Laserfiche WebLink
if h <br /> DPg4!N SAN JOAQUIN COUNTY <br /> . �'•,off <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 2 <br /> < 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax: (209)464-0138 Web:wwwsjgov.org/ehd <br /> APPLICATION FOR A TEMPORARY WAIVER <br /> FROM REQUIREMENT TO DESTROY:ABANDONED SEPTIC TANK <br /> SITE LOCATION: tZ0 CITY: 'i 4 L¢^ DATE: t 0 <br /> "RROPERTY OWNER NAME: APN• Z41- <br /> 'PROPERTY OWNER MAILING ADDRESS: <br /> ITY/STATE/ZIP: vo PHONE: � <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 indicatedon 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 conditi s for the Sept' : tem r se. <br /> CERTIFIED BY: ')Ub A A-1: <br /> PI 51GWATURE DAT <br /> FO " HDUSEONLY <br /> Se'tic s stem Histo 7PenT it Summa <br /> P,e[mlt .'v `7•( -Rate: LTi rigin ❑ <br /> al Installation❑Repair Replacement[]Addition <br /> Date: Repair❑Replacement❑Addition❑Other, <br /> L? rmlt#; Date: ❑Rep <br /> air❑Repiaiement❑Addition❑Other <br /> Permit#: Date: ❑Repair❑Replacement❑Addition❑Other <br /> Permit#: Date: ❑Repair❑Replacement❑Addition❑Other <br /> Reuse Conditions <br /> '>-AGEOFRE§IDENTIALSY$TEM: - ❑ Re-COnneF110n•InSpeCtlOn Required <br /> LESS THAN Five S :Years Old <br /> E] AGE QF RESIDENTIAL SYSTEM: <br /> El History of Failures-Additional Disposal Field Installation Required(See Comments) <br /> BETWEEN Five(5)and Ten(10)Years bid [1 Condition of System Evaluation/Inspection Required <br /> ❑,Re-Connection inspection Required <br /> ❑ History of Failures-Additional Disposal Field Installation Required (see Comments) <br /> Ace OF RESIDENTIAL.SYSTEM: SrConclition of System Inspection Required ' <br /> Over Ten(10)Years Old Disposal Field Reuse Expansion Required(50%of existing system) <br /> ❑ Re-Connection inspection Required <br /> Tobe evaluated on a case by case basis based,on scope of proposed project. <br /> ❑`Commercial System: Additional evaluation, improvement;and reporting requirements may be applicable;l <br /> Comments: IV g;I,uaZ 00 . I( I S 114V( a &0w to �E <br /> v_ - <br /> "11 <br /> ❑ Consultation erviRequi d Septic Repair Permit Required ❑Septic Repair Permit May Be Required Per Building Permit Conditions <br /> REviEwEp:BY <br /> REGISTERED ENVIRONMENTAL HEALTH SPECIMJST Date: <br /> PE SC RECEIVED BV CHECK#/ AMOUNT DATE SERVICE REQUEST# INVOICE# PERMIT ID# <br /> CODE CASH RE ITTED <br /> EH 42-021 8/25/2009 Application for Temporary Waiver to Destroy Septic Tank <br />