Laserfiche WebLink
ot,4Stlry, c SAN JOAQUIN COUNTY <br /> •o ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> –•a Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> C`��rFORN`P APPLICATION FOR A TEMPORARY WAIVER <br /> FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK <br /> SITE LOCATION: ( $l'O T J - CITY: Ot 11-10 DATE: <br /> PROPERTY OWNER NAME: LQIJCAUq✓L U It APN. OS 30 03 <br /> PROPERTY OWNER MAILING ADDRESS: <br /> .NA t'C)T* 4' C 5 C <br /> CITY/STATE/ZIP: LC PHOD�t vv <br /> q It <br /> Intent to Rebuild/Replace Statement <br /> I hereby declare that it is my intention to obtain a building permit to rebuild/replace the structure being proposed for <br /> demolition, as indicated on the demolition permit application,within three (3)months from the date of demolition, and to <br /> complete the construction and final the building permit within one (1)year from the date of demolition. <br /> Septic Tank Abandonment Statement <br /> I understand and acknowledge that should I fail to obtain a building permit within the above noted time period,the septic <br /> tank will be considered abandoned and I will be required to destroy the septic system under permit and inspection from EHD <br /> at that time. <br /> Reuse Conditions Statement <br /> I understand and acknowledge that I must satisfy the conditions for reuse of the septic system for the rebuilt/replaced <br /> structure, as indicated below. I also understand that a septic repair permit may be required prior to the final occupancy of <br /> the rebuilt/replaced structure. I understand that I will be responsible for all EHD enforcement costs should I fail to comply <br /> with these conditions for the se/pttiic By8ltem reuse. �1 Iy / <br /> CERTIFIED BY: '5t„�, Gait-. �� �T� //�9 ,3 <br /> PRdPtRTY OWNER SIGNATURE DATE <br /> .x.. 7777- <br /> 7:;,,77 .,, <br /> SEitic S stem?Histo Permit•Summa " <br /> Peftrilt# <br /> ��K#t o1 8� Date t qOngrnaltnstallat10rapRepaJrQReplacementCi_ddttion <br /> Permt[ Rate ' t. ORepalr�Reptacemenl CIAddltron C70tti'er r, <br /> :...: „- <br /> Rermlt ;n Date` x , ❑Repair�Replaeement{7Addit oD pOkher <br /> Permii`pReptacernent L1Faaixion`poihe <br /> Permit#: Date (7Repair A(d tKIrri:16th, I=- <br /> Reus'dC6nditioris ; <br /> �1 ADE OF RE$IgENTUL SYSJE� ': ,.: <br /> LEi TNAN:Fiv@ 5 YearSDld -` `- ? Conneetiot7lnspection Required ` <br /> [], <br /> AGEor REs1pENTIALSYSrEM , ,;7777 �o kJ!sfory of Failures Additronat D`isRosal Field9nstallatlon.Recjulred(See commehis) <br /> �ETYYEEN Five(5)anfl fgn(19),Yaars Old ,0.Condttion 9f System EyalUatlon/InspectlOn Required , <br /> Re.p6nriecti6n tpSpectign Requifed, <br /> Q Historyof Failures Additional Disposal Fleld'lnstallati9n Regwred tsee Co rtmems) <br /> Ace of RtftENTt4L SYsrEM C©nditron tiJ System Inspection Required '< ` <br /> -0ver Ten 00)Ysars Otd Disposal Field Reuse;Eitpansidn Rg uired(5Q°/a of existing systeln). . <br /> Ris Connection Inspection"R'quired <br /> E ;C¢tnmercial System,:: To;be eYaluated on a case by,case basis tiased 9n scgpe,of proposed project," ,- <br /> =_ Additldnat evaluation,"pr I,and reporting requirementsmay ba'applicable,. <br /> Cbtrlrrients; .,Mo9.. oVb xU, b _ Hs1.v�iY!• 1a,« <br /> 'L � w12. '.f• at . .L' t � � ' <br /> (]Consultation Service Required jaSeptic Repair;Permit Required ❑Septic Repair Permit May Be'Required PerBuilding Permit Conditions <br /> REVIEWED 9Y: <br /> REUISTERED ENVIRONMENTAL HEALTH SPECIALI$T Date; <br /> PE SC RECEIVED BY CHECK#/ AMOUNT DATE SERVICE REQUEST# INVOICE# PERMIT]D# <br /> — <br /> CODE CASH RE ITTED <br /> vJ -S'Q 0o' (._ 40 f <br /> EH 42-021 8/25/2009 Application for Temporary Waiver to Destroy Septic Tank <br />