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�cq�iN. o SAN.JOAQUIN COUNTY U, kd�,1 L� <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />y vllI < 600 East Main Street, Stockton, CA 95202-3029 Ji� '1 <br />.. �.. - :. Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd ©vRn =�TllHEALTH <br />ENVtR <br />�A�IFOR�'`P APPLICATION FOR A TEMPORARY WAIVER PE <br />RtflillSER`�ICES <br />FROM REQUIREMENT To DESTROY ABANDONED SEPTIC TANK <br />SITE LOCATION: 2}_�i✓)0 CITY: DATE: <br />PROPERTY OWNER NAME: -��L rl APN: <br />�Lt V J <br />PROPERTY OWNER MAILING A1`D'IDRES�_ J <br />CITY/STATE/ZIP:PHONE: C <br />CrZZJ L_v 1 � If z— / 1US <br />Intent to Rebuild/Replace 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 />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/repla tur -I understand that I will be responsible for all EHD enforcement costs should I fail to comply <br />with these conditl for eptic system reuse. <br />CERTIFIED BY: <br />PROPERTY OWNER SIGNATURE DATE <br />FOR EHD USE ONLY <br />Septic System Histo /Permit Summa <br />Permit <br />Date: <br />Ori final Installation []Repair ❑Replacement ❑Addition <br />Permit #: <br />Date: <br />❑Repair ❑Replacement []Addition []Other <br />Permit #: <br />Date: <br />[]Repair []Replacement []Addition ❑Other <br />Permit #: <br />Date: <br />❑Repair ❑Replacement ❑Addition ❑Other <br />Permit #: <br />Date: <br />❑Repair ❑Replacement ❑Addition ❑Other <br />Meuse Conditions <br />AGE OF RESIDENTIAL SYSTEM: <br />❑ Re -Connection inspection Required <br />LEss Tww Five (5) Years Old <br />❑ History of Failures - Additional Disposal Field Installation Required (See Comments) <br />AGE of RESIDENTIAL SYSTEM: <br />AGE <br />❑ Condition of System Evaluation/Inspection Required <br />Five (TI and Ten (10) Years Old <br />❑ Re -Connection Inspection Required <br />History of Failures - Additional Disposal Field Installation Required (See Comments) <br />AGE OF RESIDENTIAL SYSTEM: <br />Condition of System Inspection Required <br />Over Ten (10) Years Old <br />Disposal Field Reuse Expansion Required (50% of existing system) <br />Re -Connection Inspection Required <br />To be evaluated on a case by case basis based on scope of proposed project. <br />❑ Commercial System: <br />Additional evaluation, improvement, and reporting requirements may be applicable. <br />Comments: <br />Consultation Servi equired ❑ Septic F air Pe it Required ❑ Septic Repair Permit May Be Required Per Building Per it Conditions <br />REViEWED BY: a <br />REGISTEREDVIRONMENTAL HEALTH SPECIALIST Date: <br />PE SC <br />CODE <br />RECEIVED BY <br />CHECK#/ AMOUNT <br />CASH REI <br />DATE <br />SERVICE REQUEST # <br />INVOICE # <br />PERMIT ID# <br />7//0^2 <br />EH 42-021 8/25/2009 Application for Temporary Waiver to Destroy Septic Tank <br />