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QA4��N. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> �S Telephone:(209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> APPLICATION FOR A TEMPORARY WAIVER <br /> S�/FOAL) <br /> FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK <br /> SITE LOCATION: -Z L 3�� vw tt CITY: a r DATE: 113113 <br /> PROPERTY OWNER NAME: /_.Q rd6 ^ rO - ' APN: C'O-I O <br /> ll <br /> PROPERTY OWN ILING D ss: / 1 a� 4j <br /> j, / <br /> CITY/STATE/ZIP: /+ CJ meq- 9S� 3 - 17 ONE: <br /> Intent to Rebuild/Replace Statement 7 <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 9 conditions fo the se/pt�ic system reuse. <br /> RTIFIED BY: �� Z- Z - y'• .�� <br /> Pr&ERTY OWNER SIGNATURE DATE <br /> O.FOREHD USE;ONLY <br /> Se tWS stemHlst6r:%PermitSiimma <br /> Permits, b b S � s;,Date jt t��4 ..b;:, rh: On9nat ltistallatlpn©Repel}�7RePlacemer t`�Addt4on'' <br /> I?ermlt ff 3 S �dt8 t fr= 1 r?c s ,s, bl W o- r <br /> b, L7RopatrflRePPlacetT,entpAdd(4ongOtFier <br /> 1?erfhl)> , „ a rDtet ' QRgpalr lace'Jpeht QAddltT@n pother <br /> z •, r s, j3gA <br /> Rermlt# _" � � � � ate = ' � � r ` ❑Reps J]Re 1 ce7peptOAddrtfon'(�OtheT' <br /> RiCs dhdItl0n5 tmr 7 <br /> ' Re7Contlectioh=inspectloh RequiredY r , <br /> LEss THAN Five 5 Years Old � r ~�- � <br /> R ❑History of Failures Additional Disposal E1eld Installation Required(seetCmm <br /> Qe is r <br /> Q AOE OF RESIDENTIAL S'SfEM � s v - a - v r + <br /> 4BETWEEN Flye(5)and Ten(10),�Years Old Cogtj�tlon of System Evalua41on/InspegIOT1 Ra I(ed <br /> `kms ni ':a,`4jRe Connection inspection Requlrel �h <br /> ti ,° ;' ❑�ltstory 4(Failures Additional DlsposaiJ�-@je)d installatlon)3equirred(see Cou ments) <br /> AD�OF RESIDEITIALSY$TEMk'`� "' �E'i s C04S1jtIOn Of$ySte)T1 jnspe0tiOl1 R@gUlreg`=' a r t = <br /> 4L <br /> Ove�ien(10)Yea7s Old` T 3 ` )' �IDIs osal Field euse Exa Sion a wcetl 50°a of exls(In s stem ` <br /> ` y As" ' Tobe evalpate'd:on ajcase case bases based n<sco e o ro osed ro ect <br /> ._ E � �� € ft �,{« kr� t t Rddlti@nalfevaluatl�n'Improv@ment and reportmgtrequlre/nertfs may_betappJlcabl@ E, <br /> Cgmmerltsfa: ��-; h» t��=c= �'aIFn.c "" la � %A`' ;' n2 i✓ - <br /> �i 2 <br /> Consul(aUo t SeM `Requl(ed (S@pt cRepaiJ Permit Required Sep0c Repair P.erz11t May 8e Required Per Bu ldmg I'Qf 11lCOndltfohS, <br /> REVIk"lMEDl3Yts s 'y i � 1 <br /> �-- _3 „i u � _ .� 5 [IEO6SLERED EMlIRDNLI$NTAL F{FACTH SPECIALIST i,�� � >i._-a f� F t _ r y pat8.���'� ' <br /> PE SC RECEIVED BY CHECKl2/ AMOUNT DATE SERVICE REQUEST INVOICE# PERMITID# <br /> CODE CASH REh1ITTED <br /> EH 42-021 8/25/2009 OL7; a� CSGb�`� ApplicaUon for Temporary Waiver to Destroy Septic Tank <br />