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oq4 !.7. 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 /> cq�•/koR��P APPLICATION FOR A TEMPORARY WAIVER <br /> FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK 1 <br /> SITE LOCATION: aa9L 1 RN-QJ CIrY. DIE: <br /> PROPERTY OWNER NAME: "� c APN: <br /> o — --(D" <br /> PROPERTY OWNER MAILING ADDRESS: •� \ <br /> CITY/STATE/ZIP: O <br /> --7 <br /> PHONE: (y <br /> i <br /> Intent to Rebuild/Replace Statement <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 /> 1 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 rebuill/replaced structure. I understand hat I will be responsible for all EHD enforcement costs should I fail to comply <br /> with these conditi nes forseptics system r se. <br /> CERTIFIED R <br /> R P OWNER SIGNATURE <br /> OA <br /> :r9R EHDAISEONLY t . <br /> Se Gc S stemrHisfor IPermlt Summa F ,v <br /> PerrTTif# ' , s A Date k ' <br /> � r. „t. r ,- � ❑Oil9matinskai(anon❑RepallQReplacement❑Ad�IBon <br /> r <br /> Pel I Q: �c z i € .,„.. Dale x ; � ' �,� .. [ Repalr❑{2epiacement❑Adtllhgn❑Othe{ t <br /> Permit# �Y F_ _„�as'r $ , Datesr F i � `jsr„ # ❑Repairj�Replac�rnant❑Addltiop❑Other , ,; <br /> z <br /> PQrm-t# - � ' "Daje '� � ,�, � ❑Repair�Replacem�nt❑�A�idlhon❑Other <br /> Pefmlt ❑Repair 0(ieplacement❑Addiho i❑Other ` <br /> RensQ( ODdItiODS i Yz x <br /> ❑ AGEDF RESIDENTIAMI L$YSJEtd_,,._"," ,r _ `�ch €�'TN ' r i '-d—, <br /> LEss ❑R Con echoll Ir7s ect-on -renN Flue 5 Years Oid R Req#�1 Y d* r <br /> ” ❑ HfXory of Failures Additional Dlsp4sal Field Ipstaliation feq�-retsee Co <br /> d mments),_ <br /> U- <br /> -OF RESIDEgTIAL SYS EM 3 v$ s< <br /> "-BETWEEN Five(5)andjTelt10)Years0ld ❑ICond-tict#of System Evalual-on/lnspec)jon Re'qulred t fi <br /> �,; ❑R Gonnectwh Inspectlofi RegwFed- <br /> ❑+H stoty of,Fallures Add/llonal Disposal Field Installation Requ-red(bee"comments)i <br /> AGEOF REsjDENrIAL SYSTEM Candit-on of Sysfem Inspection Re�ulretl : � �, r s � _ , ' <br /> bverTen 10 ears0ld,, � t . ,� r <br /> � )1( D-sposai Feld Reuse Expansion Required (50%of existing system} I j51 l4 � '4ty, <br /> Re°Confection Inspect-on Regqued <br /> ❑�Commercial yysfem To be evaluated on case by case,,,,.basis based onscope of propgsed pro/est <br /> s � ,, � � ,,��z�=� s� � A(�tipnal evalgation improvernerlt ani repo�mg�"regUlretnegjs mqy bg applicable, <br /> "❑Coiisultahe�Semce RegUlred Septic Repai'r.Aermlt Required,❑Septic Repalr Permit May Be,ReguirecfPer;Buldlbg PeririifGonddwns, . <br /> /U7 4UAlkC( i� t <br /> REVIEWED <br /> > i _. . .., cs.•.� ,. YZEG�igryeo ENwaoRiAENru.,HErry S4Eaulsr _-:a .. =.. 5 = <br /> s s�> <br /> Dale <br /> PE SC RECEIVED BY CHECK#/ AMOUNT DATE SERVICE REQUEST# INVOICE# PER1IIT IDN <br /> //II-ODE CCASH REMITTED <br /> EH 42-021 6/25/2009 Application for Temporary Waiver to Destroy Septic Tank <br />