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DEMOLITION PERMIT APPLICATION <br /> Date <br /> Job Site Address/City <br /> Owner C5 �'D�CL l l� 2 Phone No. (,6-93ti <br /> Owner ' s Addre s s/C i ty <br /> Contractor Phone No. <br /> Contractor' s Address <br /> Assessor Parcel Number <br /> Use of Structure <br /> Water System: ❑ Private ( Public <br /> Sewer System: Private ❑ Public <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 to obtain all <br /> signatures and return this form to the Building Inspection Division. <br /> ----------------------------------------------- <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 /> 2-"This certifies that the Local Health District has issued a <br /> well permit and/or aesanitation Permit. <br /> Comments: <br /> Approval Signature Date A1_7 S>� <br /> o alinoti , Director <br /> Environmental Health Division <br /> AIR POLLUTION CONTROL DISTRICT: <br /> ❑ This certifies that the Demolition/Renovation applicant has <br /> satisfied Air Pollution Control District' s requirements. <br /> ❑ This certifies that the Demolition/Renovation application is <br /> exempt from the Air Pollution Control District ' s requirements. <br /> Comments: <br /> Approval Signature Date <br /> Lakhmir Grewal , Director <br /> Air Pollution Control District <br /> ( 5/88) <br />