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Ta r: Y pgU1N SAN JOAQUIN COUNTY �C_� Z�ot coZ ENVIRONMENTAL HEALTH DEPARTMENT �� IT < 600 East Main Street, Stockton, CA 95202-3029 �(.� 0 5, �Q�j • Telephone: (209)468-3420 Fax: (2.19)464-0138 Web:www.sjgov.org/ vIRONMENIAL HV',LTH �`q •. �'.::• �P APPLICATION FOR A TEMPORARY WAIVER PE116E RVICES <IFORa FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK SITE LOCATION: CITY: DATE: go PROPERTY OWNER NAME: I v r�n APN: — PROPERTY OWNER MAILING ADDRESS: C CITY/STATE/ZIP: L PHONE: Intent to Rebuild/Replace Statement 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 for the ati system re CERTIFIED BY: PROPERTY OWNER SIGNATURE DATE FOR EHD USE ONLY Sal2tic S stem Histo /Permit SummArV Permit#. Date: ❑Original Installation❑Repair[]Replacement[]Addition Permit#: Date: []Repair❑Replacement❑Addition[]Other Permit#: Date: ❑Repair[]Replacement[]Addition []Other Permit#: Date: ❑Repair❑Replacement❑Addition❑Other Permit#: Date: ❑Repair[]Replacement❑Addition[]Other Reuse Conditions AGE OF RESIDENTIAL SYSTEM: LESS THAN Five 5 Years Old F-1Re-ConnectionInspection Required ❑ ❑ AGE OF P.ESIDENTIAL SYSTEM: History of Failures-Additional Disposal Field Installation Required (See Comments) ISE TWEEN Five(5)and Ten(10)Years Old ❑ Condition of System Evaluation/Inspection Required ❑ Re-Connection Inspection Required History of Failures-Additional Disposal Field Installation Required (See Comments) AGF of RESIDENTIAL SYSTEM: Condition of System Inspection Required Over Ten(10)Years Old isposal Field Reuse Expansion Required (50%of existing system) Re-Connection Inspection Required ❑ Commercial System: To be evaluated on a case by case basis based on scope of proposed project. Additional evaluation, improvement, and reporting requirements may be applicable. Comments: ❑ Consultation Se Required ❑ Se epai ermit Required ❑Septic Repair Permit May Be Required Per Building Per it C ndifons REVIEWED BY: AZ 111A REGISTERED ENVIRONMENTAL HEALTH SPECIALIST Date: I� pF_ CHECK#/ AMOUNT SERVICE REQUEST# INVOICE# PERMIT ID# C JL Sc RECEIVED BY CASH REMITT DATE EH 42-021 8/25/2009 Application for Temporary Waiver to Destroy Septic Tank