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QPq�!N O SAN JOAQUIN COUNTY <br /> .p ENVIRONMENTAL HEALTH DEPARTMENT <br /> N 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd } J <br /> �q•.. . P APPLICATION FOR A TEMPORARY WAIVER <br /> <tk'OR�` 9 v <br /> FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK <br /> SITE LOCATION: ,v }- ,0 �j t„t �,i ., - <br /> CITY: � DATE: 7 <br /> PROPERTY OWNER NAME: " -�.i 4 gyl�, { APN' <br /> PROPERTY OWNER MAILING ADDRESS: Lam` -� U • ®.� � 1 <br /> CITY/STATE/ZIP: ,y t PHONE: qq col T^7 <br /> Intent to Rebuild/Replace Statement } 2" <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 c mply . <br /> with these conditions for t e septi system reus . <br /> CERTIFIED BY: <br /> PROPERTY OWNER SIGNATURE DATE <br /> FORIEHD'USEONLV <br /> Se tic S stem Histo /Permit-Summa <br /> Permit t ` J,,& Date: l a d , ❑Odginat Installation Repair❑Replacement❑Addition <br /> Permif Date: - ❑Repair❑Replacement[:]Addition❑Other <br /> pnit#,. Date: ❑Repair❑Replacement❑Addition❑Other <br /> pe[mft#r Date: ❑Repair❑Replacement❑Addition❑Other <br /> Permit#: Date: ❑Repair❑Replacement❑Addition[]Other <br /> Reuse Conditions <br /> ABED RESIDENTIAL SYSTEM: ' <br /> LEssTHAN`five 5 Years Old ❑ Re-Connection Inspection Required <br /> ,AGEOFRE$tDENTULLSYSTEM: ❑ history of Failures-Additionai Disposal Field Installation Required(See comments) <br /> 6dE OF,,N Five(5)and Ten(10)Years OItl Condition of System,Evaluation/inspection Required <br /> Re-Connection Inspection Required <br /> ❑ History of Failures-Additional Disposal Field Installation Required (See Comments) ' <br /> ❑ AGEOFRESIDENTIALSYSTEM: ❑ Condition of System Inspection Required <br /> Over Ten(10)Years Old ❑ Disposal Field ReuseExpansion Required(50%of existing system) <br /> ❑=Re-Connection Inspection Required <br /> ❑',Commercial System: ` To be evaluated on a case by case basis based on scope of proposed project. <br /> Additional evaluation, improyerrient,and reporting requirements may be applicable. <br /> Comments: t T tr V o i?t vA C, 1 i I 0> <br /> o�zrl ,G ary e i <br /> ttw �t its u, -tui;`: U if.: •i -. to <br /> � ca <br /> ❑ Consultation Service Required ❑Septic Repair Permit Required ❑Septic Repair Permit May Be Required Per Building Permit Conditions <br /> REVIEWED By. <br /> REGISTERED ENVIRONMENTAL HEALTH SPECIALIST Date:. <br /> PE $C RECEIVED BY CHECK#I AMOUNT DATE SERVICE REQUEST# INVOICE# PER ID# <br /> CODE CASH REMITTED <br /> To —,, ,v Waiver to DnMrov Seotic Tank <br />