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DE":OL7TION PERMIT APPLICATION <br /> Date <br /> Job Site Address/Cityin <br /> I / <br /> Owner 0 �`/ Phone No.63 &VZZ <br /> Owner ' s Address/City <br /> 1. <br /> Contractor �� Phone No. <br /> Contractor ' s Address �, � �✓�� ��L� 4 4Ls�7.� <br /> Assessor Parcel Number <br /> Use of StructureL./ <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 /> sig natures <br /> and r Building Ins <br /> re this form to the 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 system on the <br /> property. <br /> ❑ This certi�vesthat the Local Health District has issued a <br /> well permit - and/or a sanitation permit. <br />• <br /> Comments:: <br /> Approval Signature Date <br /> Ron Valinoti , Director <br /> Environmental Health Division <br /> -------------------------------------- <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-,.`-' 2S154 ¢� 'r <br /> Approval Signat e ' - Date <br /> Z g� <br /> SAN JOAQUIN COUNTY akh G D ector <br /> PAlppOLLUTION CONTROL DISTRICT. Air o ution Con ral District ( 5/88 ) <br /> 5/S8 ) <br />