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0.: p-UIry C\ <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />Ni 1868 East Hazelton Avenue, Stockton, CA 95205 <br />(209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />C%FORtj <br />Demolition - Scope of Work <br />To Be Completed and Submitted to Purchasing as Supplement to Requisition for Bid <br />FACILITY NAME: MAXINE ROBINSON <br />DATE: 8/30/2013 <br />LOCATION: 2156 S B STREET <br />CITY: STOCKTON <br />EHD STAFF CONTACT NAME: ROCHELLE VELOSO-CACAPIT <br />PHONE: (209) 468-9847 <br />EMAIL ADDRESS: rcacapit(cDsicehd.com <br />FAX: (209) 464-0138 <br />FACILITY FA0015640 <br />ID: <br />PROGRAM RECORD PR0537938 <br />ID#: <br />APN: 171-041-20 <br />STRUCTURES TO BE DEMOLISHED: <br />STRUCTURE TYPE/DESCRIPTION <br />STRUCTURE ID (SEE MAP) <br />#1 <br />Single Family Dwelling <br />SFD <br />#2 <br />Shed <br />Shed <br />#3 <br />Septic Tank <br />ST <br />#4 <br />Kitchen Grease Trap <br />GT <br />UTILITY CONNECTIONS: <br />ELECTRIC POWER PROVIDER: PG&E <br />® NATURAL GAS - PROVIDER: PG&E ❑ PROPANE FUEL TANK ❑ OTHER: <br />® ON-SITE SEPTIC SYSTEM # TANKS: 1 #BRICK LINED PITS: #CESSPOOL: #GREASE TRAPS: 1 <br />® PUBLIC SEWER SYSTEM - PROVIDER: CITY OF STOCKTON <br />❑ WATER WELL— EHD PERMIT REQUIRED "*ONLY A C-57 LICENSED CONTRACTOR CAN DESTROY A WATER WELL"* <br />® PUBLIC WATER — PROVIDER: CALIFORNIA WATER SERVICE <br />Items NOT Part of Demolition Activity: <br />STRUCTURE TYPE/DESCRIPTION <br />STRUCTURE ID SEE MAP <br />#1 <br />#2 <br />#3 <br />PERMITS REQUIRED: <br />ATTACHMENTS: <br />® EHD SEPTIC PERMIT(S) <br />® AERIAL PHOTO OF PARCEL <br />❑ EHD WATER WELL DESTRUCTION PERMIT(S) <br />""'ONLY A C-57 LICENSED CONTRACTOR CAN OBTAIN**** <br />® SITE MAP <br />❑ EHD WATER WELL OUT OF SERVICE PERMIT(S) <br />® PHOTOS <br />® CDD DEMOLITION PERMIT <br />❑ SEPTIC AND WELL HISTORY <br />❑ OTHER: <br />❑ OTHER: <br />COMMENTS: <br />House has a City sewer hook up. However, the septic tank and grease trap were never verified as destroyed. <br />Therefore, both must be destroyed under EHD permit and inspection. <br />COMPLETED ROCHELLE VELOSO-CACAPIT PHONE: 468-9847 <br />BY: REGISTERED ENVIRONMENTAL HEALTH SPECIALIST <br />EHD-San Joaquin County Environmental Health Department -600 East Main Street, Stockton CA <br />CDD- San Joaquin County Community Development Department -1810 East Hazelton Avenue, Stockton CA <br />EHD 13-xxx 10/26/2011 Page 1 Demolition -Scope of Work <br />