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PQ.tt Iff. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a' < 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 REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK SITE LOCATION: Clrr DATE: IBJ/ PROPERTY OWNER NAME: r APN^;! of 0 PROPERTY OWNER MAILING AD � CITY/STATE21P: PHO Intent to Rebuild/Replace 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 cons4acknowledg on d and I will be required to destroy the septic system under permit and inspection from EHD at that time. Reuse Conditiot I understand ang at I must satisfy the conditions for reuse of the septic system for the rebuilUreplaced structure, as indso understand that a septic repair permit may be required prior to the final occupancy of the rebuilUreplarstand that I will be responsible for all EHD enforcement costs should I fail to comply with these condc system reuse. J CERTIFIED BY: PL�o7�-a PROPERTY OWNER SIGNATURE DATE FOR END USE ONLY e S stem Histo /Permit Summary Permit#: Date: /!3—T 7S riginalInstallation❑Repair❑Replacement❑Addition Permit#: Date: ❑Repair❑Replacement[]Addition[]Other Permit M Date: ❑Repair❑Replacement❑Addition❑Other Permit#: Date: ❑Repair❑Replacement[]Addition[]Other Permit#: Date: []Repair❑Replacement[]Addition[]Other Reuse Conditions ElAGE of RESIDI N s SYsrEM: Re-Connection Inspection Required LESSTRAK Five 5 Years Old El AGE of RESIDENTIAL SYSTEM: ❑ History of Failures-Additional Disposal Field Installation Required (See Comments) BETWEEN Five( and Ten(10)Years Old ❑ Condition of System Evaluation/Inspection Required ❑ Re-Connection Inspection Required ❑ History of Failures-Additional Disposal Field Installation Required (See Comments) AGE OF RESIDENTIAL SYSTEM: 2 Condition of System Inspection Required er Ten(10)Years Old ❑ Disposal Field Reuse Expansion Required (50%of existing system} ,4110, [�2e-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: i gFd5 nsultation Se EJ.$tfhc Repair Permit Required ❑Septic Repair Permit May Be Required Per Building Permit Conditions REVIEWED BY: REGISTERED ENVIROMMEILL HE TH SPE Date: PE sc RECEIVED BY CHECK#I AMOUNT DATE SERVICE REQUEST# INVOICE# PERMIT IDS CODE CASH REMITTED EH 42-021 8/25/2009 Application for Temporary Waiver to Destroy Septic Tank