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PJ Pq N` SAN .JOAQUIN COUNTY ihal &Con IIJqfnrfm ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 •; Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd c\iFoiaN%P APPLICATION FOR A TEMPORARY WAIVER FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK SITE LOCATION: 1� \ CITY �� DATE: 'J , PROPERTY OWNER NAME: APN:' Y� PROPERTY OWNER MAILING ADDRESS: ]— l �� PHONE:. ,/� 2 CITY/STATE/ZIP: C c � (� y �CC� `LJ .` 1 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 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 rebuilt/replaced structure, as indicated below. I also understand that a septic repair permit may be required prior to the final occupancy of the rebuilt/replaced structure. I understand that I will be responsible for all EHD enforcement costs should I fail to comply with these conditioQ for the septic system reuse. -5Z—,l CERTIFIED BY: '�_,_; �� PROPERTY O ER SIGNATURE DATE FOR EHD USE ONLY Sootlic S stem Histo /Permit Summant Permit #: S j20o 33u Date: 14-1 pS Original Installation ❑Repair ❑Replacement []Addition Permit #: Date: [—]Repair []Replacement ❑Addition ❑Other Permit #: Date: []Repair ❑Replacement ❑Addition ❑Other Permit #: Date: ❑Repair ❑Replacement ElAddition ❑Other Permit #: Date: []Repair ❑Replacement ElAddition ❑Other Reuse Conditions AGE OF RESIDENTIAL SYSTEM: ❑ Re -Connection Inspection Required LESS THAN Five 5 Years Old T AN Five (5) ❑ History of Failures - Additional Disposal Field Installation Required (See comments) ❑ AGE SYSTEM: ❑ Condition of System Evaluation/Inspection Required BETWEEN Five (T and Ten (10) Years Old ❑ Re -Connection Inspection Required ❑ History of Failures - Additional Disposal Field Installation Required (See Comments) AGE OF RESIDENTIAL SYSTEM: ❑ Condition of System Inspection Required °o Over Ten (10) Years Old ® Disposal Field Reuse Expansion Requi edSe I ung spteer� A (� Re -Connection inspection Required )5-1 f,.v^j r 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: 8144_ IGo; 'j ccL: ELConsultation Service Required 13 Septic Repair Permit Required ❑ Septic Repair Permit May Be Required Per Building Permit Conditions REVIEWED BY: REGISTERED ENVIRONMENTAL HEALTH SPECIALIST Date: PE SC RECEIVED BY CHECK#/ CODE CASH AMOUNT REMITTED — DATE SERVICE REQUEST # INVOICE # PERMIT ID# 4 — _ /r :,3 EH d2-221 81252009 Application for Temporary Waiver to Destroy Septic Tank