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SAN JOAQUIN COUNTY <br /> ).•'..AGE-..0.. <br /> z ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> ••��'� + Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> c. .'r <br /> APPLICATION FOR A TEMPORARY WAIVER <br /> FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK <br /> SITE LOCATION: CITY: � DATE: r <br /> PROPERTY OWNER NAME: f I e kov 0 � t 0 APN: / <br /> p� F g� l/ F3 �_.—_ <br /> P e �R•A�.ITr rNEIr�^+Ae.G'A D SSC, <br /> Cl[�SKCIth• \Q S 3-b --PHONE: O� <br /> Intent to RebuildlReplace 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 /> SepticTank 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 s otic S, tem reuse. r <br /> CERTIFIED BY: or r <br /> g y f J <br /> OPERTY OWNER SIGNATURE DATE <br /> FOR EHD USE ONLY <br /> Se atic S stem Histo /Permit Summary <br /> Permit#: Date: Original Installation❑Repair[]Replacement❑Addition <br /> Permit#: Date: ❑Repair[]Replacement❑Addition❑Other <br /> Permit M Date: ❑Repair❑Replacement❑Addition❑Other <br /> Permit il: Date: ❑Repair❑Replacement❑Addition❑Other <br /> Permit Date: []Repair❑Replacement❑Addition[]Other <br /> Reuse Conditions <br /> AGE OF RESIDENTIAL SYSTEM: <br /> LESS THo Five 5 Years Old ❑ Re-Connection Inspection Required <br /> AGE GF RESIDENTIAL SYSTEM: <br /> R,History of Failures-Additional Disposal Field Installation Required (See comments) <br /> AGE of R Five(5)and Ten(10)Years Old Condition of System Evaluation/Inspection Required <br /> BETRe-Connection Inspection Required <br /> ❑ History of Failures-Additional Disposal Field Installation Required (See Comments) <br /> ❑ AGE OFRfSDEWTIALSYSTEM: ❑ Condition of System Inspection Required <br /> over Ten(10)Years Old ❑ Disposal Field Reuse Expansion Required(50%of existing system) <br /> ❑ R:Connection Inspection Required <br /> To be evaluated on a case by case basis based on scope of proposed project. <br /> ❑ <br /> Commercial System: Additional evaluation, improvement,and reporting requirements may be applicable. <br /> Comments: <br /> 1 Consultation Servi ? equired ❑Septi epair errnit Required ❑Septic Repair Permit May Be Required Per Building Permit Con tions <br /> REviEWED BY: <br /> REGISTERED ENVIRONAiFwTAL HEALTH SPECIALIST D te: <br /> PE SC RECEIVED BY CHECK91 AMOUNT <br /> , DATE SERVICE REQUEST# INVOICE# PERMIT ID# <br /> CODE _ I CASH REMITT <br /> EF.42-031 8'2S27r,y Application for Temporary waiver to Destroy Septic Tank <br />