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W: PICA SAN JOAQUIN COUNTY 01, z' ENVIRONMENTAL HEALTH DEPARTMENT y: <' 600 East Main Street, Stockton, CA 95202-3029 •'. Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd \ q •.o �P APPLICATION FOR A TEMPORARY WAIVER FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK SITE LOCATION: ` JI 1 L.�Cd vJe'� t ` 6 CITY: —rL J DATE: PROPERTY OWNER NAME: —'J \ ,.�/1 \ 1 ` ✓S APN: PROPERTY OWNER MAILING ADDRESS' CITY/STATE/ZIP: I wF� ,1 sl -)i PHONE: , _ y _ 'S�-P -1_... Intent to Rebuild/Replace Statement 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 rebuilUreplaced structure. I understand that I will be responsible for all EHD enforcement costs should I fail to comply with these conditions for theaptic system reuse. CERTIFIED BY: — PROPER OWNER SIGNATURE DATE FOR EHD USE ONLY Septic System History/Permit Summary Permit#,; —2,76 37 Date: Dlzdn 7 COOriglnal 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 TtIAN Five Years Old Eld Re-Connection Inspection Require AGF OFRFSIDENTIaI_SYSTEM: ❑ History of Failures-Additional Disposal Field Installation Required (see Comments) BETNIEE�I Five(5)and Ten(10)Years Old C]Condition of System Evaluation/Inspection Required . ❑ Re-Connection Inspection Required {t History of Failures-Additional Disposal Field Installation Required (see Comments) `' AGE OF RESIDENTIAL SYSTEM Condition of System Inspection Required Over Ten(10)Years Old Disposal Field Reuse Expansion Required (50%of existing system) Re-Connection Inspection Required E] Commercial System: To be evaluated on a case by case basis based on scope of proposed qro ect. Additional evaluation, improvement,and reporting requirements may Comments: :�IMAN 0 1 2012 ❑Consultation Service ftuiired [XSePtiCR9PaM,21 t Required ❑Septic Repair Permit May Be Required Per Building Permit C ditions REVIEWED BY: REMTERED ENVIRONMENTAL HEALTH SPECIALIST Date. PE SC RECEIVED BY CHECK#/ AMOUNT DATE SERVICE REQUEST# INVOICE# I PERMIT IDN CODE _ CA REMIT D -- EH 42-021 8i25,'2009 Application for Temporary Lvver to Destroy SeptfeTank SUE—�1� �o Sve�a�7 fi31� ICY �/ �l� -Iair /I I/Ill-f