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y <br /> DEMOLITION PERMIT APPLICATION <br /> Date <br /> job Site Address/City � - <br /> � Phone No. � <br /> Owner f1 <br /> Owner ' s Address/City <br /> 3 JVCP <br /> Phone No <br /> Contractor <br /> Contractor' s Address <br /> oS 2c <br /> Assessor Parcel Number / /3 <br /> Use of Structure <br /> ❑ Private ❑ Public <br /> Water System: '. <br /> Sewer System. ❑ Private Public <br /> ❑ <br /> Before a Demolition permit can be issued by the Building .Inspection <br /> Division, approval signatures must be obtained from each agency <br /> listed below. It is the applicant ' s responsibility t o <br /> signatures and return this form to the Building Inspe do <br /> a P <br /> SAN JOAQUIN�LOCAL HEALTH DISTRICT: <br /> ❑ This certifies that the Local Health District ' s records <br /> indicate that there is not a well or septic s stem on the <br /> property. <br /> ❑ This certifies that the Local Health District has issued a <br /> well erm�t_ and/or a sanitation permit . <br /> Comments: <br /> , � r <br /> Approval Signatur <br /> � G �, Date <br /> R Valinoti , Director <br /> Environmental Health Division <br /> AIR POLLUTION+CONTROL DISTRICT: <br /> This certifies that the Demolition/Renovation applicant has <br /> trol District' s reauirements_ <br /> satisfied Air Pollution Con <br /> FThis certifies that the Demolition/Renovation application is <br /> exempt from the Air Pollution Control District ' s requirements. <br /> �v� 5i <br /> Comments: i!Y' ` <br /> Approval Signature <br /> Date }2• Z 1 •�c� <br /> L k mir Grew= , Director . <br /> Air Pollution Control District SAN JOAQUIN COUNTY <br /> AIR Poi►.0::...:N <br />