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DEMOLITION PERMIT APPLICATION <br />Job Site Address/City 11400 &Ie;0 !3~tg a:2 !<if <br />Owner 7)c'>¥QnJS Co Phone _ <br />Owner Address/City 1{JltJO 1/-;vu/Y ;&///::WlQ.y S-;-i'Adt/'r 7auf.Jd {Ie..;~Phone 33<7'739'0-- <br />/' <br />Contractor Address/City ;;;<81 s=>trvt,$v-cI h qC <br />APN .;.-,.__Use of Structure _+-p_,,-I/_#l_+,k--'4;:;.,x.><:~~(/----,,!h,,--_v)'---,-/_~~,-- <br />Contractor <br />I certify that I will dispose of all demolition materials at an approved recycling facility or land disposal site. <br />Signature ~J ~Date I ~d-y -0 r: <br />. <br />SAN JOAQUIN ENVIRONMENT AL HEALTH DISTRICT <br />304 E.Weber Avenue,Third Floor,Stockton CA (209)468-3420 <br />WELL: <br />o Site is served by public water.J8--No record of a well on site.0 Previously destroyed under permit.'F Per applicant,well is to be retained and used for other structures/irrigation;well is in good repair and able to <br />~to function as originally designed.(Pump must be in place and have power.)fi(Well is to be taken out of service under permit and will be placed back in service within five (5)years.Wells <br />not returned to use within five (5)years must be destroyed under permit by a C-57 licensed well driller.o Well is to be destroyed under permit by a C-57 licensed well driller. <br />SEPTIC: <br />o Site is served by public sewer.S-No record of a septic on site.0 Previously destroyed under permit. <br />~Septic tank (and/or brick lined open seepage pits)to be destroyed under permit.o Septic tank to be retained for exiting structure that is currently using the system.o Septic tank to be retained under out-of-service permit for new replacement construction to be built/installed <br />within one year from this date. <br />Permit Type Permit #_=':;";;"-'=--_Date jSSUed·~~~:~~~~~~~_~~;_"'w <br />Permit Type Permit #Date issued ::;..::....;;.;:.._ <br />I 3hL 1_./Environmental Health Division Approval Signat~L .Date issued //2--e/I /)h <br />Solid Waste Division Approval Signature Date issued._ <br />SAN JOAQUIN V ALLEY UNIFIED AIR POLLUTION CONTROL DISTRICT <br />4230 Kiernan Avenue,Suite 130,Modesto CA (209)557-6400 <br />o This certifies that the demolition/applicant has satisfied the SJVU APCD requirements.The APCD allows the <br />demolition to proceed on or after _--,_-:---:--,--_..,.-.o This certifies that the Demolition Application is exemet from the SJVU APCD requirements.Comments:_ <br />Approval Signature Date _ <br />Printed Name Title _ <br />F:\BUlLOING\HANDOUTS\HANDOUT 82 (REV,B/17/01)