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n v- orctH'•N o SAN JOAQUIN COUNTY 0 ENVIRONMENTAL HEALTH DEPARTMENT < 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd oq 9 • N`P., APPLICATION FOR A TEMPORARY WAIVER C/FOR FROM.REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK SITE LOCATION: Z CITY: �Z� DATE: r APN: . 9 .PROPERTY OWNER NAME: .- /L. 9A_ezl. r"�2 'Id�• �t-® PROPERTY OWNER MAUI RESS: 1 CITY/STATE/Z �j Intent to RebuildlReplace 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 nderstand and acknowledge that I must satisfy the conditions for reuse of the septic system for the rebuilt/replaced u 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 condition ptic system reuse. CERTIFIED BY: PROPERTY OWNER SIGNATURE DATE `:FOREHD'USEONIY c Se tic S stemAlitbrylpelemiltsuimma Permit Date riginal Installation❑Repair❑Replacement❑Addition E'ermtt#, Date, QRepoir❑Replacement❑Addition❑Other P81Tnit#I„ Date ❑Repair❑Replacement❑Addition❑Other Permit Date: ❑Repair❑Replacement❑Addition❑Other Permit#: Date: ❑Repair❑Replacement❑Addition❑Other Reuse Conditions = AGEnFRESIDENrIAI SYsrEM: - Re Connection Inspection Required LESSTHAN Five (5)Years Old ❑� tlpeoFRE tDENTu�SYSrEM: ❑ History of Failures Additional Disposal Field Installation Required (See comments) ❑ Condition of System EVatuation/InspectiomRequired i BEIwEEN Five(5)and Ten(10)Years 01d Re-Connection Inspection Regpired ❑ History of Failures-Additional Disposal Field Installation Required (See comments) AGEOF RESIDENTIALSYkEM: Condition of System Inspection Required „ Over Ten(10)Years Old Disposal Field Reuse Expansion Required(50%of existing system) Re-Connection Inspection Required 0>Commercial System; Toe evaluated on a case by case basis based on Scope of proposed project. Additional evaluation, improvement;and reporting requirements may be applicable: Comments S J t o a4_ ti Vt $s W tvi d ❑ Consultation Service Required Septic Repair Permit Required ❑Septic Repair Permit May Be Required Per Building Permit Conditions REVIEWED BY: REGISTERED ENVIRONMENTAL HEALTH SPECIALIST " Date: PE SC RECEIVED BY CHECK#/ AMOUNT DATE SERVICE REQUEST# INVOICE# PERMIT ID# CODECASH REMITTED EH 42.021 8/25/2009 Application for Temporary Waiver to Destroy Septic Tank