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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT JUL 10 2018 <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/e�-fhVIPONMENTAL HEALTH <br />APPLICATION FOR A TEMPORARY WAIVER PERMIT/SERVICES <br />FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK <br />SITE LOCATION: - I' �-�C, %� J CITY: DATE:A3 v <br />C <br />PROPERTY OWNER NAME: ^ , / / ` APN�7 7 j -7� el— <br />✓V 4 l <br />PROPERTY OWNER MAILING ADDRESS: r t/PW� <br />C 1 <br />` Z ° PHONE' , - '� G / `. -1527- <br />CITY/STATE/ZIP:�� �/ <br />r <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 (33)) months from the date of demolition, and to <br />complete the construction and final the building permit within one (1I 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 these condi ions for the(rptic system reuse. <br />CERTIFIED BY: <br />PROPERTY OWNER SIGNATURE DATE <br />FOR EHD USE ONLY <br />Septic System Histo /Permit Summary <br />Permit #: <br />�, -1> <br />Date: <br />�? �' "' <br />Original Installation ❑Repair ❑Replacement ❑Addition <br />Perrnit #: <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 />�,wrm`.t #_ <br />Date: <br />❑Repair ❑Replacement ❑Addition ❑Other <br />Rause Conditions_ <br />AGE OF RESIDENTIAL SYSTEM: <br />TRm Five 5' Years Old <br />❑ Re -Connection Inspection Required <br />AFLESS <br />❑ History of Failures - Additional Disposal Field Installation Required (see Comments) <br />❑ AGE o F RESIDENTIAL SYSTEM: <br />❑ Condition of System Evaluation/Inspection Required <br />BETWEEN Five (5) 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 SYsrEM: <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 />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 />Additional <br />Comments: <br />❑ Consultation Service Required ® Septic Repair Permit Required ❑ Septic Repair Permit May Be Required Per Building Permit Conditions <br />REVIEWED BY: , i -? - /0 - / i <br />REGISTERED ENVIRONMENTAL HEALTH SPECIALIST Date: <br />PE <br />SC RECEIVED BY <br />CODe <br />CHECK#/ <br />CASH <br />AMOUNT <br />REMITTED <br />DATE <br />SERVICE REQUEST # <br />INVOICE # <br />PERMIT ID# <br />EH 42-021 8/25i2OO9 Application for Temporary Waiver to Destroy Septic Tank <br />