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DEMOLITION PERMIT APPLICATION <br />Date ---(f---'.-C?-c..'....LC(_~_O-=~~ <br />Job Site Address/City !t5()O ~£/0 tJ~hC<fIt/l. <br />Owner ---.:....d~<-"'C::........=..._J---,./J4r.:.=..::..P?'-"d:....5<--.-..:::Go:.....:;..Phone _7 <br />ownerAddress/City~~~~~~/~~~(~)~~~~~j..::..~~;~~(~f~~~~..::..~..::..~_~~~~~~~~~~~~~~~~~~~~~~~~~ <br />,;24...lTallcy 4 ,Phone ---"3.::........::..J--'C(_~_1J=--.9."..:.L'---_ <br />CootractmA~reS~Gty_~~~Z~(~-~r~~~~~~~~~~~~d~~~/~~~~~~~e~~ <br />"APN ~_-~t----UseofStrucrure--------------~ <br />! <br />Contractor <br />I certify that I will dispose of all demolition materials at an approved recycling facility or land disposal site. <br />Signat.reD~JjIk Date _1<---.;-;L"'---Yl-~_d"_ <br />SAN JOAQUIN ENVIRONMENTAL HEALTH DISTRICT <br />304 E.Weber Avenue,Third Floor,Stockton CA (209)468-3420 <br />WELL: <br />Site is served by public water.\6 No record of a well on site.0 Previously destroyed under permit. <br />Per applicant,well is to be retained~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.) <br />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. <br />Well is to be destroyed under permit by a C-57 licensed well driller. <br />SEPTIC: <br />o <br />~o <br />Site is served by public sewer.~No record ofa septic on site.0 Previously destroyed under permit. <br />Septic tank (and/or brick lined open seepage pits)to be destroyed under permit. <br />Septic tank to be retained for exiting structure that is currentiy using the system. <br />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 issued------------------------------------ <br />Permit Type Permit #Date issued _ <br />Solid Waste Division Approval Signature Date issued,_ <br />Environmental Health Division Approval Signature!'~dn.,(,)___;L Date issued->-!+,(~,---+>--b""--._ <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. <br />Comments:-------------------------------------------------------------- <br />Approval Signature Date _ <br />Printed Name Title------------------------------------------------- <br />F:\BUlLOING\HAHDOUTS\HANDOUT 82 (REV.8/11/01)