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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 />ApPLICATION FOR A TEMPORARY WAIVER <br />FROM REQUIREMENTTO DESTROYABANDONEDSEPTICTANK <br />SITE LOCATION:rQOCo tv /Jr /1]5 f 11"(//7'1 /LJ CITY:/-ud.DATE:7-/-(6 <br />PROPERTYOWNERNAME~/u C-(Jie....a Qvy o:APN:O '9?.-iJ2i)"/-0 <br />PROPERTYOWNERMAILINGA~~:J,')'/A?.5 fr f7 it.f2.{AlOI--A ~u'Q. <br />CITY/STATElZIP:L,di (A-q)',).Cf.2 v PHONE:.i-((}/-0 <joO <br />Intent to Rebuild/Replace Statement <br />I hereby declare that it is my intention to obtain a building permit to rebuildlreplace 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 understand that I will be responsible for all EHD enforcement costs should I fail to comply <br />with these conditicfJ:Jte se1:[lstem reuse.~(33i.f -/69~ <br />CERTIFIEDBy:f).YJ ~C--1~7-/-/0 <br />{/PROPiRTYOWNERSIGNATURE DATE <br />FOREHDUSE ONLY <br />Seotic System Historv/Pennit SummarY <br />Permit#:~?gqh<Date:~;'~/UbV-OOriginallnstallation ORepair ~eplacement OAddition <br />Permit#:Date:ORepair OReplacement OAddition OOther <br />Permit#:Date:ORepair OReplacement OAddition OOther <br />Permit#:Date:ORepair OReplacement OAddition OOther <br />Permit#:Date:ORepair OReplacement OAddition DOther <br />Reuse Conditions:0 AIJE OFREsiDENTIAL SYsTEM:o Re-Connection Inspection RequiredLEssTHANFive(5)Years Old <br />tt.,AGE OFRESlDEHTIAL SYSTEM:o History of Failures -Additional Disposal Field Installation Required (See Comments)o Condition of System Evaluation/Inspection RequiredBETwEENFive(5)and Ten (10)Years Old !5l Re-Connection Inspection RequiredoHistoryofFailures-Additional Disposal Field Installation Required (See Comments)o AGEOFRESIDENTIAL SYSTEM:o Condition of System Inspection Required <br />Over Ten (10)Years Old o Disposal Field Reuse Expansion Required (50%of existing system)o Re-Connection Inspection Required . <br />o Commercial System:To be evaluated on a case by case basis based on scope of proposed project. <br />Additional evaluation,improvement,and reporting requirements may be applicable. <br />Comments: <br />DI.ConsultationServiceReguired 0 SepticR~PerTT}jtRequired D SepticRepairPermitMay Be RequiredPer BuildingPermitCo)ldiUOns <br />REviEWEDBy:\..~/6Yf./(~-7/I/~/~ <br />REGISTERED ENvIwHIIENT AL HEALTH SPECIALIST <br />,Date: <br />PE SC RECEIVEfBY CHECK#/AMOUNT DA)E SERVICEREQUEST#INVOICE#PERMITID#CODE CASH;REMlneD I _...• <br />lA'?1.••7 '21 d $1711 //11 ~A ~J,r,.J,)tJ <br />EH42-021 8/25/2009 I //, <br />A licationlorTern ra Waiverto DestroSe ticTanppporyypk