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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street,Stockton,CA 95202-3029 <br />Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br />ApPLICATION FOR A TEMPORARY WAIVER <br />FROM REQUIREMENTTO DESTROYABANDONEDSEPTICTANK <br />A <br />SITE LOCATION:5'tj~5'~~f~F'~fl()ClTY:~r61'i!...7'cN DATE:7/6 /t I <br />PROPERTYOWNERNAME:(f)A,AI V t:.i-/\hJA~-,J-Q APNl7tf_O~()••Ob <br />PROPERTYOWNERMAILINGADDRESS:~J1-/1.7~~,A,..•'""b- <br />CITY/STATE/ZIP:oS r<:J Ci::...-lYt/tA <1S'd-.15 PHONE:20C1 -L.-/o3-~g07 <br />Intent to Rebuild/Replace Statement <br />I hereby declare that it is my intention to obtain a building permit to rebuild/replace the structure being proposed for <br />demolition,as indicated on the demolition permit application,within three (3)months from the date of demolition,and to <br />complete the construction and final the building permit within one (1)year from the date of demolition. <br />Septic Tank Abandonment Statement <br />I understand and acknowledge that should I fail to obtain a building permit within the above noted time period,the septic <br />tank will be considered abandoned and I will be required to destroy the septic system under permit and inspection from EHD <br />at that time. <br />Reuse Conditions Statement <br />I understand and acknowledge that I must satisfy the conditions for reuse of the septic system for the rebuilt/replaced <br />structure,as indicated below.I also ~,septic repair permit may be required prior to the final occupancy of <br />the rebuilurePI~~~~ersta that I ill be responsible for all EHD enforcement costs should I fail to comply <br />with these conditio~~ptic sys reuse.(Uq)q'f'J -tfo7'~AJ <br />CERTIFIEDBy:~""'\JII/l-];S ()A....~"7 6 '/1 <br />l./'PROPE RSIGNATURE ,DATE <br />FOR EHOUSE ONLY <br />SeDtic System HistorvlPermit SummarY <br />Permit#:77-tf2--~Date:1/IU//t:f71 ~rigjnallnstallation DRepair DReplacement DAddition <br />Permit#:Date:DRepair DReplacement OAddition DOther <br />Permit#:Date:"DRepair DReplacement DAddition DOther <br />Permit#:Date:DRepair DReplacement DAddition DOther <br />Permit#:Date:DRepair DReplacement DAddition DOther <br />Reuse Conditions~0 AGEOFREsIDeNTIAlSYsTEII:o Re-Connection Inspection RequiredLEssTHANFive(5)Years Old <br />o AGEOFRESIDENTIAlSYSTEM:o History of Failures -Additional Disposal Field Installation Required (See Comments)o Condition of System Evaluationllnspection RequiredBETwEENFive(5)and Ten (10)Years Old ORe-Connection Inspection Required <br />I ~AGEOFRESIDENTIAlSYSTEM: <br />o History of Failures -Additional Disposal Field Installation Required (See Comments)D!Condition of System Inspection Required <br />Over Ten (10)Years Old IDisposal Field Reuse Expansion Required (50%of existing system) <br />Re-Connection Inspection Required <br />o Commercial System:To be evaluated on a case by case basis based on scope of proposed project. <br />Additional evaluation,improvement,and reporting requirements may be applicable. <br />Comments:fQ)rr;/M '-'nn n== <br />U \:Jl.S[gI <br />1111 n I:'lnff <br />/I -v v "VII <br />[!]ConsultationService~ired 0 SepticReQ.aiiPerm,Required ~SepticRepairPermitMay Be RequiredPe~"~~tions <br />REvIEWEDBy:<,"A fJlArH\.)~A l <br />REGIS'TEREDENvIRoNMENTALHEALTHSPEClALJST Date: <br />PE SC RECEIVEOB~CHECK#/AMOUNT DATE SERVICEREQUEST#INVOICE#PERMITID#CODE CASIi REMITJCD <br />I/I~IJ..~/(1!>d 7/blll e:/:),....I .,/l7rZ--~.J <br />EH 42-021 812512009 ApplicationforTemporaryWaiverto DestroySepticTank