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9712-029 (SFD)LICENSED CONTRACTOR DECLARATION I hereby.affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect. License # Lic. Class Exp. Date 497584 BC -I( ft V28f98 ,/Date J17 —IO"" i ISignature of Contractor OWNER -BUILDER I hereby affirm under penalty of perjury that I am exempt from the Contractor's License Law for the following reason: ( ) I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business & Professionals Code). ( ) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business & Professionals Code). ( ) I am exempt under Section B&P.C. for this reason Date Signature of Owner WORKER'S COMPENSATION DECLARATION " ' I hereby affirm under penalty of perjury one of the following declarations: ( ) I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. . ( ) I have and will maintain workers' compensation insurance, as required by S ction 3700 of the Labor Code, for the performance of the work for'which this permit is issued. My workers' compensation insurance carrier & policy no. are: Carrier Policy No. • r �.!•..rrt �n (• GM i t) lY.l1 t{.Y� Jlti� i�+s.(. 2`131v +2I �J (This section need not be completed if the 9'ermit valuation is for $100.00 or less). ' ( ) I certify that in the performance of t e work for which this permit is issued, I shall not employ any person in any nner so as to become subject to the workers' compensation laws of Califo ia, and agree that if I should become subject to the workers' compensatio rovisions of -Section 3700 of the Labor Code, I shall forthwith comply with thbAe,6rovisions. 4Date:f Applicant Warning: Failure to secure Workes' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on his application. 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any.permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such r permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read�is application and state that the above information is correct. I agree to comp with all City, and State laws relating to the building construction, and here authorize representatives of this City to enter upon the above-mentioned frogjarty for inspection purposes. Signature (Owner/Agent)l_"'""""r'"""� Date izt&17 T# BUILDING PERMIT PERMICONTROL# 4,12-�2� 6404 DATE ^. A VALUATION SZ83 1i7 zt) LOT s- TRACT JOB SITE ADDRESS 80-4.6 R7�-/ U� 'X� NA TRAH, APN 769-420.004 OWNER ESIGNEER/ENGIINEER CONTRACTOR / DESIGNER ENGINEER (t ` itri.i •1i �3,'1'i.i S•�: A &G1is(iViaCM611'i 7327751>MITIT-Co DESERT 1311 79-070 CALLS CADM INDIAN Wi;Lt.N CA 92230 LA t;iUINTA CA 922_57 t7fi()15ti+tKIF332 fjlit.# ti;,ci USE OF PERMIT IN S-t� u Wi GUEST I [C)UiC - Pi:t A11T DOES N l Ii4CLDE M— ALN %ALB OR PORCMPA"i'lu 4 i 0,00 Si, (.iARilt:rl: CARPORT I.z97;t{t ,;I ti�w,/�A.'ttAL}1. Elf/►.*�+7 ,1 {A�f i•`f{'/. t'1 fy4/l.Y.�a11 ,�..K.t.,�c-�e �n PERTUFT Ft IF, SUMlMElR «*! . CC1N'. FRVC'I'1C)N P1,AN Cl TrtC , Ft f; i (1!-ft(Ni-�ii!3-Zt Ii Ri, its t,11 '� r<::fiti lNiC��.. !"Jxs 101-000- L21.OW $tG4.�3 � HL1 t:,"i" 4 iCIA ;1r1J1. 101–W0420-000 0420-000 I11LUNIBIN0IFk 101-OW41Q 000 S�ia.2� C gTf ON(l M<'A'10114 0-Y - 10140124143(?fi 5�,?2 C'n GRADING IT.1i 101-000.42:1•(230 5�3,(t�i ® E_ N[°i"�'`i't`TL�Tiiittf 1-01 225-604.13t-:i<i t;.c „l.Ckl 1.4 IU4T IN K41L.IC FI AC'HS-1W,41T; 701-000-2y5-i?ihi $457,84' 3 ( rrr,,IN.-W)SIT t��f►rNt 1oi. 0 STJiVTt'Y -, ), GONSTRI-tMON ANF) MAN C1IPCK -41, SI)P. T46 w t.E's.is PR.E-PA1:)1'EL' " 42,130.00 I)IJP, NOW 59.387.44 I RECEIPT DATE BY }1 DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS - Set Backs / Underground Ducts Forms & Footings U - Ducts Slab Grade Return Air Steel Combustion Air ' Roof Deck Exhaust Fans O.K. to Wrap _ F.A.U. Framing Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath - • Final >S' Final POOLS - SPAS BLOCKWALL APPROVALS steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment location Underground Electric Underground Plbg. Test Final Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines 41 /fir S Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster Sewer Lateral Pool Cover Sewer Connection Encapsulation Gas Piping Gas Test Appliances Final COMMENTS: / G c !' ` ? ` (r^S Lfh„2 /S2�W��°`� 1-taS"2 t oa)I ws Final Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring�L�/L.�— Low Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power • Final `Utility Notice (Perm) ,r ; ., .. ..+.+i li ^t•. *""F > "' SF ,Y 'Ki Cv `'rt'^ '• ^'t' :�i �1 `ir Dii it ! e ` # r . t �i w' a � T71 2 — P.O. BOX 1504 APPLICATION ONLY 29 Building q p n '''f'�y,78-496CALLETAMPICO Address Q+� �✓ �✓ Doc-' NA l P�INfAaCALIFORNIA 92253 -e LL D3TB: Mailing - -4 Address ` A.P. Number.'C_l 41.► L17-0— 10107 — 16 Legal Description a 7 "U. s I 117 7 4 _ C Arch., Engr Desi.fl te� Designer Iv AIW"ir" Pi W hg11. 111AI Tel. V7.. fifty Zip State /41QI 4024 ... Lic. e LICENSED CONTRACTOR'S DECLARATION I hereby affirm t I am licensed under provisions of Chapter 9 (commencing with Section 7000) of DivisioJ� of the Business and Professions Code, and my license is In full force and OWNER -BUILDER DECLARAVON I heresy affirm that I am exempt from the Contractol's License Law for the following reason: (Sec. 7031.5,Business and Professions Code: An). city or county which requires a permit to construct, alter, improve, demolish, or repair any --tructure, prior to'its issuance also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of. the Contractor's License Law, Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis for the alleged exemption. Any violation of Section 7031 5 by 'any applicant for a permit subjects the applicant to a civil penalty of not more than five huncred dollars ($500). f: 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon and who does such work himself or through his own employees, provided that such improvements are not intended or offeree for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he did not build or improve for the purpose of sale.) I'I I, as owner of the property, am exclusively contracting with licensed contractors to con- struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or imprcves thereon, and who contracts for such projects with a contractors) licensed pursuant to the Contractor's License Law.) 17 I am exempt under Sec. B. & P.C. for this reason Date Owner of WORKERS' COMPENS ?ION DECLARATION I hereby affirm that I have a certificat o� onsent to self -insure, or a certificate of Worker's Compensation Insurance, orcarti opy thereof. Sec„3800�,Lapor Code.) Policy No. Company •rte n Copy is filed with the city. O Cert' ed copy is hereb urnished. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed If the permit is for One hundred dollars ($100) valuation or less.) I certify that in the performance of thg work -for which this permit is issued, I shall not employ any person in any manner so as to become subjlect to the Workers' Compensation Laws of California. Date owner NOTICE TO APPLICANT: 11, after making this Certificate of Exemption you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revcked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Coda) Lender's Name Lender's Address This is a building permit when p operly filled out, signed and validated, and is subject to expiration if work thereunder is s upended for 180 days. I certify that I have read this pplication and state the- the above information is correct. I agree to comply with all c' and county ordinances and state laws relating to building construction, and hereby q h`orize representatives -of this city to enter the above. mentioned property for inspe ion purposes. Signature of applicant Date O Mailing Address City, State, Zip W Sq. Ft. 1 1¢® No. No. Dw. Size 1 Stories Units Add ❑ Alter ❑ Repair ❑ Demolition ❑ :J PERMIT I I AMOUNT Plan Chk. Dep. "L„ 50 • C10 Plan Chk. Bal. Const. Mech. Electrical Plumbing S.M.I. Grading Driveway Enc. Infrastructure TOTAL REMARKS ZONE: BY: Minimum Setback Distances: Front Setback from Center Line Rear Setback from Rear Prop. Line 1 Side Street Setback from Center Line ' Side Setback from Property Line FINAL DATE INS CTAO Issued by: DateJPe�Sit Validated by: Validation: WHITE = FINANCE YELLOW = APPLICANT lrV Lam,;.;”' r 11_ cr PINK = BUILDING DIVISION Coachella Valley Unified School District P.O. Box 847, Thermal, CA 92274 (760) 399-5137, Ext. 235 This Bus For District Use Only CERTIFICATE OF COMPLIANCE (Government Code 53080) Project Name: Date: December 17, 1997 Owner's Name: Kjel l 0stbye Phone No. Address: 80-645 La Docena Trail- La (1uinta, r_n 99253 Project Description: Single Family Dwelling APN: 769 420 ( Type of Develop Tract # Lot #: :Residential XX Commercial are eet of Building Area: 4,610 Industrial Certification of Applicant/Owners: The person signing certifies that the above information is correct and makes this statement under penalty of perjury and further represents that he/she is autorhized to sign on behaWof the owner/d eloper. 71� Dated: 2—q Signature: y SCHOOL DISTRICT REQUIREMENTS FOR THE ABOVE PROJECT HAVE BEEN OR WILL BE SATISFIED IN ACCORDANCE WITH ONE OF THE FOLLOWING (CIRCLE ONE): Gov. Code Gov. Code Project Agreement Existing Not subject to fee 53080/65995 65970 Approval ` prior to 1/1/87 requirement. Number of Sq./Ft. Amount per Sq/Ft. Amount Collected 4,610 $ -r,4"1.84 $ 8.482.40 Note: By: Foch "Tut" Pensis, Assistant Superintendent' Administrative Services Administrator in Charge Certificate issued by: Marcela Valdez Signature: NOMCE: Section 66020 of tie Govenuthmht Code enacted as Assembly Bill 3081, set fordh as Chapter 549, Statutes of die State of Catifontia, 1996 effective Jan 1, 1997, requires that this school district provide awritten n0 ice to ant Idie project applicat the time of payment of school fees, nutigation payment or odher exactions. 77his notice is to advise you tat any protest bh regard to such muounts or the validity diereof bi accordance widh Section 66'020 I of die Govenuumt Code mrd other applicable law, conunences with such payment or perfonumhce of miy other requirennent as described bh Section 66020 of tie Govenuuent Code. Additimhally, this notice advises dat the protest Hereof rmst occur within 90 calendar days thereafter. Note: AB 2926 and SB 201 fees are capped at $1.84 per square foot for all residential construction, and at $0.30 per square foot for commercial/industrial projects. Dev. Fees Disk: Misc\Cert-Com.Sam. (REV. 1/97) . RANGE COAST TITLE 00 ;3 ;dj 1' 1;G , • RECEIVED FOR RECORD 1' RECORDING REQUESTED BY I AT 8:00 O'CLOCK AND WHEN RECORDED MAIL TO: KJELL T. OSTBYE and SHARON A. OSTBYE, A.P.N.: 769420-004 TRA #: 020056 SEP 5. 1997 Romded in Ol6dal Records PAID of aiversideCounty, California Doc. Transfer Tax decor . Fees $ FRY. Co. Recorder . .. - Space Above This Line for Recorder's Use Only Order No.: R-158498-1 Escrow No.: 2-23322 GRANT DEED THE UNDERSIGNED GRANTOR(s) DECLARE(s) THAT DOCUMENTARY TRANSFER TAX IS: COUNTY $181.50 X ] computed on full value of property conveyed, or computed on full value less value of liens or encumbrances remaining at time of sale, unincorporated area; [�] City of La Ouinta , and FOR A VALUABLE CONSIDERATION, Receipt of which is hereby acknowledged, SIMPSON LEASING COMPANY, a California Corporation hereby GRANT(S) to KJELL T. OSTBYE and SHARON A. OSTBYE, Trustees of The Ostbye Family Trust dated November 26, 1991 the following described property in the City of La Quinta, County of Riverside State of California; - LEGAL DESCRIPTION IS ATTACHED HERETO & BY THIS REFERENCE IS MADE A PART OF THIS INSTRUCTION. SIMPSON LEASING C MPANY, a California Corporation .By: C rp rate officer Rk? By: ., Corporate officer Document Date: July 10, 1997 STATE OF CALIWO eIA . de )SS COUNTY OF ) 0n 7111197 before me, Diane Morales personally appeared Gary impson X10 personally known to me (or pr d to me on the basis of satisfactory evidence) to be the person(s) whose name(s)&4w-subscribed to the within instrument and acknowledged to me that executed the same irlres�heiFauthorized capacity(ies) and that b signatures) on the instrument the person(s) or the entity upon behalf of which the person(s) acted, executed the instrument. 1 WITNESS my h and oMcial seal. Signature DIANE MORALES Commisslon 111093322 q < .� Notary Pub9c — Cc90-TJ0 RFdsrslde County or R(gdd t►ata9*bwIApr 7.2000 Mail Tax Statements to: SAME AS ABOVE or Address Noted Below EXHIBIT "A" The land referred to in this Report is situated in the State of California, County of Riverside and is described as follows: Lot 4, Tract 21176, as per map recorded in book 166, pages 95-97 of Maps, records of said County. 5 ASSESSOR'S PARCEL NUMBER COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY DEPARTMENT OF ENVIRONMENTAL HEALTH PERMIT APPLICATION FOR A SUBSURFACE SEWAGE DISPOSAL SYSTEM APPLICANT: Submit this form with four copies of a SCALED plot plan (1 20 SCALE) drawn to County specifications, indicatedo� „irheattacFhed check IisL' Anon -refundable filing fee is required when the application is submitted. Check must be made payable to the County oiverside: Approval of this applica= tion shall remain valid for a period not to exceed one year from date of payment. 1238 VIC ( CHK $23.4_ 01 LOG # Agent, Contractor, Contact Person i Address - C,iii, State Zip Telephone a Owner k, T ( �-t-f3.Y Address O City State Zip `�`� � Z 10 Job Property Address �f�oo �� L� t4- 11.4L T City L Zip l.Yf IU Lot Size Water Agency/Well Use of Permit, P/P, SUP, PUP, etc. Legal Description J f q.lrt�` he✓f♦ / r i / l �%(o ! f 1 Fy r Dwelling, H Site Prep., etc. `+& i Signature f Ap(Sli nt Date CHECK BOA IF REQUIRED ❑ Holding Tank Agreements Completed ❑ Detailed Contour Plot Plans Required (1 to 5 foot interval) ❑ Certification of Existing S.D. System Required °' ❑ Grading Handout Provided m ❑ WQCB Clearance Required ❑ Staff Specialist Lot Inspection Required Z 0 (Attach For DOH -SAN -007, Santa Arra Region Only ❑ Lot Inspection U❑ Soils Percolation Report Required W ❑ Required ❑ Date Lot Inspection Completed: Initials U Special Feasibility Boring Report Remarks: ❑ Maintenance Booklet Provided Initials Date ❑ Final Inspection by Department of Environmental Health is required. C/42 / Soils Percolation Boring Report by f ` t ` UgProject # Date Soils Map Page Soil Type Approved By Date No of Systems Type of System(s) O Holding Tank El Replacement No. Dwelling Units Bedrooms, Fixture Units (1) Septic Tank Soil Rate r v f Grease/Sand {fi Grease Intcp/Lint Trap t ® New O Addition >� f p %,S'o0 9 '210 ' � o Gal. O Existing Gal. Sq. Ft. Total Linear Sidewall Allowance Leach Bed sq. ft. of Bottom Area Ft.Bottom ft. rock/ sq. ft. running ft. Install 2• Lines) s° • ft. long i ft. wide with Area Inlet Tested Depth —5"NA min. f a inches rock below drainlines or -- Proposed Bottom Tested Depth U Z Leach lines/bed special design for slope: (3) Pit Diameter No. Pits Pit Below Inlet (BI) Seepage Pit Maximum Other: O Total Depth Allowable F– Applicable �.' Depth W N/A Y/ Overburden Factor ❑ S. DIG TD%/ U Well Review Approved: Date: Well Drilling Permit # SIGNATURE Grading Plan Approved: Date: SIGNATURE > Sewer Verification Approved: Date: REMARKS: f dt%eL wrut� /.•�.( - . i r This application PROOVVE^D/ ENIED for the category checked in SECTION B XZ FOR OFFICE USE ONLY above, regarding the -design of a subsurface d'sposal system as Indicated on the acompanled plot plan, using the requirements setforth in SECTION C above. A build- / ^ ing permit is necessary for the installation of the. above -designed system. No construe- Revenue code / g{ j') Fee $ `� tion Is permitted in the required reserved 100% expansion area. �' (1� ptic Tank must be 100' minimum from any wells. Cheek # (2) Leach lines must be 100' minimum from any wells, including expansion Date l/ -4J – 4? Initial �r�• - ' (3) Sewer lines must be 50' minimum from any wells. ^ r .•....: Z . O_ (4) Seepage pits must be 150' minimum from any wells, including expansion area. f– U W U Signature of Health Official ft - - Date t - r F - DOH -SAN 122 (Rev 9/93) Ulstributlon: WMItE—Juice File; YELLOW—Applicant; PINK—Bldg. Dept.; GOLDENROL—Plans/Records N I�i��f'�:�i•1�l�ili/��� i 7 LA QUINTA POLO ESTATES Architectural Review Approved ✓ D nnditions Yes No (Jmst . �p SU�ON,� Signature ` ��1OF15 4-i W ler 6o ex4- Gtr ro►� Signature- "3Sub"^^�" ,.. � h�, pro�d�o� Cy(VV V4) f R F STRUCTURAL CONSULTANTS, INC. -------------------------------------------------------------------------------- 41865 BOARDWALK, STE 208, PALM DESERT, CA. 92211 PHONE (760) 836-1000 FAX (760) 836-0856 DECEMBER 19, 2008 THOMAS AND DIANE RICHARDS C/O JUAN CARLOS OCHOA 80645 LA DOCENA TR ATi� LA QUINTA POLO ESTATES LA QUINTA, CA 92253 RE:. THE RICHARDS RESIDENCE REMODEL ADDITION 80645 LA DOCENA TRAIL LA QUINTA, CA 92253 FOLLOW=UP.TO.STRUCTURAL OBSERVATION JOB NO. 4810 DEAR JUAN THIS LETTER ADVISES THAT WE PERFORMED THE STRUCTURAL OBSERVATION FOR THE ABOVE REFERENCED PROJECT AND FOUND THE AS BUILT CONDITION AT THE TIME OF OUR VISIT IN GENERAL CONFORMANCE WITH THE APPROVED CITY PLANS AND CALCULATIONS AND RELEVANT CORRESPONDANCE ISSUED BY OUR OFFICE. RESPECTFULLY SUBMITTED ��pP1v P. l�� 1 F C 71171 -�► sl Civic or .di, ANTHONY LITECKY, P.E. I vlit = UTHLAND EOTECWNCAL- _ FOUNDATION ENGINEERS AND MATERIALS LABS FACISMILE TRANSMITTAL, FAX NUMBER (760) 360-0521 DATE: l - c TIME: Pa+i COMPANY: Alm aM54-- ATTN: ; (;, FAX NO: '(o y+ c) 0 �o PROJECT: P �PS aIC v, PROJECT NO: NO. OF PAGES: COMMENTS: L ts}- �W G&4S G REPSONSE REQUIRED: YES NO SENDER:CZ,6i'r'- &4P'l4.+` PHONE NUMBER: (760) 360-0665 PLEASE CONTACT SENDER IF YOU DO NOT RECIEVE ALL OF TRANSMITTAL 242 NORTH 8TH STREET - EL CENTRO, CALIFORNIA 92243 - (760) 352-1242 79.807 COUNTRY CLUB DRIVE, SUITE 5 - $ERMUOA DUNES, CALIFORNIA 92201 - (760) 360.0655 2211 EAST PALO VEROE STREET - YUMA, ARIZONA 85365 • (520) 344.8844 7975 RAYTHEON ROAD, SUITE 210 • SAN DIEGO, CALIFORNIA 92123 • (6 19) 467.4900 I OUT HLAND—� EOTECHNICAL 1 7l J FOUNQATioN ENGINEERS AND MATERIALS LABS COMPACTION TESTING (Nucleor Method ASTM D-2922 & D-2950) Test No. Density Count Moisture Count Moisture Correction "-- -�-- - Mode & Depth ►' --- �— Wet Density. PCF Dry Density, PCF g M % Moisture Z. Standard Dens. (MAX) Optimum Moist. % Compaction Specified Dens. LL 0'- 5Z 6 a ""-- - Test No.: I ei'- b s� Station: Location: u,�_t� Q,o� — 7 Test No... Location: Test No.: Location: _ Test No.: Location; i r Elevotion: L l Station; Elevation: Station: Elevation: Station; Elevation: Mat'I: Mat' I: Mat'l: Test No.: Station; Elevation: Mat'f: Location: Test No.: Station: Elevation: Location: Mat'I; Test No.: Station: Elevation: Mat'I: Location: p PROJECT NAME: // )0 �j t t -C - PROJECT NO.: CLIENT: j1(� i_4 vt�� • DATE: �Z'�'� 7 TECHNICIAN:A cnt� Gauge Serial No.. Density Std:: Moisture Std.: FOrm NO: 1615 IANY. INUI -PLUS ►Melfin 315.1.23156 1 OUT HLAND -' EOTECHNIC.gL� FOUNDA110N ENGINEERS AND MATERIALS LABS COMPACTION TESTING (Nuclear Method ASTM D•2922 & D-2950) Test No•. /02-7—' % Elevation:- Station: Mat'i: Location: Oc�SC po j� t '��2„Ir► y f, p S .� ,� 21L�L....�'�►` l Din c ✓ Test No.: L0`1- D "1- Location: __ < Station: _ Il �. 4.10 k� Test No.: - O � Stotion: Elevation: Location _T> .. 'L Z -it-7 n / h f LA k" tzr C. Test No,: d L-� Location:.. l� Test No.: - 17 0 5- W 57 Location:- ! I Mat'I: MOVI: Ir Station: --Z— Elevation: ' _�. r Mat' I: Station:''� Elevation if I �,...v "9A fwt AC Si- of C�r�cr: 6 - i F2- -4S Mot'I: /I E.y r,. c,%— Test NO.:St � T �---� ation: Elevation: 1� p ~ �� Matt: t t Location: I t 1 1 , ,� —% .� J / W--- -�' Test No.: I ZO °f- d'-7 Station: Elevation: _1 S / Mat'I: _ Location: e elk., to N_ o �►n 4 n PROJECT NAME:�p---�-- t PROJECT NO.: CLIENT 1M t-�H 5 �' • DATE. TECHNICIAN: Gauge Serial No.: Density Std.: Moisture Std.: r UTNL4ND'"� EOTECHNCAL= FOUNDATION ENGINEERS AND MATERIALS LABS ov PROJECT: PROJECT N•.. l 2 CLIENT: �M BRANCH OFFIC�►ndyffc. c�Ur�-s TECHNICIAN DAILY REPORT CONTRACTOR/CLIENT REPRESENTATIVE CONTRACTOR'S REP. ON SITE: Z-'OnOWNER'S REP. ON SITE: TIME IN: -'oo •z-' 0 U TIME OUT: 'aa 36 STANDBY TIME: LUNCH/BREAKS/ETC.: MILEAGE: BILLABLE TIME: PROGRESS: (AREAS WORKED, COMPLETED ETC.) C wcv- 0 On coy^ ave o. (0. �n• rLc� P a -e. r -e w� ..v S ©nq 0 r cam.c rIVI -E k o ul - ce OBSERVATIONS: NON-CONFORMANCE AREAS: PERSON NOTIFIED:' ``5 ��� SIGNATOR cL DATE: SIGNATURE OF TECHNICIAN: F— No. 161 • Pteze Prirnen 344-236S OUTHLAND EOTECHNICAL- FOUNDATION ENGINEERS AND MATERIALS LABS COMPACTION TESTING (Nuclear Method ASTM D-2922 & D-2950) Test No. 114-0 Elevation: - 1114 -0 ((/ Density Count Test No.: (( 14-02- Station: Elevation: �\ " �• S Mat'I: Location:_ (1 Moisture Count---- 15 pf� q 0 �S 8 ' -� S Moisture Correction .— ti ,-- x 2-0 ' 1 Test No.: (/ 1 - Station: Mode & Depth Mat'I: " 1 ^.-?-?/t,) X 91 A) Test No.: Wet Density, PCF Station: v Elevation: FF Mat'I: Location: 7c� rac�►t �ac� " �� �� / .S� S o�C �l..Q (,t �, Uec Test No.: Dry Density, PCF ZO, ZO Z2, ? (Z • , 8 Z • ZZ Z, % Moisture � , Z 3 CP, 3 . , Z Standard Dens. (MAX.) �'1j�,� 3015 Q, (3b, Optimum Moist. ILD U-0 (G , D �. Q ((.0 1,' , O % Compaction , Z 9L, 01 '1, 9-3,-3 3, .3 , Specified Dens. 90 go 9 Test No.: ( ('1 -0/-�- Station: Elevation: -Z S � � Mat'I: �t Location: 4 ^' 2-0'W ZSi d fOQ Test No.: (( 14-02- Station: Elevation: �\ " �• S Mat'I: Location:_ (1 ^- L x -2-Zi N Test No.: Station: Elevation: (— Z-/ Man: Location: ti 1 �^- S LA) x 2-0 ' 1 Test No.: (/ 1 - Station: Elevation: Mat'I: Location: 1 ^.-?-?/t,) X 91 A) Test No.: Station: v Elevation: FF Mat'I: Location: 7c� rac�►t �ac� " �� �� / .S� S o�C �l..Q (,t �, Uec Test No.: < < Station: Elevation: 1 Mat'I: Location: w 20 _ , Go re\o r— Test No.: Location: PROJECT CLIENT: Gauge S Density Std.: Mat'I: 4 I 1 Moisture Std.: