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;'9LSAN JOAQUIN COUNTY �o.' •".cQ` ENVIRONMENTAL HEALTH DEPARTMENT Wi NMI 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.oCJ� 4Ir/(/,+'E/ • C9�I.FORN`P APPLICATION FOR A TEMPORARY WAIVER C D FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK SITE LOCATION: '�O Oi,�p I L CITY: - DATE: PROPERTY OWNER NAME: -' -C— APN'd ) 9' 15-6 l(gd cL PROPERTY OWNER MAILING ADDRESS: V l) CITU/STATE/ZIP: / J �2�0 PHONE: Oq -�O Intent to RebuildF/.Reola a Statement 5e-Z TIT,4o�e /e7c-r, I hereby declare that it is my intention to obtain a building permit to rebuild/replace the structure being proposed for demolition, as indicated on the demolition permit application, within three (3) months 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 u nd that I will be responsible for II EHD enforcement costs shouldy1f11 to comply with these conditions for the y em p CERTIFIED BY: PROPERTY OWNER SIGNATURE DATE FOR EHD USE ONLY Sentic S stem Histo /Permit Summanr Permit#: Date: �, I Installation❑Repai eplacement❑Addition Permit#: Date: ❑Repair❑Replacement❑Addition❑Other Permit M Date: ❑Repair[]Replacement[]Addition❑Other Permit#: Date: []Repair[]Replacement[]Addition[]Other Permit#: Date: El Repair❑Replacement❑Addition❑Other Reuse Conditions AGE OF RESIDENTIAL SYSTEM: LESS THAN Five 5 Years Old Re Connection Inspection Required ❑ AGE OF RESIDENTIAL SYSTEM: El History of Failures-Additional Disposal Field Installation Required (See comments) BETWEEN Five(TI and Ten Years Old El Condition of System Evaluation/Inspection Required ❑ Re-Connection Inspection Required ❑ History of Failures-Additional Disposal Field Installation Required (See Comments) ❑ AGE OF RESIDENTIAL SYSTEM: ❑ Condition of System Inspection Required Over Ten(10)Years Old ❑ Disposal Field Reuse Expansion Required (50% of existing system) ❑ Re-Connection Inspection Required ❑ Commercial System: To be evaluated on a case by case basis based on scope of proposed project. Additional evaluation, improvement, and reporting requirements may be applicable. Comments: �L D wt onsultation Service Required ❑Septic Repair Pet e p Permit May Be Required Per Building Permit Conditions REVIEWED BY: REGISTERED ENVR0NWNTNMXLf^PELDate' PE SC RECEIVED BY CHECK#/ AMOUNT DATE SERVICE REQUEST# INVOICE# PERMIT ID# ^CODE CASH R ITTED 1 EH 42-021 8/25/2009 Application for Temporary Waiver to Destroy Septic Tank