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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd ApPLICATION FOR A TEMPORARY WAIVER FROM REQUIREMENTTO DESTROYABANDONEDSEPTICTANK SITE LOCATION:/(}'(J'1'9 e $("A{,..Q#••.1iac.,.o7/1 CITY:eSCAtW DATE:fI-~-1I PROPERTYOWNERNAME:lev 1:#fJ Te.'APN:;J.o 7 ..tJ3p -~ PROPERTYOWNERMAILINGADDRESS::2 3 ~CJ ~N cIA!T1I1t/nt: CITY/STATElZIP:C Lei t!/fITS ,CA.qS"~,PHONE:~'i-l1fN'Sd7:< Intent to RebuildlReplace Statement 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 rebuilUreplaced structure,as indicated below.I also understand that a septic repair permit may be required prior to the final occupancy of the rebuilUreplaced structure.I understand that I will be responsible for all EHD enforcement costs should I fail to comply with these conditio~tic sy~euse.6";.3.,...11CERTIFIEDBy:11 ~r PROPERTYOWNERSIGNATURE DATEFOREHDUSEONlY Seotic System Historv/Permit SummarY Permit#:ta ~t:f 1 Date:2/f2-/,ifibs DOriginal Installation I)'Repair DReplacement DAddition Permit#:Date: , DRepair DReplacement DAddition DOther Permit#:Date:DRepair DReplacement DAddition DOther Permit#:Date: ., DRepair DReplacement DAddition DOther Permit#:Date:DRepair DReplacement DAddition DOther Reuse ConditionsoA/;C OFREsIDENTIAl.SYsmI:o Re-Connection Inspection RequiredlessTHANFive(5)Years Old , o AGE Of RESIDENTIAl.SYSTEM:o History of Failures -Additional Disposal Field Installation Required (See Comments)o Condition of System Evaluation/Inspection RequiredBE1WEEHFive(5)and Ten (10)Years Old ORe-Connection Inspection Required ~AGE OFRESlDEtfTIAl.SYSTEII: 0,History of Failures -Additional Disposal Field Installation Required (See Comments) Condition of System Inspection Required Over Tan (10)Years Old Disposal Field Reuse Expansion Required (50%of existing system) Re-Connection Inspection Required o 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: o ConsultafionServi~equired ~Se.J2.ti~~a~Permit Required 0 SepticRepairPermitMay Be RequiredPer BuildingPermitConditions REvIEWEDBy:,~.)~JL REGISTEREDEIMROHMENTALHEAl.THSPECIALIST Date: PE SC RECEIVEDBY CHECK#/AMOUNT ~ATE SERVICEREQUEST#INVOICE#PERMITID#CODE CASj(REMITJiD ""-,12-'7~Jt-o ~0 itWn/1i ",,-n.••/-".?All. I ~,/r ., EH 42-021 8/25/2009 Application for Temporary Waiver to Destroy Septic Tank