Laserfiche WebLink
Dp4uIN ° 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/eh <br /> �'• :�� APPLICATION FOR A TEMPORARY WAIVER <br /> 4</FORS <br /> FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK <br /> CITY: DATE: 1 , <br /> SITE LOCATION: � Le G ` APN: <br /> PROPERTY OWNER NAME: 7 � e�'` ?! j L) - <br /> PROPERTY OWNER MAILING ADDRESS: <br /> CITY/STATE/ZIP: AP PHONE: <br /> Intent to Rebuild/Replace Statement o <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 1 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 understand that I will be responsible for all EHD enforcement costs should I fail to comply <br /> with these co (tions ep sy� reuse. G <br /> CERTIPIEY:� `^ 2. 2t <br /> PROPERTY OWNER SIGNATURE DATE <br /> FOR EHDUSE ONLY <br /> Se�t+e Sstem HistorviPermit Summa <br /> Pe[intt# .Date _ LI L} QS1rigtrial Installation❑Repair❑Replacementdditon <br /> Permi4#: Date: ❑Repair❑Replacement❑Addition[]other <br /> P,errnit#; Date:, ❑Repair❑Replacement❑Addition❑Other <br /> Permit#: 'Date: ❑Repair❑Replacement[]Addition❑Other <br /> Permit MDate: ❑Repair❑Replacement❑Addition❑Other <br /> Reuse Conditions <br /> AGE OFREsIDENVALSYSTEM:, ❑ Re-Coinnectioninspection Required <br /> LESS THAN Five(5)Years Old <br /> ❑History of Failures-,,Additional.Disposal Field Installation Required(See comments) <br /> AGE OF RESIDENTIAL SYSTEM: <br /> ❑ condition of System /Inspection Required <br /> BETWEEN Five(5)and Ten(10)Years Old ❑ Re-Connection Inspection Required <br /> E] History of Failures-Additional Disposal Field Installation Required (see Comments)i <br /> NT <br /> AGEOF REsiDEULL <br /> , SYSTEM: Condition of System Inspection.Required <br /> OverTen(10)Years Oldv Disposal Field Reuse Expansion Required'(50%G of existing system) <br /> r . Re-Connection Inspection Required <br /> / To be evaluated on a case by case basis based on scope of proposed project. <br /> Commercial System: <br /> Lp Additional evaluation, improvement, and reporting requirements may be applicable: <br /> Comments: Z-ewwLas�. <br /> (� <br /> ❑Consultation Service quired El SepUc Repair Permit Required ElSeptc Repair Permit May Be Required Per Building Permit Conditions <br /> REVIEWED BY' / <br /> REGISTEREDENYIRONMENTAL HEALTH SPECIALIST f Date: <br /> PE $C RECEIVED BY CHECK#/ AMOUNT DATE SERVICE REQUEST# INVOICE# PERMIT ID# <br /> xxSSCAO'D((E CASH REMITTEDI II <br /> q 6/ <br /> 1VU,° R. -1( <br /> EH 42-021 8/25/2009 Application for Temporary Waiver to Destroy Septic Tank <br /> J <br />