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apq�!N �G SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT m` < 600 East MainStreet, Stockton, CA 95202-3029 �- Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd °d••� ,�`P� APPLICATION FOR A TEMPORARY WAIVER <IFOf FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK SITE LOCATION: z,� �r CITY: DATE: 1.0, � (, PROPERTY OWNER PROPERTY OWNER MAILING ADDRESS' � f 'CITY/STATE/ZIP: J�IVJ PHONE: .. Intent to Rebuild/Replace Statement L I hereby declare that it is my intention to obtain a building permit to rebuild/replace the structure being proposed for demolition, as indicated oh the demolition permit application, within three (3) month from the date of demolition, and to complete the construction and final the building permit within one (1)year from the date of demolition. Septic Tank Abandonment Statement I understand and acknowledge that should I fail to obtain a building permit within the above noted time period, the septic tank will be considered abandoned and I will be required to destroy the septic system under permit and inspection from EHD at that time. Reuse Conditions Statement I understand and acknowledge that I must satisfy the conditions for reuse of the septic system for the rebuilt/replaced structure, as indicated below. I also understand that a septic repair permit may be required prior to the final occupancy of the rebuilt/replaced structure. I understand that I will be responsible for all EHD enforcement costs should I fail to comply with these con !NoJps for the septic system reuse. / CERTIFIED 0'I1{''� ! rzA ?'G^27 a A) 0"l PROPERTY OWNER SIGNATURE DATE %!FOR£HDUSE ONLY ' /PemtSmSetic S stem Histo Permit#: tZ2? C7� Date h ' 1,� toy - Orignallnetallation❑Repair❑Replacement❑Addition Kermit#: ` Date; ❑Repair, ❑Replacement❑Addition[]Other Pemit#: 777777777777 Date ❑Repair❑Replacement❑Addition❑Other, Permit#: Dater ❑Repair❑Replacement❑Addition❑Other Permit M Date: ❑Repair❑Replacement❑Addition[]Other Reuse Conditions •AGE OFRESIDENTIALSYSTEM: ❑ Re-Connection inspection Required LESS THAN`Five 5 Years Old Ao ❑� e gFREatDENTwLSYsrE ❑History of Failures,-Additional Disposal Field Installation Required (See comments) BSYSTEM:EYWEERPive(5)and Ten(1Q)Years 018 ❑ Conm dition of SysterEvaluation%Inspection-Required ❑,Re-Connection Inspection Required ❑ History of Failures-Additional Disposal Field Installation Required(See Comments) AGEoF RESiDENTIALSYSTEM: 'SCOndition of System Inspection Required ' Over Ten(10)Years Old Disposal Field Reuse'Expansion Required'(50%of existing system) Re-Connection Inspection Required To be evaluated on a case by case basis based on scope of proposed project. ❑:Commercial System: Additional evaluation, improvement, and reporting requirements may be applicable, Comments: v✓ a /k .e (<a G,-t 4 2 -5 t ❑Consultation SenficA,Req ired Septi Permit Required ❑Septic Repair Permit May Be Required Per Building Permit Conditions REVIEWED BY: 1 O ' REGISTERED ENVIRONMENTAL HEALTH SPECIALIST Date: PE SC RECEIVED BY CHECK#/ AMOUNT DATE SERVICE REQUEST# INVOICE# PERMIT ID# CODE CASH RE TTED '. t2L3 YaA- o p EH 42-021 8/25/2009 Application for Temporary Waiver to Destroy Septic Tank