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4O1H. SAN JOAQUIN COUNTY 04• •' c s �.'•90 ENVIRONMENTAL HEALTH DEPARTMENT m 600 East Main Street, Stockton, CA 95202-3029 s Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sigov.org/ehd �q<ikoR�P APPLICATION FOR A TEMPORARY WAIVER FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK ITE LOCATION: $'"Z'L Sa �.� 1 CITY: DATE: —PROPERTY OWNER NAME: S S: ^ APN: 01 —HL ROPERTY O OWNER MAILING ADDRESS: -CITY/STATE/ZIP: / 1 10l �iV p q /' ry _57 PHONE:.y Intent to Rebuild/Replace State ent (f CN t i b l 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 conditions f the septic system CERTIFIED BY: , PROPERTY OWNER SIGNATURE DATE ^FOREHDUSEONLY Se ptic System Histo '/Permit Summa ---------------- " j`,9i Date:" j;f�r' ❑Original Installation Mepair❑Replacement❑Addition Permlt,#. , qty j a Dafe; Repair❑Repla ement❑Addition❑Other P8T}Ttlt•#.. Date: ❑Repair❑Replacement❑Addition❑Other F ermit#: ❑ Date:' Repair❑Replacement❑Addition [3Other Pel'mit#: Date: ❑Repair❑Replacement❑Addition[]Other Reuse Conditions AGE0F RESIDENTIAL SYSTEM: LESS THAN Five 5 Years Old C] Re Connection Inspection Required . ❑,f�icEopRESIDENTW SvSTEM "❑ History of Fatlures� Additional Disposal Field Installation Required (See Comments) BETuvEEN Five(5)antl n(10)Yea rs Old11 ❑ Condition of System"Evaluation/Inspection`Required ❑Re-Connection Inspection Required History of Failures-Additional Disposal Field Installation Required (See Comments) AGE OFRESIDENTIALSYSTEM Condition of System"Inspection Required i ;Over Ten(10)Years 01¢ ❑ Disposal Field Reuse Expansion Required(50% of existing system) Re-Connection Inspection Required El Commercial System: " To be evaluated on a case by case basis based on Scope of proposed project. Additional evaluation, improvement, and reporting requirements maybe applicable: Comments: lI ' C' ❑ Consultation Service equired tic Repair Permit Required ❑SepGc Repair,Permit May Be Required Per Building Permit Conditions REVIEWED BY: REGISTERED ENVIRONMENTAL HEALTH SPECIALIST.'. Date: PE SC RECEIVED BY CHECK#I AMOUNT DATE SERVICE REQUEST# INVOICE# PERMIT ID# CODE CASH REMITT AT EH 42-021 8/25/2009 Application for Temporary Waiver to Destroy Septic Tank