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oPg ty. 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.sigov.org/ehd <br /> cq<1koRt'v°' APPLICATION FOR A TEMPORARY WAIVER <br /> FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK <br /> SITE LOCATION: 01 '3 i1, t.:= rt �,�,. CITY: <br /> /_ <br /> DATE: <br /> PROPERTY OWNER NAME: Com,_,/.1, APN:Z yy-I`l�dZj <br /> PROPERTY OWNER MAILING ADDRESS: n /p�, / le:rel�rxe_— %2b <br /> CIN/STATE/ZIP: �C4eod'l4 C/q� z� 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 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 rebuilUreplaced structure. I understand that I will be responsible for all EHD enforcement costs should I fail to comply <br /> with these conditions for the septic system reuse. <br /> CERTIFIED BY: <br /> PROPERTY OWNER SIGNATURE DATE <br /> Se NCS stem IS t0 7Permtt Summa <br /> r 9Ittatlahgbw]Re( Replacemeot{�AdddiDd <br /> )' m �� � [ Re alr g mDfit Add tion©Other. <br /> Permit#t '" "'��"� ,Date, � � ��'��� `. �Repalr�Repia��ienYpgdd/t(onOQthbr; <br /> Permit# MRM <br /> Pete f2g�aK;L7Replacem@nt[[AddiG9n C70ther <br /> RBUSB.ConittiODSn <br /> 10.1001 <br /> {] AGE O�sR1SIDENTIALSYSTEM1t =. r7 •' ''v E <br /> LESSTitAN Frv¢ ,S+Yea 5 Uld� ,*C e CO`iTTtAC[IQl#IttSpeCflQn l'-S,DiP¢�.c�3- <br /> [� �GEOF I�sIDEjifIAI�SYSTEMs "�'"_,'��"��'� �H.�°��Cf,�F`�t(-�6s A�dlNo�la1 DI�oSa[F�fad an$ta�iatlon}ZegU�ired(See Camm¢nis}"'. <br /> t BETWEENIve(4)and T 1n 4)Yewg <br /> ars 01d r®Oondi((4n Qf SysteTjl Eviltaioplf}1SPeq[iGttLeQIreS[ <br /> nJi�t7artneetlof)[n�pefittontequKetl ,` �''^ u-`'? :r= <br /> `f Q'[(islary of F [luresA(ldfbona['D(sp6saliF[eld tnstallifon Required(see CwnlRentS} <br /> �. ❑trl7hdition of8ygtiem Inspec(lon Rot�uired��� � <br /> Oiler len{16)`7ears Oltl � ��Dlsposal Ftelff Reuse ExpanstQri Required(�U°Ja£of ewshtig systems <br /> ���`� ❑(2e`GonneG[i9t�[nspg�t[ofi Roquire� n���; '� <br /> [ Commer'cial Sys(etn To be eva�uateYon a casg by Case basLs ba�esl rid seppe of proposetl pro}ect <br /> frbp,CoYgmeS�E�-��,t�,rego�Ellig�'equ/rem�nt5 nJgY be�PPitcab[e'-. <br /> [)Consul[ation Semce'Reghlr It ;Sept e R pa Pg7rtttt Req lred ©.$epi c Rep�IrrPecmiJ Mayy Be[2equlred Perl3ulld ng Pe'r'mjlGopoltlon� <br /> _ .r� `�} c•y x� ' �, rRE6I5TEgEe EHYIRONAIEMAL HEALTN�PECJN.IST ,.3.10 ' $'"_�f,M '. � <br /> PE SC ri RECEIVED DY CHECK#I AMOUNT DATE SERVICE REQUEST# INVOICE# �PERMITID# <br /> CODE CASH REMITTED <br /> EH 42-021 8/25/2009 Appllcaiion for Temporary Waiver to Destroy Septic Tank <br />