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P4D'fY, 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 /> °4• :::••'�P APPLICATION FOR A TEMPORARY WAIVER <br /> 4poRN <br /> FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK ,1 <br /> SITE LOCATION: p ✓ U L�2- CITY: 1 til DATE: 1 t 5- <br /> -PROPERTY <br /> -PROPERTY OWNER NAME: ,. I APN: 9t <br /> PROPERTY OWNER MAILING ADDRESS: ,j/•� <br /> CITY/STATE/ZIP: PHONE: <br /> _/;,J a o 6 rz,3 7c - '3 ~9/ 5,7 <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 understand that a septic repair permit may be required prior to the final occupancy of <br /> the rebuilt/replaced structure. I understagd that I will be responsible for all EHD enforcement costs should I fail to comply <br /> with these conditions for <br /> the septic syst rp reuse. <br /> CERTIFIED BY: •1t -eill..._-_ �_� __— j- J -- / '/N <br /> Q PROPS, TYO NER`SIGNATURE DATE <br /> FOREHD USE ONLY, <br /> Septic System History/Permit Summa <br /> P=,ermit#,'• ', .Date riginallnstallation❑Repair❑Replacement❑Addition <br /> S.1> 6. t' <br /> Permit#c.: 1t O Or l v Lt; Date. 25 Gi' epair eplacement❑Addition❑Other <br /> Permit#t,, Date, ❑Repair❑Replacement❑Addition❑Other <br /> Permit#. `Date: ❑Repair❑Replacement OAddition❑Other <br /> Peimit#: Date: ❑Repair❑Replacement❑Addition ElOther <br /> Reuse Conditions ' <br /> AGEOFRESIDENTIALSYSTEM <br /> LEssTwui Flve 5 Years Old ❑ Re Connection Inspeptlon Required <br /> ❑jAGEQFRESIDENTIALSYSTEM "' s ❑ listory' of Failures-Aiid itional,Aisposal Fieid Installation Required ('See Comments) <br /> *.T EN Five(5) .1 Ten(10)YearsOld ❑ Condition ofSystem,Evaluation/Inspection.Required <br /> " <br /> E] Re-Connection Inspection Required " <br /> Historyof Failures-Additional Disposal Field 1 stallla-tio Required (See Comments) <br /> [ �AGEOF R�SIOEMiA4SYSTErn Condition of System Inspection Required- ` <br /> lr Over Ten(10)Years Old Disposal Field Reuse Expansion,Required (50%of existing system) <br /> Re-Connecfion Inspection Required <br /> To beevaluated on a case by case basis based on scope of proposed project: <br /> ❑'Commercial System: Additional evaluation, improvement;and reporting requirements may be applicable:` <br /> comments: 9vb' o r+ 1 i Lt� tKcbb� d- <br /> - •t-0v4/`� `.i: WY " :.._ i ta.0 'tawt W - ", .6tL ,>,0� •..t. _:-`U, 19_ <br /> t 6�,. tvibLE:Z�` t. v«I a-ev� d u a iJti &It IL <br /> ❑ Consultation Service Re uired' ,ptic Repair Permit Required ❑Septic Repair Permit May Be Required Per Building Permit Conditions <br /> REVIEWED.BY: ':1 15 <br /> I REGISTER EHVIRONMENTALHEALTHSPECIAUST '.- Date: <br /> PE SC RECEIVED BY CHECK#/ AMOUNT ICE# PERMIT DATE SERVICE REQUEST# INVOIDN <br /> CODE CASH REMITTED <br /> EH 42-021 8/25/2009 - Application for Temporary Waiver to Destroy Septic Tank <br />