witt b e Villez in C,>t y 72c1 ass Qk*/ rrpS7 f,_<P'S4/ -/4 j- dy s,',/e gaa ?jz COMMERCIAL/RESIDENTIAL. Occupancy Group Occupant Load. Construction Type ESA/Wetland(s) Yes No SEPA Checldist required? Yes No Other Subdivision. STZE/VALUATION SF /SF SF /SF SF /SF TOTAL VALUATION °e) /7iS b27/" f= 4('?da 74 /DN Proposed Sq. Ft. 4 y Gl7/7 /e/& e Zip ZONING FOR OFFICIAL LISP- rNL\ l� °0 Permit 0 C" 34 Date Approved: -o Date Issued: -7 7-0 1 Date Rec. f Phone: (360) I/52 3-?9/ TOTAL Sq Ft. I APPROVALS PLAN BLDG DPWU FIRE. OTHER. VALUATION OF CONSTRUCTION In all cases, a valuation amount must be entered by the applicant. This figure will be reviewed and may be revised by the Building Division to comply with current fee schedules. Contact the Permit Coordinator at 417 -4815 for assistance. PLAN CHECK FEE. IF a plan check fee is due it must be submitted at the time the building permit application and construction plans are submitted. All other permit fees are due at the time of permit issuance. EXPIRATION OF PLAN REVIEW If no permit is issued within 180 days of the date of application, the application will expire. The Building Official can extend the time for action by the applicant up to 180 days upon written request by the applicant (see Section RI05.3.2 of the International Buildmg/Residential Code, 2003). No application can be extended more than once. I hereby certify that I have read and examined this application and know the same to be true and correct. I am authorized to apply for this permit and understand that it is my responsibility to determine what permits are required not the City's, and that 1 must obtain such permits prior to work. —7 TIFORMS1B i.�2 IdgPerrnitform.wpd Applicant: 2 Date: 409 r 0 o w.. <J''''''~ ~ .~! CITY OF PORT ANGELES PUBLIC WORKS - ELECTRICAL DIVISION 121 EAST 5TH STREET. PORT ANGELES. WA 98362 ELECTRICAL PERMIT I . OWNER/APPLICANT ISSUED: 1/13/2000 PERMIT NO 6843 ~ort Angeles, WA 98360 360/000-0000 r: S: C01~TRACTOR ELECTRIC SERVICE 1924 DRAPER RD. :PORT ANGELES, WA 98362 360/452-6424 PROPERTY LOCATION 709 VALLEY S Lot: Block: 0 Long Legal Subdivision: Parcel No: ARCHITECT N/A , 98360-0000 360/000-0000 ~ PRCJECTINFO J: Project Type: Occupancy Type: ccupancy Group: I Electrical Heat: o Baseboard o Furnace o Heat Pump o Fan Wall Project Value: $0.00 Construction Type: SEWER PUMP Zoning Use: RES. MISC. o KW o KW o KW o KW o Riser 0 ~ Overhead Service o Temp Service Underground Service Voltage: 120,240 Phase: ~ 1 0 3 Service Size: 0 - Feeder Size: 0 PRO~ECT NOTES WifE SEWER PUMP SYSTEM ,,,j ASS",".,t Service: Additional Feeders: Circuit Wiring: Temp Service: . Mise Fee: TOTAL FEE: AMOUNT PAID: BALANCE DUE COMMLNTS/ACTJON NEEDED $44.25 $0.00 $0.00 $0.00 $0.00 $44.25 $44.25 $0.00 ELECI'RICAL PERMIT INSPECI'ION RECORD CALL 417-4735 FOR ELECTRICAL INSPECTIONS. PLEASE PROVIDE A MINIMUM 24 HOUR NOTICE. IT IS UNLA WFUL TO COVER, INSULA IT OR CONCEAL ANY WORK BEFORE IT IS INSPECTED AND ACCEPTED. KEEP PERMIT CARD AND APPROVED PLANS AT JOB SITE INSPEC110N TYPE DATE I ACCKPTED COMMENTS I VIS I NO -IN I CUVhK ~tKVICt F.IN A T II/JlW I -,rdWl I , GENERAL COMMENTS, P\V-II02.1SI06] . , CITY 'bF PORT ANGELES J LIG DEPARTMENT ELECTRICAL PERMIT N9 15992 //-/] "/ port Angeles, Washlngtonmmmm,n..m_......m...mm...nm..........m., 19n~n.:.;> In accordance with the City Ordinance to regulate the installation, extension, or repair of elec- tric I equipment In, on, or about any building or other structure In the City of Port Angeles, per- mls ion is hereby granted to do electrical work as listed below. Ad,ess ...mZ.C?nfl.__L.__l/t...-!.lbr-.m__nn.__n.__.____m______.__ Occupancy__.__,:~:..,.:,,::nmmn__...__m.______.n Owner .mm.mCr.~li;.--~..__r_.----.mn--m~.nnC.----f TenanL__....__nm__.mn.______.____.______.mm.m__m..m.m..m__ Wing Contractor m.[2.r?rL.em~:'" .__.("",~____.m___.__ By..__________m________m.__.__m____mn.m._.m.__.____m__n Llg t OutletBm.hm__.UUU_____________n__n.~. Service, volts //.?f?/.:P.:.?.t;:f..__. Type of Wiring: .y/ Reo ptacle Outlets.....m.........__............ No. wIres --..--(7;:~.--:-~--'im.. Armored Cable ...__n..............h....._ , SI i 7/& ~!-/ Non-MetallIc ........--.......--..-----....... Dry~,r, KW.................._.__..._..____._..___.__ ze w res._:;...;.",::h.'......-1'"....?t..... ......-.. oJ \..:..;..r..JI Knob & Tubem_............................_ Ran.$e, KW _______nn_n_nn__n____.h____________ MaIn fuse .....:.":..:..:..."....... ...--....... water Heater: Enclosure ___~S_~____"'______'h'___h_ Rigid ConduIt _________.____.____________nU Metallic TubIng __.h__hh________________ KW.m__.h huhm'hmmu__umUh' u__. He.t: Kw_____j..;g,,___.1l!..mmm Type of wIring: Entrance Cable ........._................... Ser. No............................................... Raceway ..............................._....._ Circuits, LighL.....__m......mm.mm........ Utility m.h....u...__._______..______.___________ Jleat ............................................... Range ..........u_................................ Water Heater .........................._.... Motor ..._........................................ Mo~ors: size, volts and phase: RigId ConduIt """,,"..mn Metallic Tubing ....m.................... Current transformers: No. & Slze.....................n................ Ser. No. nn...........................n............ Drycr .................._..........................._.. Furnace .........._..............'_................... Ser. NO............n.............n................. R~mark:~ta:.~~=:.:::~::.mn~~::;:.::.=~~--~.::.:__~:::.__m__....m...m__~:~.~:..~:::...:~.::..::~:.::..:::~.__.:: .--.jo-.----_...__.._..__________.____________.._.._._._...._.....__n..__.____.._.....____._._.__....._.....___...__n.___________..____.....__.U_..d_O__n_._u______..______ ....jo_n.....nuh_n._.__.n___nn_nun.hnnn__nnnnn.nu.u_hh.hh..n.h__.nnn_..un_n.n..u....__u..n_...nnnnunn_..__.hn..n..n.nnn_nn By /~2f~I:i~ie~L~.,-.. NOTICE-Current must not be turned on until Certificate of InspecUon has been Issued. If work is to be COD- cetlled due notice must be given the Inspector so that work may be inspected before concealment. P~rmit Fee $+._____.....m___mm__.__.__.... Treas. Receipt No......................___.... NOTIFY THE INSPECTOR BY PERMIT NUMBER WHEN READY FOR INSPECTION ELECTRICAL PERMIT N? 15992 Alldress..............................................................................__................_.......................................Date..._......_.._......_.........._........................_ O~.vner ...n.............................._......_.._......_......_.._.......n......_n................n................ ...... Tenant............n....n.._.n...................................n..n. ~hring Contractor .........._.....h....n.....................n.....nn.................................nn.....nu.................... Bynn.......................................................... NOTICE-Current must not, be turned on untn Certificate of Inspection has been issued. If work Is to be con- , cpaled due notice must be given the Inspector so that work may be inspected before concealment. "'-. ..' 1M Olvrnoic Printers, Inc. CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS .. . .. . .. .. .. . .. .. . INSPECTION REPORT.. .. . . .. .. . .. .. .. .. REQUEST: Date S - I ( or 0 b . , Time 71ltM.. Location of Work to be inspected 70 '7 So. VA.l (e", f Name of person requesting inspection De..VI."': s !3:- Address of person requesting inspection ,(' ovf r.(a...rJ.. 11 'f--16 Type of Inspection (circle appropriate one): Received by De. Vl.-V\.: ~E.(phone, person) Phone No. 1./ f 7 - <./ fN'7 Permit No. __ Sewer Excav. Othe(ZJ <c +e~ Sewer Foundation Framing Chimney Plumbing Final INSPECTION NOTES: Inspected: Date S~(! -DCa Time 10 AlA-'\. By Lkn(A,<,; C. Remarks: Cut 3/..( ~rv'(-c:..e. f'ro'"" w~+.er "^-,,,,: '" -rlA..t +~d 70'1 So. v"-((~~/ a.croSS +-~ c-r~ek. Tt..~~ S-evvl~e t0e:..5> le~/<I~ 010'\., -r~ ( wLS-I- h"y\.L of +k.e Cre..e k . ON REQUIRED .. .. .. .. .... YES ~ '\I ,~ <1'\ \Yl ~V1~{l. - . lJ d. {{ ~d 1v (XDY[ cLv CL Vl.Q.w ~ Jl ~ -+0 WJ odd.v.Qs<s~ off' of 2)~ s.+. VV\~V'\ . .OLJ...\( ((DST rJD~ ~ A.s A 5W.!l(.Q rtl\.Qk)cJ) -J ~ , l)() .. >.\l "^ -\- ~ NO jo...... ~ - ,~ ':> "t- .'- rS v0 - '8 ~ :5 -T- (8 rid3e-) SURFACE RESTORATION: SURFACE TYPE: 0 Unimproved 0 Gravel 0 Asphalt 0 pcc o Repaired by City o Repaired by Permittee o No Damage Found o Other Work Order # o COMPLETE o INCOMPLETE (Continue on reverse side if necessary) STREET SUPERINTENDENT (DATE)